1. Patient Care Unsatisfactory
Less than
Satisfactory
Satisfactory
More than
Satisfactory
Excellent Unable to
Assess
Ensures patients are treated equally
and in an efficient manner.
1
Appointments
are late and
patients receive
unequal care.
2 3
Meets
Expectations
4 5
Appointments
are on time
and patients
receive equal
care.
Examines and diagnoses patients
by following appropriate medical
policy and procedures.
1
Does not follow
proper
procedures when
diagnosing
patients.
2 3
Meets
Expectations
4 5
Follows
proper
procedure
when
diagnosing
patients.
Prescribes appropriate medications.
1
Never prescribes
correct
medication
2 3
Meets
Expectations
4 5
Always
prescribes
correct
medication
Communicates concerns and
questions with other doctors.
1
Does not initiate
conversation to
address concerns
and questions.
2 3
Meets
Expectations
4 5
Initiates
conversation
in person or
via email to
address
concerns and
questions.
Provides appropriate referrals for
patients in need of specific
procedures
1
Does not provide
names of other
doctors that
could help the
patient’s need.
2 3
Meets
Expectations
4 5
Takes time to
list various
doctors that
can help the
patient’s need.
Part II: Major Work Responsibilities/Behaviors

2. Comments:____________________________________________________________________
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Comments:____________________________________________________________________
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Ensures confidentiality with all
patients.
1
Does not keep
visit notes and
documentation
private.
2 3
Meets
Expectations
4 5
Keeps all visit
notes and
documentation
private.
Uses proper sanitation procedures.
1
Does not wash
hands before and
after touching
the patient.
2 3
Meets
Expectations
4 5
Washes hands
before and
after touching
the patient.

3. Comments:____________________________________________________________________
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OutsourcedResponsibilities Unsatisfactory
Less than
Satisfactory
Satisfactory
More than
Satisfactory
Excellent Unable to
Assess
Performs on call duties once a
month (or as needed).
1
Is not available
to come into
work for extra
shifts.
2 3
Meets
Expectations
4 5
Is available to
come into
work for extra
shifts.
Maintains availability to be
reached by nurses and patients to
assess emergency symptoms.
1
Does not keep
open
communication
for emergency
situations.
2 3
Meets
Expectations
4 5
Keeps open
communication
through email
and phone calls
for emergency
situations.
Completes in-person rounds to
patients to ensure proper hospital
care.
1
Does not
personally make
sure all patients
are being
properly cared
for.
2 3
Meets
Expectations
4 5
Personally
makes sure that
all patients are
being properly
cared for.

4. Comments:____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Administrative Behaviors Unsatisfactory
Less than
Satisfactory
Satisfactory
More than
Satisfactory
Excellent Unable to
Assess
Updates all information in the EMR
system.
1
Never inputs all
relevant
information into
the system.
2 3
Meets
Expectations
4 5
Consistently
inputs all
relevant
information
into the
system.
Completes detailed patient notes,
specifying dates and times of
treatment/incidents.
1
Never includes
specific details
of each visit.
2 3
Meets
Expectations
4 5
Always
includes
specific
details of each
visit.
Communicates with other doctors
and professionals to ensure all
components of patient care are
accounted for.
1
Never informs
and
communicates
with other
doctors
regarding patient
treatment.
2 3
Meets
Expectations
4 5
Consistently
informs and
communicates
with other
doctors
regarding
patient
treatment.
Makes sure all paperwork is
completed before leaving work
each day.
1
Never completes
patient
paperwork
before leaving
the office.
2 3
Meets
Expectations
4 5
Always
completes
patient
paperwork
before leaving
the office.
Behaviors/Capabilities Unsatisfactory
Less than
Satisfactory
Satisfactory
More than
Satisfactory
Excellent Unable to
Assess
Has a strong knowledge of
medicine and medical terminology.
1
Does not know
or utilize a
proper
knowledge of
medicine or
medical
terminology.
2 3
Meets
Expectations
4 5
Knows and
utilizes their
knowledge of
medicine and
medical
terminology.
Is up-to-date on all
pharmaceuticals and their
appropriate uses.
1
Is unaware of
new
pharmaceuticals
and their uses.
2
3
Meets
Expectations
4 5
Knows all of
the new
pharmaceuticals
and their uses.
Maintains a strong attention to
detail.
1
Does not take
notes, ask
questions, or
listen to patients’
signs and
symptoms.
2 3
Meets
Expectations
4 5
Takes detailed
notes, asks
important
questions, and
listens carefully
to patients'
signs and
symptoms.
Is dependable and accountable to
others.
1
Is not on time for
work or
appointments,
does not
complete tasks
thoroughly.
2 3
Meets
Expectations
4 5
Is on time to
work, for
appointments,
and completes
all tasks
thoroughly.
Works well and cooperates with
other employees and patients.
1
Does not display
an agreeable
demeanor.
2 3
Meets
Expectations
4 5
Displays an
agreeable
demeanor.
Has well-developed problem
solving skills.
1
Does not analyze
all information
and options
before making
decisions.
2 3
Meets
Expectations
4 5
Makes
decisions after
analyzing all
information and
options.
Makes decisive judgments when
necessary without additional input
from others.
1
Cannot make
well informed
decisions on
their own.
2 3
Meets
Expectations
4 5
Can make well
informed
decisions on
their own.

5. ______________________________________________________________________________
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Part III: Developmental Plan
3 Areas of Strength:
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
3 Areas for Improvement:
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
Comments:____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

6. ______________________________________________________________________________
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Evaluator’s Signature:____________________________________ Date:___________________
Physician’s Signature:____________________________________ Date:___________________
Performance Goals from Last Year:
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
Performance Goals Attained Over Last Year:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Performance Goals for This Year:
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________