Non-Physician Surgical First Assist Proctoring Form Name of Non-Physician Surgical First Assist : _____________________________________________________ Name of Supervising Physician : ____________________________________________________________
No Concerns
Concerns Comments / Recommendations
I . Patient Care Appropriate Care
II . Medical Knowledge Adequate Knowledge demonstrated
III . Practice-Based Learning Evidence of use of resources and guidelines
IV . Communication & Interpersonal Skills Good reports ( peers , residents , patients , staff )
V . Professionalism Available , responsive to ER Courteous , appropriate , pleasant demeanor Respected by patients and staff
Patient Care
� Demonstrates caring and respectful behavior when interacting with patients and families . � Gathers essential and accurate patient information . � Performs and dictates the H & P and discharge summary in a timely and accurate manner . � Works collaboratively in a team atmosphere . � Maintains clinical knowledge and skills . � Demonstrates proficient and appropriate use of procedural skills , both diagnostic and therapeutic . � Adheres to medical staff policies and procedures .
No Concerns
Concerns / explanation : ___________________________________________________________________________________________ ___________________________________________________________________________________________
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Review Form Revision : 11 / 20 / 2019 MM Page 3 of 5