PROFESSIONAL SUPPORT – REFERRAL FORM

NOTE FOR REFERRER

Referrers please ensure that this form is fully completed, accompanied by a Form A and that the doctor you are referring e-mails the PSU office () to indicate their acceptance of both the referral and the ‘note for trainee’ information at the foot of thispage. Without these steps being followed the referral cannot be accepted.

It is essential that Forms A & B have been shared, fully discussed, & agreed with the trainee prior to submission of the referral.

Please note trainees will be able to access these forms online.

CONFIDENTIALITY

Please password-protectyour Form before sending it to the PSU office. Please send a separate email to with details of the password you have used.

NOTE FOR TRAINEE

By agreeing to this referral and the information contained within it you are accepting the following terms for the management of your case by the Professional Support Unit:

You have read and understood the “PSU Information for Trainees” and the “FAQs for Trainees” (available from the PSU website) and understand both the purpose and the intention of the referral.

You understand that a case manager will be allocated to you and as part of the process a case file (both paper and electronic) will be opened.

You understand that information within your PSU case file is confidential and will only be accessed by members of the PSU or named case workers. Where existing documents held by members of Deanery teams are added to your file the original will remain the property of the team in question.

You are aware that the PSU will seek your permission to share relevant information with individuals, on a need to know basis, to inform and support your ongoing training.

You accept that any information which could compromise your own or your patients’ safety cannot be kept confidential and will be shared at the discretion of the Associate Dean for Professional Development

By accepting all of the above you also agree to communicate with your case manager and others involved by email and that you will ensure that the email address supplied is up to date at all times and is one that you access regularly (see Gold Guide 7.90).

Please note you will be able to access these forms on Intrepid.

PROFESSIONAL SUPPORT – Form B - SUPERVISOR ASSESSMENT

Name of doctor being assessed
Date of assessment
GMC number
Current Trust
Educational Supervisor
Programme Director
Clinical Tutor
Date of first provisional registration
Last post specialty
Last post location
Last post start date
Last post end date
Date of qualification
Medical School

Please complete the clinical and general sections of the summary of the issues that are currently affecting your trainee.

In areas identified as having borderline or unacceptable performance evidence is required. For evidence please state if based on multiple viewpoints of clinicians (if so who has been contacted) or, ideally, with specific examples.

CLINICAL SKILLS ASSESSMENT

Please rate each of the categories below for your trainee’s performance by ticking the appropriate box – for guidance scoring notes are attached.

1 – Good 2 – Satisfactory 3 – Borderline 4 - Does not reach standard

Criteria / 1 / 2 / 3 / 4 / N/A – Cannot comment / Comments and examples
1. The Consultation
a) History taking
b) Clinical examination
c) Diagnostic skills
d) Decision making
e) Treatment
f) Prescribing
g) Record keeping
h) Practical skills
2. Communication with patients, relatives and colleague
3. Respect for patients
4. Team working and relationships with staff
5. Awareness of own limitations
6. Responds effectively in emergency situations
7. Following of safe procedures
8. Understanding information technology
9. Time management
10. Demonstrates responsibility for personal education

GENERAL ASSESSMENT

Other areas of significance/concern / Yes / No / If yes please give details
Behaviour
Probity
Health / social
Failure of understanding of role/ unfamiliarity of NHS working practices
Other