Professional Reference Evaluation 22

Purpose: To provide documentation of professional references for physician prior to hiring.

Provider/Practitioner Name

My responses are based upon (check all appropriate responses)

Direct Observation Review of accumulated information and reports about the practitioner’s performance

I know the practitioner

How long have you known the practitioner?

During what time period did you have the opportunity to directly observe the practitioner’s practice of medicine?

In what setting and with what frequency did you observe the practitioner (e.g. office, hospital, residency, program, etc. daily, weekly, monthly)?

If worked together please specify the name of the facility:

How would you rate this practitioner’s performance compared to other practitioners at his/her level of training, experience, and background?

ATTRIBUTES

Do you find the practitioner’s medical knowledge and clinical skills adequate to perform the duties required by his/her specialty? If No, explain below.

Yes No N/A

Are you aware of any voluntary or involuntary, limitations, reductions, denial or loss of clinical privileges? If Yes, explain below.

Yes No N/A

Are you aware of any revocations or restrictions to any license, certifications or registrations (DEA) either voluntary or involuntary? If Yes, explain below.

Yes No N/A

Are you aware of any issues that could affect this practitioner’s ability to exercise clinical privileges as requested? If Yes, explain below.

Yes No N/A

Are you aware of any disciplinary actions that could prevent this practitioner from being fully credentialed to our medical staff? If Yes, explain below.

Yes No N/A

Is there anything that would warrant caution in adding this practitioner to the hospital medical staff? If Yes, explain below.

Yes No N/A

Would you recommend this practitioner to a family member? If No, explain below.

Yes No N/A

Competency Review Please rate the physician on the following core competencies.

Patient Care - Ability to provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health.