APP N IX A: Preceptor ompleted valuation orms...The presentation was well prepared, organized, and flowed logically. Appropriate handouts and/or audio-visual aids were used. The topic

Appendix A: Preceptor Forms Page 1

APPENDIX A: Preceptor-Completed Evaluation Forms

Contents

IPPE Oral Presentation Evaluation ............................................................................................................ 2

IPPE Preceptor Final (Summative) Evaluation of Student......................................................................... 3

APPE Oral Presentation Evaluation ........................................................................................................... 6

APPE Preceptor Final Evaluation of Student Performance ....................................................................... 8


Union University School of Pharmacy

IPPE Oral Presentation Evaluation

Student: Date:

Presentation Title:

Preceptor: Rotation Site:

Excellent.

Exceeds

Expectations.

Good.

Meets

Expectations.

Fair.

Needs

Improvement.

Poor.

Does Not Meet

Expectations.

4 3 2 1

Please circle the rating for each section.

Part I. Organization 4 3 2 1

The presentation was well prepared, organized, and flowed logically.

Appropriate handouts and/or audio-visual aids were used.

The topic was covered in time allotted.

Part II. Content 4 3 2 1

The student thoroughly researched the topic.

The student outlined the purpose or objectives of the presentation.

The student provided a thorough discussion, including comparisons and alternatives when appropriate.

The student demonstrated the ability to explain concepts and their relevance to the topic or setting.

The student’s conclusions or recommendations were reasonable and based on the information presented.

The student answered questions demonstrating an appropriate depth of knowledge in the subject area.

Part III. Communication Skills 4 3 2 1

The student spoke in a clear, audible voice with proper intonations and pace.

The student maintained eye contact, was relaxed, in control, and did not read the presentation.

The student used appropriate grammar, medical terminology, and pronunciations.

Plagiarism will result in a failing grade for the course and disciplinary action by the School of Pharmacy.



IPPE Preceptor Final (Summative) Evaluation of Student

Student Name:

Site:

Preceptor Name:

Please rate the student on each of the following areas using the rating scale listed below.

Performs

consistently

above

expectations

(Grade=A)

Performance

occasionally exceeds or

consistently meets

expectations

(Grade=B)

Performance occasionally

meets expectations or

consistently needs

improvement

(Grade=C)

Performance consistently

below expectations,

occasionally

potentially harmful

(Grade=F)

Not

applicable

4 3 2 1 NA

Description Rotation Activity Rating

Scale

Drug Distribution (30%)

Order clarification or verification

Medication dispensing

Order preparation and labeling


Utilization of pharmaceutical calculations (minimum of 4

examples)

Medication dispensing, Pharmacy

calculations

Final checking for accuracy


Comments:

Communication Skills (25%)

Interactions were courteous, respectful, compassionate, and

culturally sensitive.

Patient counseling, Interactions

with healthcare team

Information provided was accurate and appropriate Patient counseling, Interactions


Discussed options with the preceptor prior to making

recommendations

Patient counseling


Comments:

Description Rotation Activity Rating

Scale

Drug Information (15%)

Utilized appropriate resources

Med Fact Sheets, Formal

presentation

Medication Fact Sheets are complete and accurate Med Fact Sheets

Information obtained correctly and adequately answered

questions

Questions

Comments:

Professionalism (10%)

Adhered to dress code Attendance

Professional, courteous, respectful, compassionate behavior Patient counseling, Interactions


Maintained confidentiality (HIPAA) All

Exhibited cultural sensitivity (sensitive to ethnicity, economic

status, age, etc)

Patient counseling, Interactions


Punctual, no unapproved absences Attendance

Dependability, attitude, motivation, sense of duty All

Comments:

Recommended Final Grade

(Options: A, B, C or F)

Additional Comments:

Student Signature Date

Preceptor Signature Date

Please fax completed form to:

Mark Stephens, Pharm.D., BCPS

Director or Experiential Education

FAX: 731-661-5980



Student Name:

Preceptor Name:

Site:

Please provide additional information about your student’s performance.

Question 1 and 2 are for Introduction to Community Pharmacy.

1. Please rate this student’s general knowledge of non-prescription products. (Check one)

Excellent Good Needs

Improvement

Poor

2. Please rate the student’s ability to apply knowledge of non-prescription products to patient

recommendations and patient counseling. (Check one)

Excellent Good Needs

Improvement

Poor

3. Did the student show enthusiasm for learning?

Comments:

4. Did the student take the initiative to learn new information or skills?

Comments:

5. Describe the student’s response to your feedback and recommendations for improvement.

6. Given your experience with this student, would you be willing to recommend for hiring or hire this

person? Why or why not?



APPE Oral Presentation Evaluation

Student: Date:

Presentation Title:

Preceptor: Rotation Site:

Excellent.

Exceeds Expectations.

Grade=A

Good.

Meets Expectations.

Grade=B

Fair.

Needs Improvement.

Grade=C

Poor.

Does Not Meet

Expectations.

4 3 2 1

Please circle the rating for each section.

Part I. Organization 4 3 2 1

The presentation was well prepared, organized, and flowed logically.

Appropriate handouts and/or audio-visual aids were used.

The presentation content matched the audience needs.

The topic was covered in time allotted.

Comments:

Part II. Presentation of pertinent data 4 3 2 1

The student thoroughly researched the topic.

The student provided applicable background information, pharmacotherapy and disease state

information.

The student outlined the purpose or objectives of the presentation.

The student demonstrated the ability to explain concepts and their relevance to the topic or setting.

Comments:

Part III. Critical thinking skills/Mastery of subject 4 3 2 1

The student provided sound assessments and made original recommendations based on inquiry,

extensive analysis, and scientific reasoning.

The student’s conclusions or recommendations were reasonable and based on the information presented.

The student provided ample citations of current literature.

The student was able to answer questions in a logical fashion and had the ability to think on his/her feet.

Answers were accurate and corresponded with the expected degree of competence.

Comments:

Part IV. Communication Skills 4 3 2 1

The presentation was logically organized and the information was clearly explained.

The student maintained eye contact, clarity and proper rate of speech and did not read the presentation.


The student used appropriate grammar, medical terminology, and pronunciations.

Public speaking skills demonstrated no distracting behaviors.

Comments:

Plagiarism will result in a failing grade for the course and disciplinary action by the School of Pharmacy.



APPE Preceptor Final Evaluation of Student Performance

Advanced Pharmacy Practice Experiences (APPE)

Student Name (Print)

Preceptor Name (Print)

Site (Print)

Rotation Dates

Instructions

Please rate the student’s performance at the conclusion of the rotation using the scale below.

4.0 = Consistently performs at and occasionally beyond the expectation of a student at this level.

Performs without assistance 90% of the time.

3.5

3.0 = Performs at the expectations of a student at this level most of the time.

Performs without assistance 75-89% of the time.

2.5

2.0 = Performs at the expectations of a student at this level in some areas. Several areas need

improvement. Performs without assistance 50-74% of the time.

1.5

1.0 = Student needs significant improvement.

Performs without assistance < 50% of the time

NA = Not applicable to the rotation

Comments are strongly encouraged for any section in which the student scores a “2” or less.

Providing written comments allows the student to review accomplishments and recommendations for

improvement. Written comments also help the University to highlight accomplishments and assist the

student in improving areas where they have deficiencies.


I. Discuss the pathophysiology of disease states

common to the practice

Midpoint:

Final

A. Integrates biomedical, pharmaceutical,

social/behavioral/administrative, and clinical

knowledge.

B. Adequately discusses the pathophysiology of

diseases common to the practice site.

C. Appropriately prepares for discussions.

D. Asks appropriate questions.

E. Demonstrates an interest to learn.

F. Demonstrates a systematic process for self-

reflection of professional knowledge and skills.

G. Demonstrates a personal plan for continuous

professional knowledge development.

Accomplishments/

Suggestions

Accomplishments/

Suggestions

II. Discuss the current therapeutic treatment

recommendations of disease states common to the

practice

Midpoint Final

A. Integrates biomedical, pharmaceutical,

social/behavioral/administrative, and clinical

knowledge.

B. Adequately discusses the current treatment

recommendations for diseases common to the

practice site.

C. Appropriately prepares for discussions.

D. Asks appropriate questions.

E. Demonstrates an interest to learn.

F. Demonstrates a systematic process for self-

reflection of professional knowledge and skills.

G. Demonstrates a personal plan for continuous

professional development.

Accomplishments/

Suggestions

Accomplishments/

Suggestions

III. Communicate effectively with patients, caregivers,

other healthcare professionals, and the public

Midpoint Final

A. Communicates effectively with patients,

caregivers, other healthcare professionals, and the

public.

B. Listens to others with attention.

C. Identifies and accommodates for communication

barriers (cultural, language, economic, age,

Accomplishments/

Suggestions

Accomplishments/

Suggestions


cognitive, physical, spiritual, etc.)

D. Additional learning objectives not listed above

that are specific to your practice site or rotation

IV. Communicate in a written format with patients,

caregivers, other healthcare professionals, and the

public.

Midpoint Final

A. Communicates effectively in writing with

patients, caregivers, other healthcare

professionals, and the public.

B. Writes at a level appropriate to the needs of the

reader.

C. Creates documents that have a clear purpose,

appropriate content, and logical organization of

thoughts and ideas.

D. Appropriately cites resources and uses acceptable

reference format.

E. Uses appropriate medical terminology and

abbreviations.

F. Correctly uses grammar, punctuation, and

spelling

G. Additional learning objectives not listed above


Accomplishments/

Suggestions

Accomplishments/

Suggestions

V. Pharmaceutical Care:

Prepare and distribute prescription, non-

prescription, and medical products

Midpoint Final

A. Assess medications orders for appropriate

therapy, dose, dosage form

B. Analyze patient records for pertinent information

including allergies, potential interactions with

medications or disease states, or duplicate

therapy

C. Clarify or correct medication order information

to assure the order is accurate and legal. Contact

the prescriber, patient, or caregiver when

necessary.

D. Prepares and dispenses medications or medical

products appropriately

E. Prepares or compounds sterile and/or non-sterile

products

F. Performs accurate pharmacy calculations.



Accomplishments/

Suggestions

Accomplishments/

Suggestions


VI. Pharmaceutical Care:

Collect, analyze, and accurately evaluate

subjective and objective patient information for

the development of a treatment/pharmaceutical

care plan

Midpoint Final

A. Identify and obtain pertinent objective health

information from the patient’s medical record,

pharmacy profile, limited physical exam, etc.

Accomplishments/

Suggestions

Accomplishments/

Suggestions

VII. Pharmaceutical Care:

Design evidence-based treatment plans

Midpoint Final

A. Collects, analyzes, and accurately evaluates

subjective and objective patient information for

the development of a pharmaceutical care plan.

B. Applies critical thinking and problem solving

skills to make rational decisions

C. Designs and recommends pharmacotherapy plans

for identified problems including appropriate

pharmacologic and non-pharmacologic therapy

D. Designs a monitoring plan for identified

problems

E. Identifies wellness and disease prevention

strategies

F. Accurately and concisely documents

interventions using appropriate medical

terminology and abbreviations



Accomplishments/

Suggestions

Accomplishments/

Suggestions

VIII. Successfully interprets and applies current

literature to practice

Midpoint Final

A. Accurately determines the underlying question of

individuals requesting health information,

including the collection of pertinent background

information

B. Efficiently finds accurate drug and health

information from appropriate sources, including

primary, secondary, and tertiary literature as

appropriate to formulate an answer

C. Critically analyzes the design, methodology,

Accomplishments/

Suggestions

Accomplishments/

Suggestions


results, and conclusions of a given published

study

D. Responds to the question clearly and concisely,

appropriately citing sources

E. Creates a well-written response to drug

information questions

F. Provides relevant health information

appropriately targeted to patients, caregivers, and

other healthcare providers


that are specific to your practice site or rotation:

IX. Utilize informatics in daily practice Midpoint Final

Utilizing the technologies at the site, the student is able to:

A. Complete training in an appropriate period of

time

B. Follow procedures

C. Appropriately and efficiently utilize technology

to deliver patient care

D. Appropriately and efficiently utilize technology

to identify problems, solve problems, and

document activities

Accomplishments/

Suggestions

Accomplishments/

Suggestions

X. Manage a patient centered practice:

Medication distribution and patient safety

Midpoint Final

A. Manages the preparation, dispensing,

distribution, and administration of medications

by applying legal requirements, manufacturer

recommendations, and professional standards for

sterile and non-sterile products.

B. Collects, interprets, and applies data from drug

use review processes to make recommendations

and implement changes.

C. Understands medication error surveillance

systems

D. Correctly utilizes automation, technology, and

informatics to improve workload efficiency and

patient safety.

E. Additional learning objectives not listed above


Accomplishments/

Suggestions

Accomplishments/

Suggestions


XI. Manage a patient centered practice:

Administrative processes, legal issues, formulary

compliance, quality assurance

Midpoint Final

A. Applies administrative policies and procedures to

manage human resources, communications,

marketing, billing, and inventory control.

B. Understands quality improvement principles to

develop, implement, and manage medication use

C. Applies pharmacy law

D. Analyzes formulary status and therapeutic

equivalence to determine when therapeutic

substitution is appropriate or obtain prior

authorization for non-formulary medications.

E. Additional learning objectives not listed above


Accomplishments/

Suggestions

Accomplishments/

Suggestions

XII. Function with professionalism:

Altruism and excellence

Midpoint Final

A. Places patient’s or others’ needs above his/her

own.

B. Demonstrates initiative and the desire to exceed

expectations.

C. Accepts responsibility and accountability for

his/her work and actions.

D. Demonstrates punctuality; arrives on time, is

prepared, completes assignments on time

E. Demonstrates dependability, accountability,

sense of duty, willingness to learn, positive

attitude

F. Additional learning objectives not listed above


Accomplishments/

Suggestions

Accomplishments/

Suggestions

XIII. Function with professionalism:

Interpersonal skills

Midpoint Final

A. Exhibits professional, courteous, respectful,

empathetic, compassionate behavior

B. Demonstrates sensitivity to patients and family

Accomplishments/

Suggestions

Accomplishments/

Suggestions


members

C. Demonstrates respect for other health

professionals

D. Demonstrates respect for facilities, property, and

policies

E. Maintains confidentiality

F. Exhibits cultural sensitivity (sensitivity to

ethnicity, economic status, age, etc)

G. Graciously receives feedback and seeks to

improve performance

H. Adheres to University and practice dress code

I. Additional learning objectives not listed above



APPE Grading Summary

Course Assessment Final Score % of Final Grade Final Score

Example 3.5 x 15% = 0.53

Discuss the pathophysiology of disease states common to

the practice

Discuss the current therapeutic treatment recommendations

of disease states common to the practice

Communicate verbally with patients, caregivers, other

healthcare professionals, and the public.

Communicate in a written format with patients, caregivers,

other healthcare professionals, and the public.

Pharmaceutical Care: Prepare and Distribute Prescription,

Non-prescription, and Medical Products

Pharmaceutical Care: Collect, analyze, and accurately

evaluate subjective and objective patient information for

the development of a treatment/pharmaceutical care plan

Pharmaceutical Care: Design an evidence-based treatment

plan for identified problems

Successfully interprets and applies current literature to

practice

Utilize informatics in daily practice

Manage a patient centered practice: Medication

Distribution and Patient Safety

Manage a patient centered practice: Administrative

Processes, Legal Issues, Formulary Compliance, Quality

Assurance

Function with professionalism: Altruism and Excellence

Function with professionalism: Interpersonal Skills

Verbal Presentation

10%

Additional Projects/Assignments*

Final Exam* (Not greater than 20% of final score)

Final Score

*Optional

Documents

APP N IX A: Preceptor ompleted valuation orms...The presentation was well prepared, organized, and flowed logically. Appropriate handouts and/or audio-visual aids were used. The topic