"Physician Performance Evaluation Form"

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Physician Performance Evaluation
Physician Under Review:
Date of Review: / /
Section 1: Patient Care
Quality of care:
1
2
3
4
5
Adherence to QA standards:
1
2
3
4
5
Appropriateness of Diagnostics and Therapeutics:
1
2
3
4
5
Continuing Medical Education (CME) Requirements met:
Y / N
Section 2: Communication and Interaction
Communication and interaction with fellow providers:
1
2
3
4
5
Communication and interaction with staff:
1
2
3
4
5
Communication and interaction with patients and families:
1
2
3
4
5
Patient satisfaction:
1
2
3
4
5
Communication with referring physicians (including timeliness and thoroughness):
1
2
3
4
5
Timeliness, legibility, and thoroughness of documentation:
1
2
3
4
5
Physician Performance Evaluation
Physician Under Review:
Date of Review: / /
Section 1: Patient Care
Quality of care:
1
2
3
4
5
Adherence to QA standards:
1
2
3
4
5
Appropriateness of Diagnostics and Therapeutics:
1
2
3
4
5
Continuing Medical Education (CME) Requirements met:
Y / N
Section 2: Communication and Interaction
Communication and interaction with fellow providers:
1
2
3
4
5
Communication and interaction with staff:
1
2
3
4
5
Communication and interaction with patients and families:
1
2
3
4
5
Patient satisfaction:
1
2
3
4
5
Communication with referring physicians (including timeliness and thoroughness):
1
2
3
4
5
Timeliness, legibility, and thoroughness of documentation:
1
2
3
4
5
Section 3: Other
Financial contribution and workload:
1
2
3
4
5
Punctuality:
1
2
3
4
5
Attitude:
1
2
3
4
5
Flexibility:
1
2
3
4
5
Participation in group activities, meetings, projects:
1
2
3
4
5
Comments:
Comments/response from physician under evaluation:
Signatures:
____________________________________
Medical Director
Date
____________________________________
Physician
Date
Form originally supplied by PhysiciansPractice.com
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