Multisource feedback
Logo placement area
assessment form
Candidate information
Candidate Name
Gender
Date of Assessment
Current Position
Male
Female
Length of time in current position
Please rate yourself on the performance statements according to the following scale. Please use the unable to assess if you have insufficient information to
answer a question. Please mark (√) with an ink pen.
This doctor:
1.
Communicate well with patients.
2.
Reach the correct diagnosis in a timely manner.
3.
Refer patients appropriately.
4.
5.
6.
7.
Provide appropriate information for colleagues
to provide follow-up patient care.
Accept responsibility for care of ongoing issues.
Provide pertinent and timely information about
patients when required.
Make appropriate use of community resources
for patient management (for example public
health, social services, mental health sevices).
8.
9.
Participate in a system to provide care for
patients outside of regular office hours.
Recognise and take action when urgent
intervention is required.
10.
Take responsibility for actions and decisions.
11.
Demonstrate appropriate clinical judgement.
12.
Maintain patient confidentiality.
13.
Work well with colleagues.
14.
15.
16.
17.
Speak respectfully of colleagues in
conversations with patients and co-workers.
Document care appropriately.
Appropriately integrate clinical practice
guidelines into patient care.
Manage stressful situations constructively.
Unable to
I strongly
assess
disagree
0
0
0
0
0
0
0
0
0
0
0
0
I strongly
agree
I disagree
Neutral
I agree
1
0
1
0
1
0
1
0
1
0
1
0
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
0
0
1
0
2
3
4
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
Multisource feedback
assessment form
This doctor:
assess
disagree
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
personal time.
19.
21.
I strongly
Maintain a healthy balance of work and
18.
20.
Unable to
Recognise my own limitations.
Have an organised approach to referral and
consultation.
Provide appropriate care and have the relevant
skills and abilities.
Demonstrate commitment to continuing
22.
professional development.
23.
Provide appropriate continuity of care.
24.
Make an effort for patients requiring extra care.
Practice medicine. (I am unencumbered by
25.
physical and mental health problems and drug,
alcolhol and substance abuse).
Global Rating
Neutral
I agree
1
0
1
0
1
0
1
0
1
0
1
0
1
0
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
1
0
2
3
4
5
An overall rating of your performance and professionalism in all areas.
Below expected level
1
2
3
At expected level
4
5
6
Above expected level
7
8
Comments
Signature of
Candidate:
I strongly
agree
I disagree
Date:
/
/
9
Multisource feedback
assessment form
Aim of Multisource feedback assessment1
Notes
Multisource feedback (MSF) is an assessment which
provides evidence on the performance of a candidate from a
variety of sources. These sources may include colleagues,
other co-workers (nurses, allied health) and patients.
Questionnaires completed by each of these groups assess a
candidate’s performance over time in contrast to a specific
candidate encounter. MSF enables the assessment of
proficiencies that underpin safe and effective clinical
practice, yet are often difficult to assess including
interpersonal and communication skills, teamwork,
professionalism, clinical management and teaching abilities.
If there are further notes they may be included here.
Overall performance
An overall judgement of performance at the expected level
(PGY1).
After completing your feedback form please ensure that
it is signed.
1
Please visit wbaonline.amc.org.au for MSF training video and further information