Biographical sketch, kathy matzka, cpmsm, cpcs



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Peer Recommendations


A peer recommendation is a statement provided in support of an applicant’s request for appointment/ reappointment and/or privileges by a practitioner in the same professional discipline as the applicant. Peer recommendations are typically obtained from prior training program directors, department chairs, chiefs of staff, or others familiar with the applicant’s professional history and current clinical competence. Friends, neighbors, and relatives are not appropriate sources for peer recommendations. Peer recommendations should include reference to the applicant’s competence and ability to perform the privileges requested.
Peer recommendations should address the practitioner’s relevant training and experience, current competence, and any effects of health status on privileges being requested.Sample Peer Recommendation Letter
Date
Facility Name

Facility Address

Regarding applicant: John Doe, M.D.

Specialty: General Surgery


Dear ______________:
We have received an application from the above-named provider for medical staff appointment and privileges. A copy of the privileges requested is attached. The applicant has listed you as a peer who will be willing to provide a recommendation. In order to process the application we require your evaluation of the applicant’s experience, ability, and current competence in the areas of medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism.
Our policies require completion of the enclosed form. Failure to receive this form will delay consideration of the applicant’s request for privileges. You may supplement the form with additional information, if you so desire. The applicant has authorized you to provide this information to our organization via signature on the attached Authorization and Release Form.

Sincerely,

Medical Staff Coordinator

Sample Peer Recommendation Form

CONFIDENTIAL Professional Peer Reference & Competency Validation

Page 1 of 2


Name of Applicant:________________________________________________________________________________

Name of Evaluator:____________________________________ Relationship to Applicant:________________________


How well do you know the applicant?  not well  casual personal acquaintance  professional acquaintance  very well
Do you refer your patients to the applicant?  yes  no. If no, list reason(s) why not ___________________________________

_________________________________________________________________________________________________________


PLEASE RATE THE PRACTITIONER IN THE FOLLOWING AREAS





Excellent

Good

Fair

Poor

Unable to

evaluate

Medical knowledge - Practitioner should have a good knowledge of established and evolving biomedical, clinical, and cognate sciences, and how to apply this knowledge to patient care. This is evidenced by completion of educational and training requirements as well as on-the-job experience, inservice training, and continuing education.
















Technical and clinical skills - Skill involves the capacity to perform specific privileges/procedures. It is based on both knowledge and the ability to apply the knowledge.
















Clinical judgment - Clinical judgment refers to the observations, perceptions, impressions, recollections, intuitions, beliefs, feelings, inferences of providers. These clinical judgments are used to reach decisions, individually and/or collectively with other providers, about a patient’s diagnosis and treatment.
















Communication skills - The provider should create and sustain a therapeutic and ethically sound relationship with other care givers, patients, and their families. He/she should be able to communicate effectively and demonstrates caring, compassionate, and respectful behavior. This also includes effective listening skills, effective nonverbal communication, eliciting/providing information, and good writing skills
















Interpersonal skills - Areas of evaluation include how the provider works effectively with other professional associates, including those from other disciplines, to provide patient-focused care as a member of a healthcare team.
















Professionalism - Professionalism is demonstrated by respect, compassion, and integrity. It means being responsive and accountable to the needs of the patient, society, and the profession. It means being committed to providing high-quality patient care and continuous professional development as well as being ethical in issues related to clinical care, patient confidentiality, informed consent, and business practices.
















CONFIDENTIAL Professional Peer Reference & Competency Validation

Page 2 of 2
Name of Applicant:__________________________________________________________________________

Name of Evaluator:________________________________________________________________________________


Relevant training and experience – In reviewing the attached request for privileges, do you feel that the applicant’s training and experience are adequate to carry out these procedures?
 No - If no, please provide an explanation_______________________________________________________________

 Yes


 Unable to evaluate

Current competence – In reviewing the attached request for privileges, do you feel that the applicant is currently competent to carry out these procedures?
 No - If no, please provide an explanation_______________________________________________________________

 Yes


 Unable to evaluate
Health Status - Are you aware of any physical or mental condition that could affect this practitioner’s ability to exercise clinical privileges in his/her specialty area, or would require an accommodation to exercise those privileges safely and competently?
 No

 Yes - If yes, please provide an explanation_______________________________________________________________

 Unable to evaluate

_________________________________________________________________________________________________


Overall Recommendation (check ONE):
 I recommend privileges as requested without reservation.
 I recommend privileges as requested with the following reservation(s) (use back of form, if necessary

_______________________________________________________________________________________________

_________________________________________________________________________________________________

 I do not recommend this applicant for the following reason(s) ___________________________________________

_______________________________________________________________________________________________

_________________________________________________________________________________________________


_______________________________________ _____________________________

Signature Date

_______________________________________ _____________________________

Name, Position/Title (Please Print) Phone Number


Please return this form within 2 weeks. Failure to receive the form will delay consideration of the applicant’s request for privileges.

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