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Sample year-to-date medical encounter report. This is included to show an example of how encounter reports can be written.
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Sample forms to help calculate provider productivity incentives.
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A sample written provider productivity incentive plan.
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Sample provider contract.
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Sample provider contract with a physician.
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Staff member must be able to demonstrate the knowledge and skill necessary to provide care based on physical, psychosocial, educational, safety and related criteria appropriate to the age of the patients served in their assigned area. Validation to be completed by a co-worker with minimum of equivalent licensure, physician and/or manager/supervisor. Person validating must initial, date and indicate method of validation in appropriate column and sign form.

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Staff member must be able to demonstrate the knowledge and skill necessary to provide care based on physical, psychosocial, educational, safety and related criteria appropriate to the age of the patients served in their assigned area. Validation to be completed by a co-worker with minimum of equivalent licensure, physician and/or manager/supervisor. Person validating must initial, date and indicate method of validation in appropriate column and sign form.
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Member must be able to demonstrate the knowledge and skill necessary to provide care based on physical, psychosocial, educational, safety and related criteria appropriate to the age of the patients served in their assigned area. Your validation needs to be completed by a co-worker with minimum of equivalent licensure and/or physician. Person validating must initial, date and indicate method of validation in appropriate column and sign form.
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Tool that can be used to evaulate support staff (RN, LPN, MA) competencies in key areas.
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Comprehensive evaluation of staff nurse competencies.
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Guidelines/Evaluation for Medical Interpreters
Form to evaluate lab proficiency testing competencies during training.
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Form for use in evaluating testing personnel competencies.
A third example of a checklist to determine provider competencies at all age levels.
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Another example of a checklist to determine provider competencies at all age levels.
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Checklist to determine provider competencies at all age levels.
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Competency Development Additional Considerations
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Sample credentialing policy (see Human Resources for other credentailing resources).
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Checklist of delineation of privileges for OB/GYN care for applicants or new hires.
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Checklist of clinical social worker privileges for use with any applicants or new hires.
Checklist of registered dietician privileges for use with any applicants or new hires.
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Comprehensive Health Center guidelines for privileging, credentialing and appointments.
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Health Center credentialing and priviliging policy statement.
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Sample policy on employee TB skin testing.
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Outline of scope of medical practice guidelines.
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The intent of this privilege list is to aid in evaluating the abilities and training of applicants and as a general guide to the level of functioning of that provider.
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The initial credentialing process must include primary source verification of graduation from an accredited professional school and residency training program and a query of the National Practitioner Data Bank. This outlines the policy and provides a release of information form.
Checklist of requirements for any practitioner reappointment. Recommended that it be filled out every two years following initial appointment.
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Checklist that outlines requirements for any physician’s initial appointment to the health center.
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Checklist of Delineation of Privileges in Family Practice Ambulatory Care for applicants or new hires.