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INTERN Term Assessment Form

First name

Term Dates:

Last name

Unit Name:
Hospital:
Term Number:

Mid Term

End of Term

This form is for assessing INTERN performance against the Australian Medical Council and Medical Board of
Australia's Intern training - Intern outcome statements.
Ins tructions for Supe rvisors :
* Obs erve th e in te rn in the w orkp la ce an d in clu de o bs ervatio ns from m ul ti pl e s o urce s .
* C om pl ete an d di s cu s s the form w ith th e in te rn.
* All ra ti ng s of 1 , 2, u ns atis fa cto ry an d s o m e b ord erl in e ratin gs re qu ire a n IPAP to be co m p le te d. Pl ea s e re fe r to th e
I n te rn Te rm Assessm en t Gu id e fo r ra ti ng d es crip to rs http ://q he ps .h ea lth.ql d.go v.au /m etros ou th /m ed ica l-e du catio n

INTERN OUTCOME STATEMENTS

DOMAIN 1: Scie nce a nd Schola rship - The intern as scientist and scholar
1.1 Consolidate, expand and apply k nowledge of the aetiology,
pathology, clinical features, natural history and prognosis of common
and important presentations at all stages of life.
DOMAIN 2: Clinica l Pra ctice - The intern as a practitioner
2.1 Place the needs and safety of patients at the centre of the care
process. Demonstrates safety sk ills including effective clinical
handover, graded assertiveness, delegation and escalation,
infection control and adverse event reporting.
2.2 Communicate clearly, sensitively and effectively with patients,
their family/carers, doctors and other health professionals.
2.3 Perform and document patient assessment - incorporating a
problem focused medical history with a relevant physical examination
and generate a valid differential diagnosis.
2.4 Arrange common, relevant and cost-effective investigations, and
interpret their results accurately.
2.5 Safely perfrom a range of common procedural sk ills required for
work as an intern.
2.6 Make evidence-based management decisions in conjunction
with patients and others in the healthcare team.
2.7 Prescribe medications safely, effectively and economically,
including fluid, electrolytes, blood products and selected inhalational
agents.
2.8 Recognise and assess deteriorating and critically unwell
patients who require immediate care. Perform basic emergency and
life support procedures including caring for the unconscious patient
and performing cardiopulmonary resuscitation.
2.9 Retrieve, interpret and record information effectively in clincial
data systems (both paper and electronic).

N /O

INTERN Term Assessment Form

INTERN OUTCOME STATEMENTS

DOMAIN 3: He a lth & Socie ty - The intern as a health advocate

3.1 Apply knowledge of population health, including issues relating
to health inequities and inequalities; diversity of cultural, spiritual and
community values; and socio-economic and physical environment
factors.
3.2 Apply knowledge of the culture, spirituality and relationship to
land of Aboriginal and Torres Strait Islander peoples, to clinical
practice and advocacy.
3.3 Demonstrate ability to screen patients for common diseases,
provide care for common chronic conditions, and effectively
discuss healthcare behaviours with patients.
3.4 Participate in quality assurance, quality improvement, risk
management processes and incident reporting.
DOMAIN 4: Profe ssiona lism a nd le a de rship - The intern as a professional and leader
4.1 Provide care to all patients in accordance with Good Medical
Practice: A Code of Conduct for Doctors in Australia, and
demonstrate ethical behaviours and professional values including
integrity, compassion, empathy and respect for all patients, society
and the profession.
4.2 Optimise their personal health and well-being, including
responding to fatigue, managing stress and adhering to infection
control to mitigate health risks of profesional practice.
4.3 Self-evaluate their professional practice, demonstrate lifelong
learning behaviours and participate in educating colleagues.
4.4 Take increasing responsibility for patient care while recognising
the limits of their own expertise and involving other professionals as
needed to contribute to patient care.
4.5 Respect the roles and expertise of other healthcare professionals,
learn and work effectively as a member or leader of an interprofessional team, and make appropriate referrals.
4.6 Effectively manage time and workload demands, be punctual and
show ability to prioritise workload to manage patient outcomes and
health service functions.
METRO SOUTH HEALTH PRIORITY AREA: Discha rge Summa rie s
5.1 Discharge summaries are accurate and concise.
5.2 Discharge summaries are completed in a timely manner.

N /O

INTERN Term Assessment Form

The term supervisor should make a global rating at mid and end of term. Consider the intern's ability to:
* Practise safely
* Work with increasing levels of responsibility
* Apply exisitng knowledge and skills and learn new knowledge and skills as required.
at the level expected of an intern. The term supervisor should also consider the AMC Intern training - guidelines for
terms.
6. Have the intern's le a rning obje ctive s been discussed?

Y ES

NO

7. Give a globa l ra ting of progress toward completion of internship informed by the ra tings in Doma ins 1-4:
Sa tisfa ctory - the intern has met performance expectations in the term.
Borde rline - further information, assessment and/or remediation may be required before deciding that the intern
has met performance expectations.
Unsa tisfa ctory - the intern has not met performance expectations in the term.
8. Ha ve you ticke d Borde rline , Unsa tisfa ctory or a 1 or 2 for a ny of the outcome
sta te me nts in Doma ins 1-4?

Y ES

NO

If you se le cte d YES, ple a se conta ct the MEU to de te rmine w he the r a n Improving Pe rforma nce Action Pla n is
re quire d. An IPAP template an can accessed here http://qheps.health.qld.gov.au/metrosouth/medical-education
TERM SUPERVISORS ple a se comme nt on the follow ing:
Stre ngths

Are a s for Improve me nt

INTERN ple a se comme nt on your a sse ssme nt

All i nform atio n on thi s fo rm m a y be ke pt for res ea rch pu rpo s e s no w or in the future tha t are a pp roved b y a Hu m a n
R es ea rch Eth ics C om m i ttee . Th is i nform atio n wi ll b e no n-i de ntifia bl e. If yo u do not wi s h for th e in fo rm a ti on o n th is
form to be u s e d fo r re s e arch , pl ea s e p la ce an X in the b ox.

Consultant Supervisor Name: ______________________ Signature: ___________________ Date: ____/____/____

Intern Name: _______________________________ Signature: ________________________ Date: ____/____/____
MEO/DCT Name: ___________________________ Signature: ________________________ Date: ____/____/____

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