Physician Orders for Life-Sustaining Treatment (POLST): Medical Education Module On-Demand - CME Evaluation

POLST: Medical Education Module (Part 1A Continuing Medical Education Eval)

SOWEGA-AHEC Continuing Medical Education-Evaluation Form
POLST: Medical Education Module (On-Demand)

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* 1. Name

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* 2. Mailing Address

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* 3. Office Phone Number & Fax Number

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* 4. Email Address

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* 5. Professional Degree & Specialty

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* 6. Which type of CME/CE hour are you requesting?

Physicians - CME

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* 7. OBJECTIVES: At the conclusion of this activity, the participant should be able to:
1. Recognize how POLST is different than Advance Directives.
2. Apply the use of POLST in their practice.
3. Determine how to respond when a patient has a POLST.
(1=Poor & 5=Excellent)

Please assess the presentation:

	1 (Poor)	2	3	4	5 (Excellent)
Overall content:	Overall content: 1 (Poor)	Overall content: 2	Overall content: 3	Overall content: 4	Overall content: 5 (Excellent)
Objective(s) achieved:	Objective(s) achieved: 1 (Poor)	Objective(s) achieved: 2	Objective(s) achieved: 3	Objective(s) achieved: 4	Objective(s) achieved: 5 (Excellent)
Speaker's presentation style:	Speaker's presentation style: 1 (Poor)	Speaker's presentation style: 2	Speaker's presentation style: 3	Speaker's presentation style: 4	Speaker's presentation style: 5 (Excellent)

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* 8. Did the format of the activity allow you to achieve your desired results?

Yes

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* 9. Please assess the change in your clinical skill level. (1=Low & 5=High)

	1 (Poor)	2	3	4	5 (Excellent)
Clinical skill level before the activity.	Clinical skill level before the activity. 1 (Poor)	Clinical skill level before the activity. 2	Clinical skill level before the activity. 3	Clinical skill level before the activity. 4	Clinical skill level before the activity. 5 (Excellent)
Clinical skill level after the activity.	Clinical skill level after the activity. 1 (Poor)	Clinical skill level after the activity. 2	Clinical skill level after the activity. 3	Clinical skill level after the activity. 4	Clinical skill level after the activity. 5 (Excellent)
Rate your level of mastery of the material.	Rate your level of mastery of the material. 1 (Poor)	Rate your level of mastery of the material. 2	Rate your level of mastery of the material. 3	Rate your level of mastery of the material. 4	Rate your level of mastery of the material. 5 (Excellent)

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* 10. This activity will assist in the improvement of my: (check all that apply)

Competence

Performance

Patient Outcomes

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* 11. As a result of this session, list strategies that you will incorporate into your practice area:

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* 12. Please list suggestions for future topics and speakers:

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* 13. I plan to make the following changes to my practice: (check all that apply)

Modify treatment plans

Change my screening/prevention practice

Incorporate different diagnostic strategies into patient care

Use alternative communication methodologies with patients and families

None. The activity validated current practice.

Other (please specify)

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* 14. What are the barriers you face in your current practice setting that may prevent implementing the strategies introduced at this activity: (check all that apply)

Lack of time to assess/counsel patients

Insurance / Reimbursement issues

Lack of consensus on professional guidelines

Lack of administrative support/resources

Patient compliance issues

Cost

Other (please specify)

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* 15. Did the presentation contain anything that reflected commercial bias or influence?

Yes

If yes, what?

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* 16. May we contact you for a post-activity evaluation to determine educational effectiveness?

Yes