Multi-source feedback form (FPM CPD) "*" indicates required fields InstagramThis field is for validation purposes and should be left unchanged.Thank you for agreeing to complete this form. The specialist who sent you this form is participating in this voluntary activity as part of the Australian and New Zealand College of Anaesthetists (ANZCA) and the Faculty of Pain Medicine (FPM) Continuing Professional Development (CPD) Program. The purpose of the multi-source feedback is to support the ongoing development of specialists by asking colleagues and co‑workers to identify their strengths and areas for further growth. Your feedback is confidential and all questions are optional. Please provide honest feedback. Anaesthetic Group will summarise the results from individual forms onto a summary sheet. Anaesthetic Group will then provide de-identified, summarised feedback to the specialist pain medicine physician and their Facilitator. Please be assured that you will not be identified. In line with ANZCA and FPM requirements, all individual forms are confidentially destroyed once the summary is complete. We appreciate you taking the time to provide this feedback. STOP! PLEASE DO NOT FILL IN THIS FORM. This form has not been linked to an Anaesthetist. Please ask the Anaesthetist for their special link to complete their form. If you are an Anaesthetist looking to receive your own MsF form - please visit anaestheticgroup.com.au/msf360This Multi-source feedback form is for:*Your rolePlease selectPain medicine colleagueReferring specialistGeneral practitionerTrainee / studentAdministrative staffAllied health colleagueOtherOther (please describe your role)Patient managementProvides effective clinical assessment and plans Consistently Usually Sometimes Never N/A - Not observed Demonstrates proficient technical / procedural skills Consistently Usually Sometimes Never N/A - Not observed Provides clear advice and ongoing management plans Consistently Usually Sometimes Never N/A - Not observed Efficiently manages appointments, procedure lists and ward commitments Consistently Usually Sometimes Never N/A - Not observed Works in a calm and considered manner, even in stressful situations Consistently Usually Sometimes Never N/A - Not observed With regards to patient management, are there any comments you would like to make?Communication and teamworkCommunicates effectively with patients and their family / carers Consistently Usually Sometimes Never N/A - Not observed Communicates effectively with colleagues and other health professionals Consistently Usually Sometimes Never N/A - Not observed Clearly documents assessment and management plans Consistently Usually Sometimes Never N/A - Not observed Provides relevant and clear information to referring doctors and handover for inpatients Consistently Usually Sometimes Never N/A - Not observed Recognises and respects the contribution of other team members Consistently Usually Sometimes Never N/A - Not observed Participates in team aspects of care Consistently Usually Sometimes Never N/A - Not observed Leads the team when circumstances require Consistently Usually Sometimes Never N/A - Not observed With regards to communication and teamwork, are there any comments you would like to make?Advocacy and professional attributesShows respect for patient privacy and dignity Consistently Usually Sometimes Never N/A - Not observed Advocates for management options in the best interests of the patient Consistently Usually Sometimes Never N/A - Not observed Recognises and manages the limits of their experience and expertise Consistently Usually Sometimes Never N/A - Not observed Recognises and manages conflict Consistently Usually Sometimes Never N/A - Not observed Acts in an ethical manner Consistently Usually Sometimes Never N/A - Not observed Shows cultural awareness and sensitivity Consistently Usually Sometimes Never N/A - Not observed Is punctual and reliable Consistently Usually Sometimes Never N/A - Not observed Is contactable and responds when needed Consistently Usually Sometimes Never N/A - Not observed With regards to advocacy and professional attributes, are there any comments you would like to make?Teaching and learningActively increases personal knowledge and skills Consistently Usually Sometimes Never N/A - Not observed Contributes to and facilitates the learning of other team members on appropriate pain management Consistently Usually Sometimes Never N/A - Not observed Is available for advice and help when needed Consistently Usually Sometimes Never N/A - Not observed With regards to teaching and learning, are there any comments you would like to make?General commentsIt would be helpful to the team if they continued to do the followingIt would be helpful to the team if they considered the following improvementsWould you be happy to work with this specialist again? Yes No
