Purpose: To provide documentation of professional references for physicians prior to hiring.
Provider/Practitioner Name:
My responses are based upon (check all appropriate responses): Direct ObservationReview of accumulated information and reports about the practitioner’s performance
I know the practitioner: Very wellWellCasuallyPersonallyProfessionally
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
RESPONSES
Do you find the practitioner’s medical knowledge and clinical skills adequate to perform the duties required by his/her specialty?
YesNoN/A
Are you aware of any voluntary or involuntary, limitations, reductions, denial or loss of clinical privileges?
Are you aware of any revocations or restrictions to any license, certifications or registrations (DEA) either voluntary or involuntary?
Are you aware of any issues that could affect this practitioner’s ability to exercise clinical privileges as requested?
Are you aware of any disciplinary actions that could prevent this practitioner from being fully credentialed to our medical staff?
Is there anything that would warrant caution in adding this practitioner to the hospital medical staff?
Would you recommend this practitioner to a family member?
Comments:
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.
OutstandingComponentPoorUnable to Evaluate
Medical/Clinical Knowledge – Demonstrates knowledge of established and evolving medical, clinical and social sciences and applies this knowledge to patient care and the education of others.
Practice-Based Learning and Improvement – Uses evidence-based methods to investigate, evaluate and continually improve patient care.
Interpersonal and Communication Skills – Demonstrates interpersonal skills that result in effective exchange of information and collaboration with physicians, patients/families, and other health professionals.
Professionalism – Demonstrates a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diverse patient populations. Respects and responds appropriately to the needs of patients, families and the health care team.
Systems-Based Practice – Works effectively in various health care delivery settings and coordinates patient care within the health care system relevant to their clinical specialty. Advocates for quality patient care and optimal patient care systems.
Work Flow Efficiency – Timely completion of electronic health records, problem list review and medicine reconciliation. Effectively manages daily schedule to maintain office flow and timely patient visits.
Strengths/Weaknesses:
Print Name:
Phone:
Date: