Northwest Region Prehospital Care Program

INSTRUCTIONS FOR USE

The CME Completion Form is to be completed by Paramedics following the completion of any approved clinical CME activity. This form is to be submitted to NWRPCP prior to the CME deadline date as outlined in the CME Program and Catalogue; December 15th or next business day. Please complete in as much detail as possible to provide context for full analysis. Note: please don’t include any patient health information (PHI) in your entries.

Name(*)

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Email(*)

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EHSN#

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Date of CME

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Hours Attended

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Title of CME Event

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Education Methods

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Please describe

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Summary of Clinical Value/Knowledge Gained

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Did this event include Patient Contact(s)

Yes Invalid Input

Add 2nd patient contact?

No
Yes Invalid Input

Patient 1 Demographics & Working Dx

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Patient 1 Care Performed

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Add 3rd patient contact?

No
Yes Invalid Input

Patient 2 Demographics & Working Dx

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Patient 2 Care Performed

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Patient 3 Demographics & Working Dx

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Patient 3 Care Performed

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Were your goals/objectives met?

Yes
No Invalid Input

Please explain

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Would you recommend this CME activity to other Paramedics?

Yes
No Invalid Input

Suggestions for improving this CME activity: (If Applicable)

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Please attach your certificate or other supporting document.

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For Office use only

Date Approved (D/M/Y - 01/01/2020)

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Approved by

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Clinical Hours Approved

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CME Completion Form

INSTRUCTIONS FOR USE

For Office use only

Forms