360 Evaluation forms from Firelands Regional Medical Center, Sandusky, OH:
Evaluation of Resident Physician by Nursing Staff
Evaluation of Resident Physician by Non-Clinical Support Staff
Evaluation of Resident Physician by Resident Physician
Self-Evaluation of Resident Physician
======================================================================================================
____________________ MEDICAL CENTER FAMILY PRACTICE CLINIC
The staff at FRMC Family Practice Clinic is dedicated to delivering care of the highest quality to you. As a valued patient, we respect your opinion on how well we are delivering that care. We would like you to take a few moments to share your opinion with us on how your care today with Dr. ___________ met your needs. This survey is anonymous and your name will not be noted on this document. Please leave this form with your nurse before you leave the exam room or with the staff at the front desk. Thank you for helping us to identify ways that we can better serve you!
1. Do you feel that talking with the doctor today helped you to
develop an effective doctor-patient relationship? (think
about whether or not the doctor seemed interested in hearing
your needs and getting to know you personally.) (IS-3) Yes_____ No______
2. Do you feel that the doctor really understood and addressed the
main purpose of your visit today? (CA-1) Yes_____ No______
3. Did you understand the doctor’s explanations? Were your
questions answered in words and terms that you could
understand? (CA-5) Yes_____ No______
4. Did the doctor explain the methods and plan for evaluating
your problem and your role in that plan? (CA-7) Yes_____ No______
5. If additional tests were ordered today, do you understand
what the tests are and why the doctor feels that they are
needed? (CA-2) (CA-6) Yes_____ No______
6. Do you feel that your doctor considered your cultural,
family and/or financial issues when the tests, visits or
consultations were ordered? (CA-6) Yes_____ No______
7. As a partner with your doctor in health care decisions, do
you understand the need for the tests, visits or
consultations? (CA-6) Yes_____ No______
8. If you received prescriptions, do you understand what the
medicine is for, how and when to take it,
and anyth
problems
that you should report to your doctor? (CA-7) Yes_____ No______
9. Do you understand the details of your plan of care and
follow-up? (CA-10) Yes_____ No______
10. Do you agree with the plans that you and your doctor have
discussed? (CA-10) Yes_____ No______
11. Have you been informed on how to obtain test results in a
timely manner? (CA-10) Yes_____ No______
=========================================================================
Evaluation of Resident Physician by Nursing Staff
Resident __________________. Month _______ Year _________
Scoring: 5=always 4=most of the time 3=occasionally 2=rarely 1=never N/A=no opinion or not applicable
1) 1) This resident responds to telephone encounters (ROD duties, patient calls, refills) promptly and courteously.
5 4 3 2 1 N/A
2) This resident responds to pages in a timely manner.
5 4 3 2 1 N/A
3) This resident is present in clinic and prepared to begin seeing patients on time.
5 4 3 2 1 N/A
4) When problems arise, this resident is easy to contact and responsive to your questions or concerns.
5 4 3 2 1 N/A
5) This resident is courteous and respectful of you and your opinions or suggestions.
5 4 3 2 1 N/A
6) This resident fosters an atmosphere of teamwork and collegiality.
5 4 3 2 1 N/A
7) This resident is approachable and easy to share problems with.
5 4 3 2 1 N/A
8) This resident is a positive role model for other residents/interns/students, and presents the residency program and
FRMC in the best possible way.
5 4 3 2 1 N/A
9) This resident’s behavior is positive and he/she does not tend to be moody or complain.
5 4 3 2 1 N/A
10) This resident is flexible in working in acute visits.
5 4 3 2 1 N/A
11) This resident gives you clear instructions regarding follow-up appointments, lab, x-ray,
or referrals after the patient encounter is complete.
5 4 3 2 1 N/A
**Additional comments are encouraged and may be written below or on the reverse side.
======================================================================
Evaluation of Resident Physician by Non-Clinical Support Staff
Resident _______________ Month _________ Year _________
Scoring: 5=always 4=most of the time 3=occasionally 2=rarely 1=never N/A=no opinion or not applicable
1. When problems arise, this resident is easy to contact and is responsive to your questions or concerns.
5 4 3 2 1 N/A
2. This resident is courteous and respectful of you and your opinions or suggestions.
5 4 3 2 1 N/A
3. This resident fosters an atmosphere of teamwork and collegiality.
5 4 3 2 1 N/A
4. This resident is approachable and easy to share problems with.
5 4 3 2 1 N/A
5. This resident is a positive role model for other residents/interns/students, and presents the residency program and
FRMC Hospital in the best possible way.
5 4 3 2 1 N/A
6. This resident’s behavior is positive and he/she does not tend to be moody or complain.
5 4 3 2 1 N/A
7. This resident is flexible and able to adapt easily to changes in routine.
5 4 3 2 1 N/A
8. This resident allows sufficient latitude for you to manage his/her schedule and does not
try to maintain excessive control. (for desk/schedulers only)
5 4 3 2 1 N/A
9. This resident gives you clear instructions regarding follow-up appointments, lab, x-ray,
or referrals after the patient encounter is complete.
5 4 3 2 1 N/A
10. This resident is flexible in working in acute visits.
5 4 3 2 1 N/A
**Additional comments are encouraged and may be written below or on the reverse side.
=========================================================================
Evaluation of Resident Physician by Resident Physician
Resident Physician (being evaluated) ____________ Month ___________ Year _____
Scoring: 5=always 4=most of the time 3=occasionally 2=rarely 1=never N/A=no opinion or not applicable
1. 1) This resident is flexible in working in acute visits or transferring patients to their schedule if other providers have conflicts or illness.
5 4 3 2 1 N/A
2. 2) When problems arise, this resident is easy to contact and responsive to your questions or concerns.
5 4 3 2 1 N/A
3. 3) This resident is courteous and respectful of you and your opinions or suggestions.
5 4 3 2 1 N/A
4. 4) This resident fosters an atmosphere of teamwork and collegiality.
5 4 3 2 1 N/A
5. 5) This resident is approachable and easy to share problems with.
5 4 3 2 1 N/A
6. 6) This resident is a positive physician role model, and presents the residency program and
FRMC in the best possible way.
5 4 3 2 1 N/A
7. 7) This resident’s behavior is positive and he/she does not tend to be moody or complain.
5 4 3 2 1 N/A
8) This resident is flexible and able to adapt easily to changes in routine.
5 4 3 2 1 N/A
9) This resident’s chart documentation is concise yet thorough and easy to read.
5 4 3 2 1 N/A
10) This resident demonstrates dedication to and an aptitude for teaching colleagues, students and staff.
5 4 3 2 1 N/A
11) This resident is dedicated to osteopathic concepts and philosophy and demonstrates an aptitude for OMM.
5 4 3 2 1 N/A
**Additional comments are encouraged and may be written below or on the back of this form
============================================================
Self-Evaluation of Resident Physician
Resident Physician (being evaluated)_ ________________ Month ____________ Year ____
Scoring: 5=always 4=most of the time 3=occasionally 2=rarely 1=never N/A=no opinion or not applicable
1. 1) I am flexible in working in acute visits or transferring patients to their schedule if other providers have conflicts or illness.
5 4 3 2 1 N/A
2. 2) When problems arise, I am easy to contact and responsive to questions or concerns.
5 4 3 2 1 N/A
3. 3) I am courteous and respectful of others opinions or suggestions.
5 4 3 2 1 N/A
4. 4) I foster an atmosphere of teamwork and collegiality.
5 4 3 2 1 N/A
5. 5) I am approachable and easy to share problems with.
5 4 3 2 1 N/A
6. 6) I am a positive physician role model, and I present the residency program and
FRMC in the best possible way.
5 4 3 2 1 N/A
7. 7) My behavior is positive and I do not tend to be moody or complain.
5 4 3 2 1 N/A
8) I am flexible and able to adapt easily to changes in routine.
5 4 3 2 1 N/A
9) My chart documentation is concise yet thorough and easy to read.
5 4 3 2 1 N/A
10) I demonstrate dedication to and an aptitude for teaching colleagues, students and staff.
5 4 3 2 1 N/A
11) I am dedicated to osteopathic concepts and philosophy and I demonstrate an aptitude for OMM.
5 4 3 2 1 N/A
**Additional comments are encouraged and may be written below or on the back of this form