APPENDIX TWO: REPORT TEMPLATE for Route 2 and 2a applications

Each template must be dated and must relate to practice within the past two years. Undated, inappropriate evidence will be rejected.You may use one piece of evidence to demonstrate that you meet the requirements of more than one section. Please ask for guidance if in doubt.

Please cross reference where, in your evidence, you meet the section descriptors (appendix one)

DATE EXAMPLE
SECTION ONE - A / Professional autonomy and accountability:a high level of personal autonomy and originality is required to make sound judgments in the absence of complete data and communicate their conclusions clearly to specialist and non-specialist audiences; taking into account critical evaluation of current best practice and research and audit.
TYPE OF EVIDENCE
Why have you chosen this evidence
I have chosen an xxxxxxx case study as evidence…….
How does it meet the definition for this section?
The consultant may be asked to supervise for complicated
cases(criteria 1.1, 1.5). Furthermore, the surgical approach may be modified with regards to any
presence of disturbances in neurophysiological data (criteria 1.3, 2.1, 2.3, 2.4, 4.6).
Junior colleagues are present during this particular monitoring for teaching purposes
(criteria 6.1).
What additional documents (if any) are provided in support of this evidence?
List any evidence you are going to upload. Please ensure that any evidence is anonymised
DATE
SECTION ONE -A / Professional autonomy and accountability:a high level of personal autonomy and originality is required to make sound judgments in the absence of complete data and communicate their conclusions clearly to specialist and non-specialist audiences; taking into account critical evaluation of current best practice and research and audit.
TYPE OF EVIDENCE
Why have you chosen this evidence
How does it meet the definition for this section?
What additional documents (if any) are provided in support of this evidence?
DATE
SECTION ONE - B / Professional autonomy and accountability:a high level of personal autonomy and originality is required to make sound judgments in the absence of complete data and communicate their conclusions clearly to specialist and non-specialist audiences; taking into account critical evaluation of current best practice and research and audit.
TYPE OF EVIDENCE
Why have you chosen this evidence
How does it meet the definition for this section?
What additional documents (if any) are provided in support of this evidence?
SECTION TWO -A / Scientific and clinical practice:understand and apply the scientific and clinical body of knowledge that underpins the modality and clinical practice within an evidence based practice framework. Plan, undertake, order and/or report on a complex range of procedures and/ or treatments, using appropriate equipment required to meet the health needs of service users and to exercise a professional duty of care.
TYPE OF EVIDENCE
Why have you chosen this evidence
How does it meet the definition for this section?
What additional documents (if any) are provided in support of this evidence?
DATE
SECTION TWO -B / Scientific and clinical practice:understand and apply the scientific and clinical body of knowledge that underpins the modality and clinical practice within an evidence based practice framework. Plan, undertake, order and/or report on a complex range of procedures and/ or treatments, using appropriate equipment required to meet the health needs of service users and to exercise a professional duty of care. .
TYPE OF EVIDENCE
Why have you chosen this evidence
How does it meet the definition for this section?
What additional documents (if any) are provided in support of this evidence?

.

DATE
SECTION THREE -A / Professional relationships: experience of verbal and non verbal communication in clinical settings, the need for effective communication throughout the care of the patient, recognising the need to use interpersonal skills to encourage the active participation of service users obtaining feedback at an individual and organisation level and acting on outcomes. Achieving informed consent taking into account the differing needs of individuals and demonstrating effective leadership through engagement in multi-disciplinary teams. Appropriate record keeping
TYPE OF EVIDENCE
Why have you chosen this evidence
How does it meet the definition for this section?
What additional documents (if any) are provided in support of this evidence?
DATE
SECTION THREE B / Professional relationships: experience of verbal and non verbal communication in clinical settings, the need for effective communication throughout the care of the patient, recognising the need to use interpersonal skills to encourage the active participation of service users obtaining feedback at an individual and organisation level and acting on outcomes. Achieving informed consent taking into account the differing needs of individuals and demonstrating effective leadership through engagement in multi-disciplinary teams. Appropriate record keeping
TYPE OF EVIDENCE
Why have you chosen this evidence
How does it meet the definition for this section?
What additional documents (if any) are provided in support of this evidence?
DATE
SECTION FOUR -A / Research & service improvement: Develop, monitor and manage quality assurance processes, demonstrating a knowledge of a range of techniques (qualitative and quantitative) and their application to health improvement, which includes audit and involvement in research, and /or service improvement
TYPE OF EVIDENCE
Why have you chosen this evidence
How does it meet the definition for this section?
What additional documents (if any) are provided in support of this evidence?
DATE
SECTION FOUR B / Research & service improvement: Develop, monitor and manage quality assurance processes, demonstrating a knowledge of a range of techniques (qualitative and quantitative) and their application to health improvement, which includes audit and involvement in research, and /or service improvement
TYPE OF EVIDENCE
Why have you chosen this evidence
How does it meet the definition for this section?
What additional documents (if any) are provided in support of this evidence?
DATE
SECTION FIVE A / Safe, effective practice, quality assurance:the requirements and importance of health, safety (including safe systems of work), risk management and quality control and assurance in practice; record keeping and utilisation of protocols and procedures; relevant accreditation and review systems.
TYPE OF EVIDENCE
Why have you chosen this evidence
How does it meet the definition for this section?
What additional documents (if any) are provided in support of this evidence?
DATE
SECTION FIVE B / Safe, effective practice, quality assurance:the requirements and importance of health, safety (including safe systems of work), risk management and quality control and assurance in practice; record keeping and utilisation of protocols and procedures; relevant accreditation and review systems.
TYPE OF EVIDENCE
Why have you chosen this evidence
How does it meet the definition for this section?
What additional documents (if any) are provided in support of this evidence?
DATE
SECTION SIX A / Training & education:the development of others, e.g. patients, public, colleagues, peers and students.
TYPE OF EVIDENCE
Why have you chosen this evidence
How does it meet the definition for this section?
What additional documents (if any) are provided in support of this evidence?
DATE
SECTION SIX B / Training & education:the development of others, e.g. patients, public, colleagues, peers and students.
TYPE OF EVIDENCE
Why have you chosen this evidence
How does it meet the definition for this section?
What additional documents (if any) are provided in support of this evidence?

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RCCP Appendix Two: Report TemplateVersion 3 May 2016