Saskatchewan Pharmacy Professionals Learning Portfolio

Copyright 2002, University of Saskatchewan

Reproduction of this course is strictly prohibited without permission from the University of Saskatchewan,College of Pharmacy and Nutrition

Continuing Professional Development for Pharmacy Professionals (CPDPP) is a cooperative activity of the Saskatchewan College of

Pharmacy Professionals and the University of Saskatchewan.

ACKNOWLEDGEMENTS

University of Alberta, Faculty of Pharmacy and Pharmaceutical Sciences and the Alberta College of Pharmacists for permission to adapt materials from the RxCEL Learning Portfolio.

Saskatchewan pharmacists Learning Portfolio Pilot Project volunteers for their input and feedback.

CPP#

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APPENDIX t w o69

APPENDIX 2:BLANK LEARNING PROJECT RECORD AND

PROFESSIONAL DEVELOPMENT LOG FORMS

Saskatchewan Pharmacists Learning Portfolio

This appendix contains the following blank forms:

Accredited Live CE Program - 10 copies Accredited Self-study CE Program - 10 copies Non-accredited Professional Development - 10 copies Non-accredited Professional Development - Long-term CE Activity - 4 copies Professional Development Log - 4 copies

Reproduce copies of these forms as required.

Copies of these forms for both manual and electronic completion will also be available in Fall 2002 on the Continuing Professional Development for Pharmacists home page at : www.usask.ca/pharmacy-nutrition/services/cpdp. At that point you may choose to keep your forms electronically or manually. However, you must submit a hardcopy of your completed Professional Development Log at the end of each licensing year when you send your license membership renewal to SCP.

Name _____________________________ SCP #___________ Licensing Year____________

PROGRAM INFORMATION

Program Name: ____________________________________________________________

Speaker: ______________________________ Date :______________________________

Location: _____________________________ Sponsor: ____________________________

Program Provider: __________________ Accredited by: _______________CEUs: ____________

PRACTICE ISSUE:

Identify a gap in your knowledge and skills that is relevant to your practice and state your learning objective for attending this CE program.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

OUTCOME:

Identify the impact your learning will have on your practice.

❏ I plan to modify my practice. ❏ Confirmed no change in my practiceneeded at this time.

❏ More information needed to modifymy practice.

REFLECTION NOTES:

Evaluate your learning activity.

Provide a brief summary of:

1. Key learning points gained from your attendance at this program.

2. How you plan to use your new knowledge/skills in your practice, and

3. Any additional learning that is needed.

Notes:_____________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Complete and retain this document in your personal learning portfolio.

LEARNING PROJECT RECORD –ACCREDITED LIVE CE PROGRAM

Name _____________________________ SCP #___________ Licensing Year____________

PROGRAM: ________________________________________________________________________________

Program Provider: __________________ Accredited by: _______________CEUs: ____________

PRACTICE ISSUE:

Identify a gap in your knowledge and skills that is relevant to your practice and state your learning objective for completing this CE program.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

OUTCOME:

Identify the impact your learning will have on your practice.

❏ I plan to modify my practice. ❏ Confirmed no change in my practice needed at this time.

❏ More information needed to modifymy practice.

REFLECTION NOTES:

Evaluate your learning activity.

Provide a brief summary of:

1. Key learning points gained from your attendance at this program,

2. How you plan to use your new knowledge/skills in your practice, and

3. Any additional learning that is needed.

Notes:_____________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Complete and attach this form to your self-study learning project answer sheet or letter/certificate of completion, and retain in your

personal learning portfolio

LEARNING PROJECT RECORD –ACCREDITED SELF-STUDY CE PROGRAM

Name _____________________________ SCP #___________ Licensing Year_____________

Topic:__________________________________________ Project Date(s): _______________

PRACTICE ISSUE:

Identify a gap in your knowledge and skills that is relevant to your practice and state your learning objective with respect to the identified need._____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

STIMULUS:

Indicate the factors that helped you identify this issue in your practice.

❏ Management of a patient or practice problem ❏ Discussion with peers or others❏ Completing a self-assessment program ❏ Feedback about my practice, e.g., practice❏ Scanning the literature (journals, newsletters, internet) review, external directive, patient complaint❏ Engaging in teaching, writing, research ❏ Participation in a volunteer activity❏ Participation in a CE program ❏ Other (specify in Notes)❏ Reflecting on a series of similar patients or

practice problems

Notes:_____________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

RESOURCES

Briefly identify your learning activities.

Time: _____ hours (Estimate the approximate CEUs claimed: _____ (number of hourstime spent on this project in increments of 0.5 h) recorded at left to a maximum of 4)

❏ Non-accredited group program (workshop, ❏ Reading (articles, texts, newsletters,course, conference) manuals, internet

❏ Self-study program (print, ❏ Planned literature search, e.g., Medline,video/audio, internet) Internet

❏ Self-assessment program ❏ Discussion with colleague or expert❏ Preceptorship or mentorship with ❏ Other (specify in Notes)

an expert

Notes:_____________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________

LEARNING PROJECT RECORD –NON-ACCREDITED PROFESSIONAL DEVELOPMENT

___ h

___ h___ h

___ h

___ h

___ h___ h

___ h

OUTCOME:

Identify the impact your learning will have on your practice.

❏ I plan to modify my practice. ❏ Confirmed no change in my practiceneeded at this time.

❏ More information needed to modifymy practice.

REFLECTION NOTES:

Evaluate your learning activities.

Provide a brief summary of:

1. Key learning points from your project;

2. Was your approach the most sensible/appropriate one;

3. How you plan to use your new knowledge/skills in your practice, and

4. Any additional learning that is needed.

Notes:_____________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Complete and retain this document in your personal learning portfolio.

LEARNING PROJECT RECORD – NON-ACCREDITED

Name _____________________________ SCP #___________ Licensing Year____________

Topic:__________________________________________ Project Date(s): _______________

PRACTICE ISSUE:

Identify a gap in your knowledge and skills that is relevant to your practice and state your learning objective with respect to the identified need.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

STIMULUS:

Indicate the factors that helped you identify this issue in your practice.

❏ Management of a patient or practice problem ❏ Discussion with peers or others❏ Completing a self-assessment program ❏ Feedback about my practice, e.g., practice❏ Scanning the literature (journals, newsletters, internet) review, external directive, patient complaint❏ Engaging in teaching, writing, research ❏ Participation in a volunteer activity❏ Participation in a CE program ❏ Other (specify in Notes)❏ Reflecting on a series of similar patients or

practice problems

Notes:_____________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

TIME LINE:

Develop a time line for this learning activity. Include the stages you will take to complete your activity and an estimated date of completion. In your outline, briefly identify your expected learning activities on a monthly basis.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

LEARNING PROJECT RECORD –NON-ACCREDITED PROFESSIONAL DEVELOPMENT

LONG-TERM ACTIVITY

Month _____ (If required)_______________

Time: __________ Hours (Estimate the approximate CEUs claimed:______________ (number of time spent on this project in increments of 0.5 h) hours recorded at left to a maximum of 4)

❏ Non-accredited group program ❏ Reading (articles, texts, newsletters,(workshop, course, conference) manuals, internet)

❏ Self-study program (print, video/audio, internet) ❏ Planned literature search, e.g.,❏ Self-assessment program Medline, Internet❏ Preceptorship or mentorship with an expert ❏ Discussion with colleague or experts

❏ Other (specify in Notes:)

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________

Total CEUs claimed for this long-term CE activity: __________

If you require more space for recording subsequent months of activity, photocopy page three of this form and enter the Month number to reflect continuous activity.

OUTCOME:

Identify the impact your learning will have on your practice.

❏ I plan to modify my practice. ❏ Confirmed no change in my practiceneeded at this time.

❏ More information needed to modifymy practice.

REFLECTION NOTES:

Evaluate your learning activities.

1. Key learning points from your project;2. Was your approach the most sensible/appropriate one;3. How you plan to use your new knowledge/skills in your practice; and4. Any additional learning that is needed.

Notes:_____________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Complete and retain this document in your personal learning portfolio.

___ h___ h___ h___ h

___ h

___ h___ h___ h

Month _____ (If required)_______________

Time: __________ Hours (Estimate the approximate CEUs claimed:______________ (number of time spent on this project in increments of 0.5 h) hours recorded at left to a maximum of 4)

❏ Non-accredited group program ❏ Reading (articles, texts, newsletters,(workshop, course, conference) manuals, internet)

❏ Self-study program (print, video/audio, internet) ❏ Planned literature search, e.g.,❏ Self-assessment program Medline, Internet❏ Preceptorship or mentorship with an expert ❏ Discussion with colleague or experts

❏ Other (specify in Notes:) ___ h

Notes:_____________________________________________________________________________________________________________________________________________________________________________________________________

Month _____ (If required)_______________

Time: __________ Hours (Estimate the approximate CEUs claimed:______________ (number of time spent on this project in increments of 0.5 h) hours recorded at left to a maximum of 4)

❏ Non-accredited group program ❏ Reading (articles, texts, newsletters,(workshop, course, conference) manuals, internet)

❏ Self-study program (print, video/audio, internet) ❏ Planned literature search, e.g.,❏ Self-assessment program Medline, Internet❏ Preceptorship or mentorship with an expert ❏ Discussion with colleague or experts

❏ Other (specify in Notes:) ___ h

Notes:_____________________________________________________________________________________________________________________________________________________________________________________________________

Month _____ (If required)_______________

Time: __________ Hours (Estimate the approximate CEUs claimed:______________ (number of time spent on this project in increments of 0.5 h) hours recorded at left to a maximum of 4)

❏ Non-accredited group program ❏ Reading (articles, texts, newsletters,(workshop, course, conference) manuals, internet)

❏ Self-study program (print, video/audio, internet) ❏ Planned literature search, e.g.,❏ Self-assessment program Medline, Internet❏ Preceptorship or mentorship with an expert ❏ Discussion with colleague or experts

❏ Other (specify in Notes:)

Notes:_____________________________________________________________________________________________________________________________________________________________________________________________________

___ h___ h___ h___ h

___ h___ h___ h___ h

___ h

___ h___ h

___ h

___ h___ h

___ h___ h___ h___ h

___ h

___ h___ h___ h

RESOURCES:

Briefly identify your learning activities.

Month 1: _______________________

Time: __________ Hours (Estimate the approximate CEUs claimed:______________ (number of hours time spent on this project in increments of 0.5 h) recorded at left to a maximum of 4)

❏ Non-accredited group program ❏ Reading (articles, texts, newsletters,(workshop, course, conference) manuals, internet)

❏ Self-study program (print, video/audio, internet) ❏ Planned literature search, e.g.,❏ Self-assessment program Medline, Internet❏ Preceptorship or mentorship with an expert ❏ Discussion with colleague or experts

❏ Other (specify in Notes:)

Notes:_____________________________________________________________________________________________________________________________________________________________________________________________________

Month 2: _______________________

Time: __________ Hours (Estimate the approximate CEUs claimed:______________ (number of hours time spent on this project in increments of 0.5 h) recorded at left to a maximum of 4)

❏ Non-accredited group program ❏ Reading (articles, texts, newsletters,(workshop, course, conference) manuals, internet)

❏ Self-study program (print, video/audio, internet) ❏ Planned literature search, e.g.,❏ Self-assessment program Medline, Internet❏ Preceptorship or mentorship with an expert ❏ Discussion with colleague or experts

❏ Other (specify in Notes:)

Notes:_____________________________________________________________________________________________________________________________________________________________________________________________________

Month 3: _______________________

Time: __________ Hours (Estimate the approximate CEUs claimed:______________ (number of hours

time spent on this project in increments of 0.5 h) recorded at left to a maximum of 4)

❏ Non-accredited group program ❏ Reading (articles, texts, newsletters,(workshop, course, conference) manuals, internet)

❏ Self-study program (print, video/audio, internet) ❏ Planned literature search, e.g.,❏ Self-assessment program Medline, Internet❏ Preceptorship or mentorship with an expert ❏ Discussion with colleague or experts

❏ Other (specify in Notes:) ___ h

Notes:_____________________________________________________________________________________________________________________________________________________________________________________________________

___ h___ h___ h___ h

___ h___ h___ h___ h

___ h___ h___ h___ h

___ h

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___ h

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LEARNING PROJECT RECORD –ACCREDITED SELF-STUDY CE PROGRAM