Multisource feedback
Logo placement area
assessment form (Patient)
Doctor’s information
Doctor’s Name
Gender
Date of Visit
I am
Male
Female
Current Position
Today’s visit was
A new
An onoing
Completion
Routine
mainly for
problem
problem
of forms
checkup
Other:
Please think back to all your previous visits to the doctor named above, and answer the following questions.Please mark (0) ‘Unable to assess’ if you are
unable to answer an item. Your own repliues are confidential. Repliesby mulitple patients will be compiled before feedback is given to the doctor.
Please mark (√) with an ink pen.
This doctor:
1.
disagree
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
0
0
0
0
0
0
The doctor shows interest in my health
problems.
3.
The doctor listens to me.
4.
I understand what this doctor is telling me.
This doctor discusses treatment options with
me.
I can ask the doctor questions and get
6.
7.
I strongly
assess
I am treated with respect.
2.
5.
Unable to
answers.
When this doctor does an examintion, I know
what is going to be done and why.
8.
9.
10.
The doctor deals with my problems carefully.
This doctor’s office has a system for me to
receive care after office hours.
When I need reports, files or letters, this doctor
provides them in a timely manner.
I am given information about preventative
11.
care. (for example, quitting smoking, blood
pressure control, weight control, sleeping,
alcohol, nutrition and exercise).
12.
13.
I believe this doctor is knowledgeable and
skilled in providing proper care.
I would send a friend or family member to this
Global Rating
doctor.
Neutral
I agree
I strongly
agree
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
1
0
2
3
4
5
1
0
1
0
2
3
4
5
2
3
4
5
I disagree
An overall rating of the doctor’s performance and professionalism in all areas.
Below expected level
1
2
3
At expected level
4
5
6
Above expected
level
7
8
9
Multisource feedback
assessment form
Comments
Signature of
patient:
Date:
/
/
Multisource feedback
assessment form
Aim of Multisource feedback assessment1
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.
Notes
If there are further notes for this doctor they may be included
here.
Level of Assessment
It is important to note that the candidate is being rated at the
level of PGY1 (intern) level and should demonstrate
characteristics that are satisfactory at that level.
Assessors
Assessors MUST be familiar with the candidate’s usual
performance in his/her work. If you do not know the
candidate well enough to do this, please return the form to the
provider so that another assessor may be selected.
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