Surgical or Procedural Proctoring Report Form
CONFIDENTIAL for the file of ___________________________________________________________ MD / DO / Other Date : ______________________ Medical record #: _________________________________________ Procedure / Exam : ____________________________________________________________________ Proctor ’ s name printed with title / position :________________________________________ Proctor ’ s specialty :_________________________________________________________
� Concurrent / direct observation Knowledge / skill
� Retrospective / chart review
Performance 1 . Was the practitioner on time ? Yes No N / A 2 . Was pre-op exam consistent with chief complaint ? Yes No N / A 3 . Were consent and options discussed with the patient ? Yes No N / A 4 . Were potential risks explained to the patient ? Yes No N / A 5 . Was documentation appropriate , legible , and timely ? Yes No N / A 6 . Was there adequate evidence to support the admission ? Yes No N / A 7 . Were technical skill and clinical knowledge adequate ? Yes No N / A 8 . Was clinical judgment appropriate ? Yes No N / A 9 . Were there any complications ? ( specify below ) Yes No N / A 10 . Were complications recognized and managed appropriately ? Yes No N / A 11 . Was the practitioner able to manage multiple , complex problems simultaneously ? Yes No N / A 12 . Were consults obtained promptly if needed ? Yes No N / A 13 . Were ancillary services appropriately utilized ? Yes No N / A 14 . Was the plan of care appropriate to the diagnosis ? Yes No N / A 15 . Was drug use appropriate ? Yes No N / A 16 . Was conduct appropriate ? Yes No N / A Overall rating of practitioner ’ s skill and competence in performing this procedure ( circle one ).
1 = No concerns 2 = Some concerns ( provide details below ) 3 = Significant concerns ( provide details below and refer to clinical service chief immediately )
Comments :__________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Proctor Signature ____________________________________
Date : ___________________________