Children's Hospitals and Clinics of Minnesota
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Resident Competencies Evaluation Form
Please complete the following questions. All items with a red star * are required fields. When complete, scroll down and click the submit button.
*Your Name (Evaluator)
*Housestaff Name:
 *Program and Level of Practice:
Rotation Start Date:
  MM/DD/YYYY		 Rotation End Date:
  MM/DD/YYYY		   *Rotation Campus:

Evaluation
A. Patient Care
*History/Gathering Data
*Assessment / Clinical Judgement
*Management Plan and Follow-Up
*Patient/Family Counseling
*Use of Tech. to Support Decisions
*Procedure Competence
*Provides Preventative Care
*Multi-disciplinary Approach
Patient Care Comments
(500 Characters)
B. Medical Knowledge
*Fund of Knowledge
*Investigation and Analysis
Medical Knowledge Comments
(500 Characters)
C. Professionalism
*Respect, Compassion, Integrity
*Teamwork and Accountability
*Demonstrates Ethical Practice
*Demographic Sensitivity
Professionalism Comments
(500 Characters)
D. Interpersonal Communication
*Therapeutic Relationships
*Communication Skills
*Works Effectively with Others
*Facilitates Learning of Others
Interpersonal Communication Comments
(500 Characters)
E. Optional Criteria
Practice Based Learning
Systems Based Practice
Overall Comments (500 characters)