Sample Performance Appraisal Form for Doctors Pdf

PHYSICIAN PERFORMANCE APPRAISAL AND COMPETENCY REVIEW

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I. GENERAL INFORMATION

Appraisee Name: [___________________________]
Employee ID/License #: [___________________________]
Department/Specialty: [___________________________]
Review Period: From [____/____/____] To [____/____/____]
Appraiser Name: [___________________________]
Appraiser Title: [___________________________]
Date of Review Meeting: [____/____/____]

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II. CLINICAL COMPETENCY & PATIENT CARE

Rate the physician’s clinical performance using the scale: 1 (Unsatisfactory), 2 (Needs Improvement), 3 (Meets Expectations), 4 (Exceeds Expectations), 5 (Outstanding).

1. Diagnostic Accuracy & Clinical Judgment: [___]
2. Quality of Procedural Skills (if applicable): [___]
3. Adherence to Evidence-Based Clinical Guidelines: [___]
4. Timeliness and Completeness of Medical Documentation: [___]
5. Patient Safety Protocols and Risk Management: [___]

Comments on Clinical Performance:
[__________________________________________________________________________]

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III. PROFESSIONALISM & INTERPERSONAL COMMUNICATION

1. Communication with Patients and Families: [___]
2. Collaboration with Multidisciplinary Healthcare Team: [___]
3. Ethics, Integrity, and Professional Conduct: [___]
4. Responsiveness to Consult Requests/On-Call Obligations: [___]

Comments on Professionalism:
[__________________________________________________________________________]

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IV. ADMINISTRATIVE & OPERATIONAL METRICS

1. Compliance with Billing and Coding Standards: [___]
2. Participation in Quality Improvement (QI) Initiatives: [___]
3. Attendance at Mandatory Departmental/Staff Meetings: [___]
4. Efficient Use of Healthcare Resources/Cost-Effectiveness: [___]

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V. GOALS & DEVELOPMENTAL PLAN

Key Achievements during this period:
[__________________________________________________________________________]

Performance Goals for Next Period:

1. [________________________________________________________________________]
2. [________________________________________________________________________]

Required Training/CME Requirements:
[__________________________________________________________________________]

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VI. OVERALL PERFORMANCE RATING

Overall Rating: [___]

Summary/Appraiser Remarks:
[__________________________________________________________________________]

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VII. ACKNOWLEDGEMENT AND SIGNATURES

The signature of the physician below indicates that this appraisal has been discussed with them. It does not necessarily imply agreement with the contents of the appraisal. The physician has the right to provide a written response to be attached to this document.

Appraiser Signature: ___________________________ Date: [____/____/____]

Appraisee Signature: ___________________________ Date: [____/____/____]

Medical Director/HR Representative: ___________________________ Date: [____/____/____]

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CONFIDENTIAL: This document contains privileged information and is intended for the internal use of the Human Resources Department and the Medical Board only.