Employee Evaluation
& Wage Review
Employee Date
Title Time in Present Position Date of Last Review
Attendance Tardies Unexcused Excused Vacation
Scoring EXCEEDS MEETS NEEDS
71-90 41-70 IMPROVEMENT
0-40
GENERAL Exceeds Meets N.I.
1. Accountability - Accepts responsibility for actions, answerable to consequences 3 2 1
2. Punctuality & Attendance - Is rarely absent, arrives punctually, works required hours 3 2 1
3. Cooperation -- Has ability to get along with coworkers and management 3 2 1
4. Attitude/Respectfulness - Shows initiative, optimism, and politeness 3 2 1
5. Accepts Criticism - Has ability to learn from suggestions and change behavior 3 2 1
6. Flexibility - Has capacity to respond to changing situations and expectations 3 2 1
7. Policy & Procedures - Follows organization's policies and procedures 3 2 1
8. Completion of Assignments - Successfully completes tasks and meets all deadlines 3 2 1
9. Patient Interaction - Ensures high-quality care, respects patients’ dignity and confidentiality 3 2 1
10. Quality of Work - Is thorough, accurate, and neat in work 3 2 1
11. Willingness to Develop Skills - Desires to take on challenges and learn new techniques 3 2 1
12. Communication Skills - Conveys information effectively and efficiently 3 2 1
13. Organizational Skills - Has capacity to stay on track and use time effectively 3 2 1
14. Confidentiality - Does not discuss internal events with coworkers 3 2 1
15. Appearance/Dress Code - Demonstrates a professional and well-kept appearance 3 2 1
16. Appearance of Work Area - Keeps work area neat and orderly 3 2 1
17. Conflict Resolution - Seeks constructive approaches to resolving workplace issues 3 2 1
18. Safety - Contributes to a safe and secure environment by following established procedures 3 2 1
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Employee Evaluation
& Wage Review
19. Job Knowledge - Demonstrates working knowledge of procedures and health 3 2 1
20. OSHA & HIPPA Compliance - Understands regulations and performs tasks appropriately 3 2 1
21. Expense Management - Operates and uses supplies to maximize cost efficiency 3 2 1
22. Inventory - Has ability to keep a well-recorded stock of items used and needed 3 2 1
23. Availability - Is available to work any shift as needed by the practice 3 2 1
TOTAL SCORE GENERAL (MAXIMUM 69)
FRONT OFFICE Exceeds Meets N.I.
24. Scheduling - Maximizes production by scheduling appointments 3 2 1
25. Computer Skills - Effectively navigates all computer programs necessary to complete tasks 3 2 1
26. Telephone Manners - Sounds professional & successfully uses supplied scripts/techniques 3 2 1
27. Case Presentation - Has capacity to accurately prepare and effectively present quotes 3 2 1
28. Patient Flow - Has ability to keep schedule on time and limit patient waiting times 3 2 1
29. Insurance/EOBs - Has capacity to read, understand, and process insurance breakdowns & EOBs 3 2 1
30. Office Tidiness - Keeps waiting rooms, bathrooms, & break room cleaned and stocked 3 2 1
TOTAL SCORE FRONT OFFICE (MAXIMUM 21)
BACK OFFICE Exceeds Meets N.I.
31. Clinical Skills & Duties - Has mastery of clinical procedures and daily maintenance duties 3 2 1
32. Patient Preparation - Prepares instruments & room, obtains tests, gains written consent 3 2 1
33. Chairside Manner/Gentleness - Performs procedures with minimum discomfort to patients 3 2 1
34. Patient Treatment - Has ability to accurately complete test results and needed treatment 3 2 1
35. Charting Accuracy - Has capacity to chart from dictation and complete procedure notes 3 2 1
36. Patient Dismissal - Provides post-op instructions, hands patient to front, sterilizes room/supplies 3 2 1
37. Lab - Completes cases with accuracy & urgency, does not leave cases unmarked or unfinished 3 2 1
TOTAL SCORE BACK OFFICE (MAXIMUM 21)
TOTAL OVERALL SCORE (MAXIMUM 90)
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Employee Evaluation
& Wage Review
Employer's Remarks & Recommendations
Specific Development Plan/Goals
Employee's Comments
SALARY REVIEW
Current Wage per Hour New Wage Per Hour
Employer Signature Date
Employee Signature Date
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