ER Group

The Clinical Proficiency Scorecard remains the property of ER Corporate cc.

The Clinical Proficiency Scorecard is designed to be an objective scoring system aimed at doctors working Emergency Units in South Africa.

Once completed, the Clinical Proficiency Scorecard should be returned by e-mail using the SUBMIT button at the end of the form.

Scores will be returned by e-mail to doctors within 72 hours and recommendations for training within 1 month form submission.

Qualification *
DoctorNurseParamedic

Surname *

First Names *

HPCSA Number

MPS/Other #

Qualifying Year

Place of Work

Company/State
Private - NetcarePrivate - LifePrivate - Medi-ClinicPrivate - OtherGovernmentSelf-Employed

Email Address *

Contact Number

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I give permission for my details to be stored on a confidential ER Consulting Inc database. I understand that these details will not be divulged to any third parties without my express permission

Please enter the time (years) in the past 10 years you have spent practicing Emergency Medicine:

Full Time (>40 hours per week) in a Level 1 or 2 Emergency Centre: ---011.522.533.544.555.566.577.588.599.510

Full Time (>40 hours per week) in a Level 3 or 4 Emergency Centre: ---011.522.533.544.555.566.577.588.599.510

Part Time (20 to 40 hours per week) in a Level 1 or 2 Emergency Centre: ---011.522.533.544.555.566.577.588.599.510

Part Time (20 to 40 hours per week) in a Level 3 or 4 Emergency Centre: ---011.522.533.544.555.566.577.588.599.510

Part Time (<20 hours per week) in a Level 1 or 2 Emergency Centre: ---011.522.533.544.555.566.577.588.599.510

Part Time (<20 hours per week) in a Level 3 or 4 Emergency Centre: ---011.522.533.544.555.566.577.588.599.510

Level 1 Unit is equivalent to a major Academic Trauma and Emergency Centre. Level 4 Unit is equivalent to a rural or community Emergency Centre.

Please use your Hospitals classification for the purpose of this questionnaire.

Clinical experience includes all clinical attachments in the last 10 years, inclusive of internship, but outside an Emergency Centre

Please list each rotation on a separate line:

Please include all non-clinical experience that you have been engaged in within the last 10 years. Please only mention experience of greater than 6 months duration.

Please list each category on one line.

Please indicate your involvement in academic disciplines related to Emergency or Acute Care Medicine within the last 12 months:

Current Registration Category:
---InternCOSMORegistrarGP - StateGP - PrivateSpecialist - StateSpecialist - Private

Documentary Evidence must be provided in support of the above statements

Formal Qualification in Emergency Medicine? ---YesNo

Qualification ---FCEMM.Med (EM)Honorary FCEMM.Phil (Emergency Medicine)M.Sc Med. (Emergency Medicine)DipPEC

 Specialist Emergency Physician Eligible for Specialist Registration Not Eligible for Specialist Registration

Formal Qualification in Related Fields? ---YesNo

Use Ctrl-Click to Select more than one option. All courses must be current. Documentary Evidence must be available.

Qualification
---DADip O&GDTM&HDCH

Emergency Medicine Short Courses (Pick all that apply)
---ATLSACLSACLS - Experienced ProviderAPLSPALSANLSAMLSSA - AIMEBESTHMIMMS/MIMMSAviation Medicine (AHCP)BurnsOther

Other:

Please be as accurate as possible. From 2011, evidence of competence must be provided in the ER Consulting Practical Assessment Logbook (e-PAL), which will be distributed in January 2011.

Please pick the statement you feels best applies to yourself
---I feel confident to manage any case that presents to the emergency centreI feel confident to manage most cases that present to the emergency centre, except for resuscitationsI feel confident to manage minor cases onlyI do not feel confident to manage patients in this category

Please indicate the number of cases you have been responsible for in the last 12 months:

Please pick the statement you feels best applies to yourself
---I feel confident to manage any case that presents to the emergency centreI feel confident to manage most cases that present to the emergency centre, except for resuscitationsI feel confident to manage minor cases onlyI do not feel confident to manage patients in this category

Please indicate the number of cases you have been responsible for in the last 12 months:

Please pick the statement you feels best applies to yourself
---I feel confident to manage any case that presents to the emergency centreI feel confident to manage most cases that present to the emergency centre, except for resuscitationsI feel confident to manage minor cases onlyI do not feel confident to manage patients in this category

Please indicate the number of cases you have been responsible for in the last 12 months:

Please pick the statement you feels best applies to yourself
---I feel confident to manage any case that presents to the emergency centreI feel confident to manage most cases that present to the emergency centre, except for resuscitationsI feel confident to manage minor cases onlyI do not feel confident to manage patients in this category

Please indicate the number of cases you have been responsible for in the last 12 months:

Please pick the statement you feels best applies to yourself
---I feel confident to manage any case that presents to the emergency centreI feel confident to manage most cases that present to the emergency centre, except for resuscitationsI feel confident to manage minor cases onlyI do not feel confident to manage patients in this category

Please indicate the number of cases you have been responsible for in the last 12 months:

Please pick the statement you feels best applies to yourself
---I feel confident to manage any case that presents to the emergency centreI feel confident to manage most cases that present to the emergency centre, except for resuscitationsI feel confident to manage minor cases onlyI do not feel confident to manage patients in this category

Please indicate the number of cases you have been responsible for in the last 12 months:

Results will be analysed electronically, and you will be informed of your score within 72 hours. Training recommendations will be made within 14 days.

Should you feel that the results are inaccurate, or you have made an error in submitting the form, please contact ClinicalGovernance@ERCorporate.co.za and we will discuss the situation with you in more detail.