ProAssurance.com : Treated Fairly



This sample form will assist you in creating a unique form for your practice. Effective forms address the specific circumstances of each practice. Employee Name (print)Reviewer Name (print)DateDirect Source Verification of License: Yes No License Number DateGeneral Category and Skill/Skill SetDemonstrates Competence:Reviewer’s Comments:General Office Policies and ProceduresYesNoN/ADemonstrates knowledge of policies & procedures:[List specific policies/procedures here, e.g. Patient Confidentiality]Demonstrates knowledge of age-specific patient needsUnderstands/follows chain of commandFor release of medical records:Processes requests/subpoenas for medical recordsObtains proper authorization for records releaseDemonstrates knowledge of infection control practices Exhibits training/education in equipment use & maintenanceDemonstrates appropriate blood-draw techniqueDemonstrates appropriate specimen handling & documentation (e.g., Pt. ID, date/time collected w/appropriate lab documents)Follows process for diagnostic test tracking and referral tracking[Other relevant skill/skill set] [Other relevant skill/skill set]Telephone ProceduresYesNoN/ASchedules & documents appointmentsSchedules & documents referralsSchedules & documents procedures Accurately records messagesDemonstrates proper telephone triage assessmentFollows protocols for telephone triageObtains physician review of triaged telephone callsFollows protocols for medication refillsReview social media policy according to guidelines[Other relevant skill/skill set]Patient IntakeYesNoN/AFor vital signs:Checks and documents vital signsReports deviationsDocuments height/weightDocuments current medications/allergies on each visitUpdates problem listDocuments chief complaint/onset of symptomsAssesses and documents changes in patient’s condition Assesses and documents pain using a scale/scorePerforms waived testing as indicated[Other relevant skill/skill set][Other relevant skill/skill set]Examination RoomYesNoN/APrepares/positions patient for examinationAssists with procedures:[List specific office procedures here]Assists as a chaperone in appropriate settingsProvides discharge instructions/prescriptionsProvides and documents patient educationProvides instruction in health promotion/maintenance[Other relevant skill/skill set][Other relevant skill/skill set]Medication AdministrationYesNoN/AFor oral medications:Identifies appropriate medicationVerifies written physician order w/medication to be givenCompletes sample medication log appropriatelyFor injectable medications:Identifies appropriate syringe for administrationProperly draws up medications Correctly performs subcutaneous injectionsCorrectly performs intramuscular injectionsCorrectly performs intradermal injectionsMonitors for reactionsDocumenting medication administration:Drug nameDosage RouteSite (if injection) Date and time of administrationPost-injection observation of patient[Other relevant skill/skill set][Other relevant skill/skill set]Medical EmergenciesYesNoN/AMaintains current BLS/ACLS/PALS certification (as appropriate)Demonstrates knowledge of medical emergency response planDemonstrates knowledge of emergency equipment & supplies[Other relevant skill/skill set][Other relevant skill/skill set]Employee SignatureDateReviewer SignatureDate ................
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