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Proctor Evaluation
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Medical Staff Services
Proctor Evaluation
Proctor's Full Name (Physician)
Full Name (Proctoree)
Date
Age of Patient
Medical Record Number
Admitting Diagnosis or Complaint
Procedure Performed
Discharge Diagnosis
Proctor's Appraisal - Please Check the Appropriate Number
Necessity for Admission/Procedure
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
History
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Physical Examination
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Use of Laboratory Studies
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Use of Imaging Studies
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Use of Drug Therapy
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Follow-Up Care
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Level of Care
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Consultations
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Progress Notes
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Complications
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Pre-Procedure/Work-Up
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Procedure Judgment
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Procedure Technique
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Knowledge of Procedure
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Results of Procedure
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Procedure Time
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
Overall Quality of Care
1 - Reviewed care/outcome was expected and acceptable.
2 - Reviewed care/outcome not necessarily routine, but not totally unexpected.
3 - Reviewed care/outcome unexpected.
4 - Reviewed care/outcome very unexpected.
5 - Unable to evaluate.
General Comments
By checking this box, I acknowledge that I am electronically signing this document.
Email Address (Proctoree)
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