ALLIED HEALTH PROFESSIONAL



Name:

Job Title: Physician's Assistant

Evaluation Date:

Sponsoring Physician(s): _____________________

The above Allied Health Practitioner (AHP) is due for an annual competency evaluation. In order for the applicant to be appropriately evaluated for continued affiliation and/or employment with University Hospital, it is necessary that a sponsoring physician complete the evaluation. Please answer the following questions and provide additional information to any question answered with “yes”.

WORK HISTORY:

|How long have you been a sponsoring physician for the applicant? | |

|Were you previously, are you now, or are you about to become related to the applicant as family? | |

| |_____YES _____NO |

|Since the applicant’s last assessment, how many hours have you directly observed or supervised the applicant in |____Less than 8 hours a week. |

|the hospital setting? |____8 – 16 hours a week. |

| |____16 – 32 hours a week. |

| |____32 + hours a week. |

JOB PERFORMANCE / COMPETENCY:

Please base your evaluation of the following factors on the applicant’s demonstrated performance compared to that reasonably expected of an allied health professional with a similar level of training, experience and background as the above listed AHP.

|Based on your personal knowledge and observation, do you believe that the above referenced AHP has| |

|had sufficient clinical experience during the past year to remain competent to perform the |_____YES _____NO |

|duties/responsibilities which he/she has requested on the attached form. | |

|To your knowledge, has the applicant been involved in an incident which is a deviation from the | |

|standard of care? |_____YES _____NO |

|To your knowledge, has the applicant been the subject of a malpractice suit, judgment or settlement| |

|or is a case pending? |_____YES _____NO |

|Standard |Exceptional |Commendable (2) |Needs Improvement (1) |N/A |

| |(3) | | | |

|Performs and documents complete assessments according to protocol | | | | |

| Infant | | | | |

| Child | | | | |

| Adolescent | | | | |

| Adult | | | | |

| Geriatric | | | | |

|Communicates health assessments and immediate plan of care to members | | | | |

|of the health care team and other community based providers | | | | |

|Develops/initiates/evaluates patient/family | | | | |

|education/counseling/discharge planning | | | | |

|Progress notes/discharge summaries are accurate and complete | | | | |

|Orders and/or performs and/or interprets diagnostic tests according to | | | | |

|established protocols | | | | |

|Appropriately and accurately initiates physician's prescription for | | | | |

|medical treatment in collaboration with physician | | | | |

|Executes and manages non-invasive and other clinical procedures | | | | |

|according to protocol | | | | |

ALLIED HEALTH PROFESSIONAL

COMPETENCY EVALUATION

PAGE 2

NAME: _______________________

JOB TITLE: PHYSICIAN'S ASSISTANT

|Standard |Exceptional |Commendable (2) |Needs Improvement (1) |N/A |

| |(3) | | | |

|Supports patient rights/patient safety goals; maintains patient | | | | |

|confidentiality | | | | |

|Incorporates principles of Infection Control | | | | |

|Applies and/or assists with traction application/removal | | | | |

|Applies and/or assists with cast applications/removals | | | | |

|SURGICAL ASSISTANT DUTIES | | | | |

| Scrubbing/Gowning & Gloving | | | | |

| Patient Positioning/Patient Prep | | | | |

| Utilization of Electrocautery Unit | | | | |

| Passing of Instruments | | | | |

| Proper Care of Instrumentation | | | | |

| Retraction | | | | |

| Suction | | | | |

| Cutting of Suture | | | | |

| Knowledgeable of instrumentation | | | | |

| Possesses knowledge of and practices sterile technique | | | | |

HEALTH STATUS:

|To your knowledge, is the applicant’s health sufficient to perform the duties outlined in the attached | |

|delineation of Duties/Responsibilities Form? |_____YES _____NO |

SPONSORING PHYSICIAN STATEMENT:

I have reviewed / observed the applicant’s professional performance, conduct and ability to perform the duties requested. Based on my observations, I make the following recommendation:

| |Continued AHP Status |

| |Continued AHP Status with modification to job duties as listed below.** |

| |Other________________________________________________________ |

**ADDITIONAL COMMENTS:

| |

| |

| | | |

|Sponsoring Physician Signature | |Date |

| | | |

| | | |

|Printed Name | | |

FOR MEDICAL STAFF OFFICE USE ONLY:

|QUALIFICATIONS |VERIFIED |PROBLEMS (IF ANY) |

| | | |

|Current License/Registration (if applicable) | | |

| | | |

|Current Certification (if applicable) | | |

| | | |

|Current DEA (if applicable) | | |

| | | |

|Current BLS/ACLS/PALS/ETC. | | |

| | | |

|Current PPD Test Results | | |

| | | |

|Current Insurance Certificate | | |

11/21/05 L:Common/AHP/11-05 PA Annual Evaluation

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