Multi-source Feedback (MSF) Assessment Form

Please complete the question using a cross (x). Please use black ink and CAPITAL LETTERS

Trainee’s surname
Trainee’s forename(s)
GMC number / GMC NUMBER MUST BE COMPLETED
Observed by / Role
Signature
GMC/NMC/HPC number / GMC/NMC/HPC NUMBER MUST BE COMPLETED
Date

Which clinical setting have you primarily observed the doctor in?

Theatre ICU A&E Delivery Suite Pain Clinic Other

How do you rate this doctor in their: / Good / Satisfactory / Needs to improve / Unacceptable / Unable to comment
Knowledge, skills, performance
  1. Ability to diagnose patient problems

  1. Ability to plan patient care

  1. Awareness of their own limitations

  1. Ability to keep up to date with knowledge and skills

  1. Responds to pain and distress in patients appropriately

  1. Technical skills [appropriate to grade]

  1. Ability to multitask and work effectively in a complex environment

  1. Ability to manage time effectively/prioritise

  1. Able to cope under stress

  1. Willingness and effectiveness when teaching/training colleagues

  1. Ability to take leadership role when circumstances required

  1. Keeps clear, accurate, legible records contemporaneously

Safety and quality
  1. Contributes constructively to audit, appraisal and clinical governance

  1. Safeguards and protects patients wellbeing

  1. Responds promptly to risks posed by patients

Communication, partnership and teamwork
  1. Communication with patients

  1. Communication with carers and/or family

  1. Verbal communication with colleagues

  1. Written communication with colleagues

  1. Ability to recognise and value the contribution of others

  1. Accessibility/reliability

Maintaining trust
  1. Respect for patients privacy, right for confidentiality

  1. Polite, considerate and honest to patients

  1. Treats patients fairly and without discrimination

  1. Treats colleagues fairly and without discrimination

  1. Honest and objective when appraising and assessing colleagues

Are there any concerns about this doctor’s probity or health? Yes No
If yes, please provide details
Please add any additional comments
If any boxes were marked with minor or major concerns, please explain why
Signature / Date

Royal College of Anaesthetists

Churchill House, 35 Red Lion Square, London WC1R 4SG

Tel 020 7092 1500 Email Website

Twitter @RCoANews | Find us on FacebookPage 1 of 3