PERFORMANCE APPRAISAL

Nurse Practitioner / Physician Assistant

Employee Name	Evaluator's Name
Date:	Title:

For each area of performance evaluate the level of achievement demonstrated during the past year.

AREAS OF PERFORMANCE	LEVEL OF ACHIEVEMENT
Autonomy and Accountability	5 - Outstanding
Professionalism	4 - Highly Effective
Patient Care Management	3 - Effective
	2 - Improvement Needed
	1 - Unacceptable
	NA- Not Applicable

Areas of Performance		Level of Achievement
A. Autonomy and Accountability
1. Functions within legal framework of the state currently employed.
2. Demonstrates reliability in meeting deadlines and completing responsibilities.
3. Demonstrates responsibility and reliability in meeting scheduled deadlines.
4. Complies with hospital policies and procedures.
5. Displays ability to utilize appropriate channel(s) for communication and/or problem solving.
6. Performs work assignment with minimum need for supervision and guidance.
7. Possesses skills and technical competence to execute work responsibilities.
8. Operates within the established company guidelines
9. Assists with training/education of staff, contributes to an open learning environment.
10. Adheres to Hospital and Company health and safety standards.
	B. Patient Care Management
	11. Completes and documents initial and ongoing assessments as per policy.
	12. Prioritizes treatment based on medical and nursing diagnosis, patient history, and expected patient outcomes.
	13. Completes responsibilities with timeliness, schedules and uses time efficiently.
	14. Functions as a patient advocate assuring patient's right to information, providing patient safety at all times, and maintaining confidentiality.
	15. Utilizes clinical knowledge and skills to assess the needs of patients.
	16. Written communication is clear, legible and objective.
	17. Demonstrates ability to set goals, assign priorities, anticipate problems, establish limits and achieve quality results.
	18. Develops comprehensive plan of Treatment for assigned panel of patients based on patient needs, standards of care, clinical knowledge and expected patient outcomes.

Areas of Performance	Level of Achievement
C. Professionalism
19. Promotes good public relations for CCMS and the Hospital.
20. Establishes and maintains therapeutic and supportive relationship.
21. Effectively expresses self. Listens attentively and creates a climate of open communication. Respects confidentiality and privacy.
22. Accepts constructive comments from hospital/contracting company as a mechanism for improvement.
23. Functions as an integral part of the health care delivery team and participates in the maintenance of a cohesive work environment.
24. Maintains credentials and education files as per JCAHO standards and Department of Health Regulations.
25. Communicates accurately/appropriately with patients, family and other personnel.
26. Reports to work in a timely manner.

GOALS AND COMMENTS:

Signature of Nurse Practitioner: Date

Signature of Clinical Director: Date

Signature of CCMS Manager: Date