Medical Staff Peer Evaluation Form

This physician, dentist, podiatrist or allied health professional has identified you as a peer who has specific knowledge of his/her practice and quality of care. On his/her behalf, please complete the following assessment form and return it to Medical Staff Services.

Submit any additional comments you may have regarding this practitioner in the comments section at the bottom of this form or send them to:

Providence St. Peter Hospital Medial Staff Services
413 Lilly RD NE; MS: LLH22
Olympia WA, 98506

FAX: 360/493-5226
EMAIL: Jane.Porter@providence.org

Applicant Name:

Peer Reference Name
Degree
Speciality

1. Do you have specific knowledge regarding the current competence and quality of the care provided by this Practitioner?

Yes No

IF YOUR RESPONSE IS NO, NO FURTHER INFORMATION IS NECESSARY.

2. How long have you know the applicant?

3. Completion of this evaluation is based on the following approximate time period?

Last two years  
From: Month/Year to Month/Year

4. How are you acquainted with the applicant? (Check all that apply.)

Medical business or professional partner
Post Graduate training
Referral Source
Specialty Peer
Other Professional Peer Affliation

5. With what frequency did you observe the work with the applicant? (check one)

Almost Daily Many Times a Week
Several Times per Week Several Times per Month
Several Times per Year  

6. To your knowledge, has this practioner exhibited any disruptive behavior?

Yes No

7. To your knowledge, is there any physical or mental condition, including possible dependence on drugs or alcohol, which would affect this practitioner's ability in carrying out responsibilities to patients?

Yes No

8. Please Rate the applicant for the following?

I. Patient Care
  Excellent Good Fair Unsatisfactory No
Info
Provides care with compassion
Provides clinically appropriate care
Considerate of patient's family/friends
Availability/timeliness
Patient Outcomes

II. Medical Knowledge
  Excellent Good Fair Unsatisfactory No
Info
Basic medical/clinical knowledge
Knowledge in specialty
Technical Skills
Appropriate use of resources

III. Practice -based learning and improvement
  Excellent Good Fair Unsatisfactory No
Info
Medical knowledge is up to date
Timely, appropriate use of consultants

IV. Interpersonal and Communication Skills
  Excellent Good Fair Unsatisfactory No
Info
Overall communication
Verbal and written English fluency
Rapport with patients
Communication with peers
Communication with hospital staff
Ability to work with healthcare team
Writes legibly

V. Professionalism
  Excellent Good Fair Unsatisfactory No
Info
Ethical standards of treatment
Maintains patient confidentiality
Maintains responsibility for patients
Fulfills on-call duties
Sensitive to diversity

VI. Systems-Based Practice
  Excellent Good Fair Unsatisfactory No
Info
Use of electronics in medicine
Familiarity with electronic medical record
Familiarity using protocol and practice guidelines
Complete, appropriate and timely medical record documentation

9. Would you recommend this practitioner for promotion or reappointment to the medical staff of Providence St. Peter Hospital?

Yes No

Comments

Contact and Date:

Hospital/organization name:
Printed Name
Phone
Email
Date

Thank You!