Doctor’s Name / Gender I am / / Male / / Female
Date of Visit / Current Position
Today’s visit was mainly for / / A new problem / / An onoing problem / / Completion of forms / / Routine checkup / / Other:
Please think back to all your previous visits to the doctor named above, and answer the following questions.Please mark (0) ‘Unable to assess’ if you are unable to answer an item. Your own repliues are confidential. Repliesby mulitple patients will be compiled before feedback is given to the doctor.
Please mark (√) with an ink pen.
This doctor: / Unable to assess / I strongly disagree / I disagree / Neutral / I agree / I strongly agree
1. / I am treated with respect. / / / / / /
2. / The doctor shows interest in my health problems. / / / / / /
3. / The doctor listens to me. / / / / / /
4. / I understand what this doctor is telling me. / / / / / /
5. / This doctor discusses treatment options with me. / / / / / /
6. / I can ask the doctor questions and get answers. / / / / / /
7. / When this doctor does an examintion, I know what is going to be done and why. / / / / / /
8. / The doctor deals with my problems carefully. / / / / / /
9. / This doctor’s office has a system for me to receive care after office hours. / / / / / /
10. / When I need reports, files or letters, this doctor provides them in a timely manner. / / / / / /
11. / I am given information about preventative care. (for example, quitting smoking, blood pressure control, weight control, sleeping, alcohol, nutrition and exercise). / / / / / /
12. / I believe this doctor is knowledgeable and skilled in providing proper care. / / / / / /
13. / I would send a friend or family member to this doctor. / / / / / /
Global Rating An overall rating of the doctor’s performance and professionalism in all areas.
Below expected level / At expected level / Above expected level
Comments
Signature of patient: / / Date: /
Aim of Multisource feedback assessment[1]
Multisource feedback (MSF) is an assessment which provides evidence on the performance of a candidate from a variety of sources. These sources may include colleagues, other co-workers (nurses, allied health) and patients. Questionnaires completed by each of these groups assess a candidate’s performance over time in contrast to a specific candidate encounter. MSF enables the assessment of proficiencies that underpin safe and effective clinical practice, yet are often difficult to assess including interpersonal and communication skills, teamwork, professionalism, clinical management and teaching abilities.
Level of Assessment
It is important to note that the candidate is being rated at the level of PGY1 (intern) level and should demonstrate characteristics that are satisfactory at that level.
Assessors
Assessors MUST be familiar with the candidate’s usual performance in his/her work. If you do not know the candidate well enough to do this, please return the form to the provider so that another assessor may be selected.
Overall performance
An overall judgement of performance at the expected level (PGY1).
After completing your feedback form please ensure that it is signed. / Notes
If there are further notes for this doctor they may be included here.
[1] Please visit wbaonline.amc.org.au for MSF training video and further information