Physician Reference/Evaluation Form
Medical Staff Services
Physician Reference/Evaluation Form
The following is being submitted in response to your request for information on the applicant named below. This reference was completed for the provider at the time of his/her resignation. We are not able to speak to current information on this provider. A copy of the applicant’s privileges at the time of resignation is attached.
Name of Applicant:
Dates of AffiliationPrivileges:
Staff Category:Department/Specialty:
Photograph Attached: Yes No Photo not available
How long have you known the applicant? ______
In what capacity have you known the applicant? ______
EVALUATION
This evaluation should be based on demonstrated performance compared to that reasonably expected of a physician with a similar level of training, experience, and background as this one. Please rate the applicant in the following areas by circling the appropriate number (1- unable to evaluate, 2- Poor, 3- Fair, 4 -Good, 5- Excellent”):
Patient Care is compassionate, appropriate and effective for treatment of health problems and the promotion of health.- Patient Management
- Medical Record Currency
- Quality of Medical Records
- Legibility
Medical Knowledge about established and evolving biomedical, clinical and cognitive, e.g. epidemiological and social-behavior sciences and the application of this knowledge to patient care
- Clinical Competence
- Technical Skill
Practiced Based Learning and Improvement that involves investigation and evaluation of their patient care, appraisal and assimilation of scientific evidence and improvement in patient care. / 1 / 2 / 3 / 4 / 5
Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families and other health professionals.
- Ability to understand, speak and write English
- Ability to understand, speak, and write other languages
(1- unable to evaluate, 2- Poor, 3- Fair, 4 -Good, 5- Excellent”):
Professionalism as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population- Cooperativeness, Ability to Work with Others
- Relationship with Nursing Staff
- Sense of Responsibility
Systems Based Practice as manifested by action that demonstrate an awareness of and responsiveness to the larger context and system of healthcare and the ability to effectively call on system resources to provide care that is of optimal value
- Participation in Medical Staff activities
- Cooperation with Medical Staff and Hospital Requirements
ACTIONS TAKEN
If answer is “yes” to any of the following in this section, please give details on a separate sheet.
During the time on Medical Staff at ______was this physician ever investigated or subject to any disciplinary action such as imposition of consultation requirements, suspension, or termination? / Yes / NoTo your knowledge, has the physician ever been investigated by any governmental or other legal body? / Yes / No
At the time the physician left your institution, were any actions instituted, in process, or pending? / Yes / No
CONDUCT
Does the physician relate to hospital employees, patients and other physicians in a courteous and professional manner? / Yes / NoHEALTH
Does the applicant have a physical or mental condition which could affect his/her ability to exercise the clinical privileges requested, or would require an accommodation in order for the applicant to safely and competently exercise the privileges requested? (If answer is “yes” please give details on a separate sheet) / Yes / NoHas the physician ever shown signs of any behavior, drug or alcohol problems? / Yes / No
GENERAL IMPRESSION
Please describe your general impression of the applicant.
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Printed NamePosition
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SignatureDate form was completed