<p>______Medical Student (print) Preceptor (print) Date</p><p>Chronic Care Clerkship Educational Tasks Checklist</p><p>INSTRUCTIONS: The list below includes core experiences that each student should complete before the end of the clerkship. All students must meet with his/her clerkship preceptor at the end of the second week of the rotation to discuss these core experiences. This conversation will also give the student and the preceptor(s) an opportunity to discuss the educational experience and student’s performance to date, and to determine a plan for core experiences that still need to be completed before the end of the rotation.</p><p>After the conversation, students must return this checklist page to Teresa Jewell (fax 206-616-3908, [email protected]). Completed forms must be received before the end of the third week of the clerkship. Completing the educational tasks conversation, and this page, is a requirement for passage of the clerkship.</p><p>CORE EXPERIENCES:</p><p>Met this Still to be Goal Performed</p><p>Observed or performed a conversation regarding poor prognosis</p><p>Performed or observed a functional or life skills assessment</p><p>Attended a family conference Evaluated a patient with a non-physician health professional e.g. rehabilitation therapist (PT, OT, SLP), social worker or hospice nurse, psychologist, etc.</p><p>Participated in a discussion regarding health care financing (e.g. insurance) and the interaction with medical decision making and patient care</p><p>Performed a home/community visit</p><p>Discussed Visit Summary 1 assignment with preceptor (palliative care only)</p><p>Other discussion:</p><p>______Medical Student Signature Preceptor Signature Student: </p><p>Chronic Care Mid-Clerkship Feedback and Coaching (Student copy – not for submission)</p><p>Preceptor 1:_(name)______</p><p>Students and preceptors are encouraged to discuss performance to date, learning goals, current preceptor observations of student performance, and ways to optimize the remainder of the rotation. Preceptors are encouraged to ask students for their feedback.</p><p> Student’s Strengths:</p><p> Next Skills & Knowledge to develop:</p><p> Any Areas Currently Below Expectations:</p><p> Other:</p><p>Preceptor 2:_(name)______</p><p>Students and preceptors are encouraged to discuss performance to date, learning goals, current preceptor observations of student performance, and ways to optimize the remainder of the rotation. Preceptors are encouraged to ask students for their feedback.</p><p> Student’s Strengths:</p><p> Next Skills & Knowledge to develop:</p><p> Any Areas Currently Below Expectations:</p><p> Other:</p>