American Board of Allergy and Immunology

CLINICAL COMPETENCE EVALUATION FORM

In compliance with the ACGME Program Requirements for Residency Training in Allergy and Immunology, a semi-annual record must be maintained and submitted to the ABAI for tracking purposes. The Clinical Competence form evaluates the resident's knowledge, skills, overall performance, and development of professional attitudes consistent with being a physician, by rating them on the 6 General Competencies and in Allergy/Immunology-specific competencies.

First Name
Middle Name
Last Name
Email Address

Months of Training
Dates Evaluated: Start Date: ,
TO
End Date:   ,

Primary Certification
Program Information
Name of ACGME-Training Program
ACGME/RRC#
Program Director (Full Name)
Program Director Email


GENERAL COMPETENCIES:

  Unsatisfactory Satisfactory Superior
1. Patient Care
  • Performs accurate and comprehensive medical interview, physical examinations, and review of data.
  • Capable of essential procedural skills.
  • Makes diagnostic and therapeutic decisions based on evidence/clinical data patient preferences.
2. Medical Knowledge
  • Knowledge of basic and clinical sciences.
  • Demonstrates interest in development of knowledge.
  • Understands complex relationships and mechanisms of diseases
3. Practice-Based Learning and Improvement
  • Self-evaluates performance.
  • Incorporates feedback.
  • Uses technology to enhance patient care and self-improvement.
4. Interpersonal and Communication Skills
  • Explains medications in language appropriate to patients.
  • Ensures patients understand condition and treatment.
  • Encourages questions from patients.
  • Educates and counsels patients, families, colleagues.
5. Professionalism
  • Respectful, compassionate, honest, and has integrity.
  • Exhibits responsible behavior.
  • Committed to self-assessment.
  • Acknowledges errors.
  • Considers needs of patients, families, and colleagues.
6. System-Based Practice
  • Utilizes/accesses outside resources.
  • Aware of patients' financial constraints.
  • Incorporates subspecialty consultation.
  • Aware of economic, systemic, and social factors on health care.

ALLERGY & IMMUNOLOGY SPECIFIC COMPETENCIES:

1. Medical Interview
Conducts comprehensive and detailed medical interview with children and adults who present with suspected allergic and/or immunologic disorders.
Comments:
2. Physical Examination
Performs a physical examination appropriate to the specialty.
Comments:
3. Diagnostic Tests and Studies
Selects, performs, and interprets diagnostic tests or studies.
Comments:
4. Risks and Benefits of Therapy
Assesses the risks and benefits of therapies for allergic and immunologic disorders (e.g. drug therapy, allergen immunotherapy, immunomodulatory therapy).
Comments:
5. Counseling Patients
Counsels and educates patients about diagnosis, prognosis, and treatment.
Comments:
6. Consulting Resources
Consults with and educates other physicians and health care providers.
Comments:
7. Application of Basic and Clinical Science
Applies basic and clinical science to the clinical care of patients.
Comments:
8. Research and Participation
Quality of resident's research and participation. Include short description.
Comments:
9. Coordination of Patient Care
Coordinates the care of patients, including the use of consultation; Interaction with faculty, peers, and supportive staff.
Comments:
10. Lifelong Learning
Accepts the need for a lifelong pursuit of excellence, self-directed learning, and continuing education.
Comments:
Overall Clinical Competence in Allergy & Immunology

REVIEW AND SIGN


Print names in signature box to indicate that a hard copy was signed.
Resident (Full Name): Program Director/Supervisor (Full Name):
Resident (Signature): Program Director/Supervisor (Signature):
Date:
5/9/2008 10:56:47 AM
Final Evaluation