Initial FPPE_Non-Physician Surgery First Assist Proctoring Form

Non-Physician Surgical First Assist Proctoring Form

Name of Non-Physician Surgical First Assist : _____________________________________________________ Name of Proctor / Mentor : ____________________________________________________________

Medical Knowledge � Demonstrates good investigative and analytical thinking . � Demonstrates knowledge and application of basic sciences .

No Concerns

Concerns / explanation : ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

Practice-Based Learning � Analyzes own practice for needed improvements . � Uses information communication and technology .

No Concerns

Communication & Interpersonal Skills � Accurately conveys relevant information to patients , families , and colleagues . � Respects patient confidentiality , privacy and autonomy . � Listen effectively .

No Concerns

Review Form Revision : 11 / 20 / 2019 MM Page 4 of 5

Initial FPPE_Non-Physician Surgery First Assist Proctoring Form | Page 4