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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