DAILY EVALUATION (optional)
(Your) (My) work with
(Patient's Name)
Today was:
from Scale A from Scale B from Scale C
(Date)
in because
........... ............
the of
........... ............
area (your)
........... ............
of (my)
........... ............
SCALE A: 1 2 3 4
outstanding satisfactory needing improvement unsatisfactory
SCALE B:
1. PATIENT EVALUATION 4. PROGRAM IMPLEMENTATION
2. GOAL SETTING 5. PERSONAL QUALITIES
3. PROGRAM PLANNING
SCALE C:
1. Openness 16. Planning
2. Judgement 17. Questioning
3. Thoroughness 18. Reinforcement/feedback
4. Vagueness 19. Listening
5. Receptivity 20. Patient demonstration
6. Awareness 21. Orientation
7. Creativity 22. Pre-Planning
8. Sensitivity 23. Assignment
9. Encouragement 24. Evaluation
10. Responsiveness 25. Objectives/goals
11. Inflexibility 26. Organization
12. Flexibility 27. Ability to think on your feet
13. Discouragement 28. Communication Skills
14. Lack of Knowledge 29. Rapport with the patient
15. 30.
RATIONALE FOR YOUR EVALUATION:
RESULTS OF DISCUSSION:
Signed:
(Clinical Supervisor)
_______________________________
(Student)