Physician Assistant Site Visit Form (Page 2 of 2) in pdf

QUALITY IMPROVEMENT PROCESS: [Section .0213]

Documentation of Quality Improvement meetings (signed/dated by PA & PSP): Yes_____ No_____

(Required to be available for inspection [Section .0213 (d)])

(Meetings are required monthly for first 6 months in new practice arrangement; thereafter are required no

less than every 6 months)[Section .0213 (d)])

Dates of most recent Quality Improvement Meetings:

Date: ________ Clinical problems discussed: __________________________________________

SUPERVISING PHYSICIAN AND RESPONSIBILITIES OF PRIMARY

SUPERVISING PHYSICIANS IN REGARD TO BACK-UP SUPERVISING

PHYSICIANS: [Section .0214 & .0215]

Primary Supervising Physician (“PSP”): _______________________________________________

Back-up Supervising Physician(s): _______________________________________________________

_______________________________________________________

Back-up Supervising Physician(s) list available for inspection: [Section .0215 (b)] Yes_____ No_____

CONTINUING MEDICAL EDUCATION: [Section .0216]

CME during previous 2 year period[a]: (100 hours of which 50 hrs of Category I are required)

2-Year Period: _______ to ______

Documentation available for inspection: Yes____ No____

List Category 1 _______________________________________________________________________

CME

________________________________________________________________________

OR;

Certification with the National Commission on Certification of Physician Assistants (NCCPA)

Yes_____ No_______ [Section .0216 (b)]

CONCLUSIONS:

Compliance Issues summarized (in PA’s presence):______________________________________

______________________________________________________________________________

_______________________________________________________________________________

______________________________________________________________________________

________________________________________________________________________________

______________________________________________________________________________

If yes, date PA to provide documentation to demonstrate compliance with rules:

___/___/____

PSP advised of site check and compliance issues (if any): Yes ___ No _____

Date:___/___/____

Re-visit recommended:

Yes ___ No _____

NCMB Representative Signature:_____________________________________ Date: __/__/___

Physician Assistant Signature: _______________________________________ Date: __/__/___

Primary Supervising Physician Signature:_______________________________ Date: __/__/___

s:sitevisit.pa.doc Revision Dates: 11/17/09; 5/2/13, 10/2/14

Physician Assistant Site Visit Form Page 2