Certified Performance Evaluation For Physician Assistant Form - 1999
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1PHYSICIAN ASSISTANT - CERTIFIED
PERFORMANCE EVALUATION
PA-C______________________________
Collaborating Physician________________________
Location___________________________
Date of Evaluation________________________
Instructions:
State law requires that collaborating physicians conduct periodic performance assessments and evaluations of the
physician assistants with whom they maintain collaborative agreements. Please observe and evaluate the knowledge, skills, and
performance of the physician assistant. Utilize this form to initiate discussion with the physician assistant and maintain a copy in your
records which are subject to audit by the State Medical Board.
RATING SCALE:
5 - Outstanding
4 - Very good
3 - Average
2 - Marginal
1 - Unsatisfactory
____
Medical Knowledge
____
Relationships with Patients
____
Clinical Skills
____
Relationships with Colleagues
____
Problem Solving/Case Management Skills
____
Ability to Accept/Execute Responsibility
____
Medical Records
____
Professional Behavior
____
Clinic Record keeping
____
Communications/Cooperation
____
Clinical Judgement
____
Attitudes (toward work, patients, staff)
OVERALL RATING:
_______
SUMMARY COMMENTS:
Personal Attitudes and Work Habits:
_________________________________________________________________
Initiative, Diligence, Follow-through:
_________________________________________________________________
Willingness to Seek/Accept Advice:
_________________________________________________________________
Additional Education/Training:
_________________________________________________________________
Areas for Improvement:
_________________________________________________________________
STRENGTHS ____________________________________________________________________________________
____________________________________________________________________________________
WEAKNESSES ____________________________________________________________________________________
____________________________________________________________________________________
SPECIAL INTERESTS OF THE PA:
_________________________________________________________________
FUTURE PLAN FOR CONTINUING EDUCATION/DEVELOPMENT:
_________________________________________________________________________________________________
Date of Evaluation________________
_____________________________________________
Signature of Evaluator Physician
08-4348 (12/99)
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