Fillable Scipai Miami Valley Hospital *** Rehabilitation Institute of Ohio

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Scipai Miami Valley Hospital *** Rehabilitation Institute of Ohio

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Intellectual Property of the University of Dayton Doctor of Physical Therapy Program
Use only with express written permission.
Student & Clinical Instructor Performance Assessment Tool (SCIPAI)
Student: _______________________________ CI : ____________________________
Clinical Site_______________________________________
Clinical Week # _____ Date of meeting: _________________
Student and CI complete ratings and comments; then compare with each other
Clinical Instructor Performance:
Supervision __________ % (Rate % of the time, 0-100%, CI manages effectively without needing cues)
CI responsive to informal meetings, responsive to student needs/questions; CI provides appropriate balance of
close/distant supervision; CI readily accessible
______________________________________________________________________________________
______________________________________________________________________________________
Feedback __________ % (Rate % of the time, 0-100%, CI manages effectively without needing cues)
CI answers questions regarding patient treatment or refers Intern to appropriate person or resources; CI provides
positive reinforcement and critical comments – comments help with professional/personal growth
______________________________________________________________________________________
______________________________________________________________________________________
Kudos - CI performance from this past week
______________________________________________________________________________________
______________________________________________________________________________________
Goals - CI performance for next week
______________________________________________________________________________________
______________________________________________________________________________________
Student Performance:
Evaluation ________ % (Rate % of the time, 0-100%, student manages effectively without needing cues)
Student uses technically correct mechanics – i.e., MMT, ROM, sensory testing, functional mobility, etc. - in
obtaining and documenting the data necessary to make treatment decisions
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Treatment ______ % (Rate % of the time, 0-100%, student manages effectively without needing cues)
Student able to plan and complete appropriate treatments; provide creative treatment alternatives; justify
treatment strategies – logic and evidence-based practice; competently apply treatment technique
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Intellectual Property of the University of Dayton Doctor of Physical Therapy Program
Use only with express written permission.
Communication _______ % (Rate % of the time, 0-100%, student manages effectively without needing cues)
Student appropriately initiates and receives feedback from CI, peers (all other healthcare providers, including
vendors), and patients/caregivers; appropriately interacts with CI, peers, patients/caregivers
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Professional Behavior______ % (Rate % of the time, 0-100%, student manages effectively without needing
cues)
Student demonstrates professional behavior in all situations: teamwork, initiative, punctuality, reliability,
appropriate attire; integrity; compassion; caring; empathy; productive relationships; contributions to a positive
work environment; accepts feedback, conflict management; values dignity of all; seeks and provides feedback
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Kudos - Student performance from this past week
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Goals - Student performance for next week
______________________________________________________________________________________
_______________________________________________________________________________________
_____________________________________________________________________________________
Student Independence
Performance Rating
Independence
(Rate % of caseload, 0-100%,
student manages independently)
Simple cases
Complex cases
Overall Caseload
To assist with ongoing dialogue between the University of Dayton, its students, and its clinical partner
sites, students will input electronically on the SCIPAI App any SCIPAI data completed on paper. This
will allow for DCE and CCCE review of the SCIPAI content. Access the SCIPAI App at:
Post SCIPAI Review Comments (optional)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Scipai Miami Valley Hospital *** Rehabilitation Institute of Ohio

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Completed 12 February 2020

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