360 Degree Evaluation v1 - Model
Print Form
Name of reviewer
Hospital
Title
Address
360 Degree
City, State, Zip code
Evaluation for:
Please print full name
of physician being
reviewed
Please rate the above-named
PERFORMANCE RATINGS
physician on the six general
competencies as identified by the
The following guidelines are to be used in selecting the appropriate rating:
Accreditation Council for Graduate
Medical Education (ACGME) and
1
2
3
4
5
6
the American Board of Medical
Never
Rarely
Occasionally
Frequently Always Not Applicable
Specialties (ABMS).
Patient Care
1
2
3
4
5
6
Implements the highest standards of practice in the effective and timely treatment of all patients regardless
of gender, ethnicity, location, or socioeconomic status.
Medical Knowledge
1
2
3
4
5
6
Keeps current with research and medical knowledge in order to provide evidence-based care.
Interpersonal and
1
2
3
4
5
6
Communication Skills
Works vigorously and efficiently with all involved parties as patient advocate and/or consultant.
Practice-based Learning
1
2
3
4
5
6
and Improvement
Assesses medical knowledge and new technology and implements best practices in clinical setting.
Professionalism
1
2
3
4
5
6
Displays personal characteristics consistent with high moral and ethical behavior.
Systems-based Practice
1
2
3
4
5
6
Efficiently utilizes health-care resources and community systems of care in the treatment of patients.
Please Return Completed Form To Physician For His/Her Confidential Records - Do Not Send to the ABPN
American Board of Psychiatry and Neurology, Inc., 2150 E. Lake Cook Road, Suite 900, Buffalo Grove, IL 60089
Ph: 847.229.6500 Fax: 847.229.6600