| 2 | The content was relevant to my work | This event provided me with new information (or clarified existing Information) | I intend to use what I learned from this activity | If you agree with the previous statement, please provide us with details as to which component(s) of the conference you plan on using. | The speaker was knowledgeable about the subject | The speaker was effective in helping me learn new information (or clarifying existing information) | The speaker was responsive to participant's needs and questions | The presentation(s) was well organized, clear and concise | Additional Speaker Comments: | Overall, the conference was free of bias | The learning environment was conducive to learning | What other learning formats would have been helpful for this activity? | If other, please specify. | Please provide us with suggestions for improving the content, facilitation, delivery, environment and/or utility of this event. | Objective 1 | Objective 2 | Objective 3 | Objective 4 | Objective 5 | Objective 6 | Objective 7 | Objective 8 | Objective 9 | Objective 10 | Objective 11 | Objective 12 | Objective 14 | Objective 14 | Objective 15 | Objective 16 | Objective 17 | Objective 18 | Objective 19 | Objective 20 | Commitment to Change Areas | Please identify any barriers you perceive in implementing these changes: | If other barrier, please specify: | If you do not plan to make a change in your performance, please indicate the reason below: | If other reason, please specify: | Clinical Assessment/Physical Exam - List the specific, measurable change(s) you plan to make: | Clinical Assessment/Physical Exam - How confident are you that you will be able to make this change? | Clinical Assessment/Physical Exam - Have you been able to implement the change(s) listed above? | Clinical Assessment/Physical Exam - Briefly describe the outcome of implementing the change(s) in terms of how it affected your practice, team or patient outcomes: | Clinical Assessment/Physical Exam - PROVIDER: | Clinical Assessment/Physical Exam - TEAM: | Clinical Assessment/Physical Exam - PATIENT: | Clinical Assessment/Physical Exam - SYSTEM/ORGANIZATION: | Clinical Assessment/Physical Exam - OTHER: | Clinical Assessment/Physical Exam - What might you do to address barriers you encountered? Please indicate your next steps: | Diagnosis - List the specific, measurable change(s) you plan to make: | Diagnosis - How confident are you that you will be able to make this change? | Diagnosis - Have you been able to implement the change(s) listed above? | Diagnosis - Briefly describe the outcome of implementing the change(s) in terms of how it affected your practice, team or patient outcomes: | Diagnosis - PROVIDER: | Diagnosis - TEAM: | Diagnosis - PATIENT: | Diagnosis - SYSTEM/ORGANIZATION: | Diagnosis - OTHER: | Diagnosis - What might you do to address barriers you encountered? Please indicate your next steps: | Patient Communication - List the specific, measurable change(s) you plan to make: | Patient Communication - How confident are you that you will be able to make this change? | Patient Communication - Have you been able to implement the change(s) listed above? | Patient Communication - Briefly describe the outcome of implementing the change(s) in terms of how it affected your practice, team or patient outcomes: | Patient Communication - PROVIDER: | Patient Communication - TEAM: | Patient Communication - PATIENT: | Patient Communication - SYSTEM/ORGANIZATION: | Patient Communication - OTHER: | Patient Communication - What might you do to address barriers you encountered? Please indicate your next steps: | Increase/Decrease Testing - List the specific, measurable change(s) you plan to make: | Increase/Decrease Testing - How confident are you that you will be able to make this change? | Increase/Decrease Testing - Have you been able to implement the change(s) listed above? | Increase/Decrease Testing - Briefly describe the outcome of implementing the change(s) in terms of how it affected your practice, team or patient outcomes: | Increase/Decrease Testing - PROVIDER: | Increase/Decrease Testing - TEAM: | Increase/Decrease Testing - PATIENT: | Increase/Decrease Testing - SYSTEM/ORGANIZATION: | Increase/Decrease Testing - OTHER: | Increase/Decrease Testing - What might you do to address barriers you encountered? Please indicate your next steps: | Formulate Plan of Care - List the specific, measurable change(s) you plan to make: | Formulate Plan of Care - How confident are you that you will be able to make this change? | Formulate Plan of Care - Have you been able to implement the change(s) listed above? | Formulate Plan of Care - Briefly describe the outcome of implementing the change(s) in terms of how it affected your practice, team or patient outcomes: | Formulate Plan of Care - PROVIDER: | Formulate Plan of Care - TEAM: | Formulate Plan of Care - PATIENT: | Formulate Plan of Care - SYSTEM/ORGANIZATION: | Formulate Plan of Care - OTHER: | Formulate Plan of Care - What might you do to address barriers you encountered? Please indicate your next steps: | New Prescription - List the specific, measurable change(s) you plan to make: | New Prescription - How confident are you that you will be able to make this change? | New Prescription - Have you been able to implement the change(s) listed above? | New Prescription - Briefly describe the outcome of implementing the change(s) in terms of how it affected your practice, team or patient outcomes: | New Prescription - PROVIDER: | New Prescription - TEAM: | New Prescription - PATIENT: | New Prescription - SYSTEM/ORGANIZATION: | New Prescription - OTHER: | New Prescription - What might you do to address barriers you encountered? Please indicate your next steps: | Change Prescription - List the specific, measurable change(s) you plan to make: | Change Prescription - How confident are you that you will be able to make this change? | Change Prescription - Have you been able to implement the change(s) listed above? | Change Prescription - Briefly describe the outcome of implementing the change(s) in terms of how it affected your practice, team or patient outcomes: | Change Prescription - PROVIDER: | Change Prescription - TEAM: | Change Prescription - PATIENT: | Change Prescription - SYSTEM/ORGANIZATION: | Change Prescription - OTHER: | Change Prescription - What might you do to address barriers you encountered? Please indicate your next steps: | Increase Dose - List the specific, measurable change(s) you plan to make: | Increase Dose - How confident are you that you will be able to make this change? | Increase Dose - Have you been able to implement the change(s) listed above? | Increase Dose - Briefly describe the outcome of implementing the change(s) in terms of how it affected your practice, team or patient outcomes: | Increase Dose - PROVIDER: | Increase Dose - TEAM: | Increase Dose - PATIENT: | Increase Dose - SYSTEM/ORGANIZATION: | Increase Dose - OTHER: | Increase Dose - What might you do to address barriers you encountered? Please indicate your next steps: | Decrease Dose - List the specific, measurable change(s) you plan to make: | Decrease Dose - How confident are you that you will be able to make this change? | Decrease Dose - Have you been able to implement the change(s) listed above? | Decrease Dose - Briefly describe the outcome of implementing the change(s) in terms of how it affected your practice, team or patient outcomes: | Decrease Dose - PROVIDER: | Decrease Dose - TEAM: | Decrease Dose - PATIENT: | Decrease Dose - SYSTEM/ORGANIZATION: | Decrease Dose - OTHER: | Decrease Dose - What might you do to address barriers you encountered? Please indicate your next steps: | Education for Patient/Family/Self - List the specific, measurable change(s) you plan to make: | Education for Patient/Family/Self - How confident are you that you will be able to make this change? | Education for Patient/Family/Self - Have you been able to implement the change(s) listed above? | Education for Patient/Family/Self - Briefly describe the outcome of implementing the change(s) in terms of how it affected your practice, team or patient outcomes: | Education for Patient/Family/Self - PROVIDER: | Education for Patient/Family/Self - TEAM: | Education for Patient/Family/Self - PATIENT: | Education for Patient/Family/Self - SYSTEM/ORGANIZATION: | Education for Patient/Family/Self - OTHER: | Education for Patient/Family/Self - What might you do to address barriers you encountered? Please indicate your next steps: | Specify other area: | Other (specify area) - List the specific, measurable change(s) you plan to make: | Other (specify area) - How confident are you that you will be able to make this change? | Other (specify area) - Have you been able to implement the change(s) listed above? | Other (specify area) - Briefly describe the outcome of implementing the change(s) in terms of how it affected your practice, team or patient outcomes: | Other (specify area) - PROVIDER: | Other (specify area) - TEAM: | Other (specify area) - PATIENT: | Other (specify area) - SYSTEM/ORGANIZATION: | Other (specify area) - OTHER: | Other (specify area) - What might you do to address barriers you encountered? Please indicate your next steps: |
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