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 UniversityHospital, 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 the hospital setting? / ____Less than 8 hours a week.
____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 duties/responsibilities which he/she has requested on the attached form. / _____YES _____NO
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
(3) / Commendable (2) / Needs Improvement (1) / N/A

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
(3) / Commendable (2) / Needs Improvement (1) / N/A
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