October, 2017
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Approved Provider Activity Documentation Tool
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TITLE PAGE
Organization Name:
DEMOGRAPHIC DATA:
Title of Activity:
Date(s) of first presentation:
Location(s) of activity (if applicable) – City and State:
This activity is: (Please check one.)
Provider-Directed (live – in person or webinar)
Learner-Paced (enduring material)
Start Date:
Expiration Date:
Blended Activity
Date(s) of Learner-Paced work:
Date(s) of Provider-Directed portion:
Number of Contact Hours Awarded:
How often will this activity be offered? One-time Multiple times
Is this continuing nursing education? Does the content of this education activity enable the Registered Nurse learner to acquire or improve knowledge, skills, or practice that promote the professional development or performance of the Registered Nurse while enhancing his/her contribution to quality healthcare? Is the content generalizable regardless of the employer? Does the content meet the definition of and criteria for continuing nursing education as outlined in chapter 216 of the Texas Board of Nursing’s rules and regulations?
YesPlease continue to the next question.
No STOP! – you may not submit an individual activity application.
Is a currently licensed Registered Nurse with a valid, current, unencumbered nursing license and with a baccalaureate degree or higher in nursing is actively involved, as the Nurse Planner, in the planning, implementing and evaluation process of this continuing nursing education activity?
Yes ____ Please continue.
No ____ STOP! You may notprovide this activity for CNE.
Please list the name and credentials of the Approved Provider Unit Nurse Planner involved with/responsible for this education activity:
Nurse Planner: (Name and degrees/credentials)Will this activity offer other types of continuing education? Yes No
If yes, what?Continuing Medical Education Social Worker
Pharmacy Others:
Have you read the “Approved Provider Activity Documentation Tool Guidelines and Criteria”?
YesPlease continue to the next question.
No STOP! Go back and read the information in the “Approved Provider ActivityDocumentation Tool Guidelines and Criteria.” If you have questions, contact your Approved Provider Unit’s Primary Nurse Planner.
Have you read the ANCC “Content Integrity Standards”?
YesPlease continue to the next question.
No STOP! Go back and read the information in the “Content Integrity Standards.” If you have questions, contact your Approved Provider Unit’s Primary Nurse Planner.
Activity Documentation Tool
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A.Description of the professional practice gap (e.g. change in practice, problem in practice, opportunity for improvement) [see “Guidelines” – page 4]
Describe the current state:
What are you seeing in practice that creates the need for this activity?B.Evidence to validate the professional practice gap (check all methods/types of data that apply) [see “Guidelines” – page 4]
1. Survey data from stakeholders, target audience members, content experts, etc.
Input from stakeholders such as Registered Nurses, managers, or content experts
Evidence from quality studies and/or performance improvement activities to identify opportunities for improvements
Evaluation data from previous education activities
Trends in literature, law and health care
Direct observation
Other – Describe:
2.Please provide a brief summary of data gathered that validates the need for this activity:
C.Description of Target Audience [see “Guidelines” – page 4]
Identify the Registered Nurse target audience for which this continuing nursing education activity is being designed:
All Registered Nurses
Advanced Practice Registered Nurses
RNs in a specialty area
Identify specialty:
D.Educational need that underlies the target audience’s professional practice gap [see “Guidelines” – page 4]
Gap in knowledge (doesn’t know)
Gap in skills (doesn’t know how)
Gap in practice (not able to show/do in practice)
E. Description the desired state – Learning outcome[see “Guidelines” – page 4]
D.Description of Target Audience
Identify the Registered Nurse target audience for which this continuing nursing education activity is being
F.Description of the outcome measure(A quantitative [measurable/observable] statement as to how the learning outcome(s) provided in Section E will be measured. This should tie to Section O.) [see “Guidelines” – page 5]
G.Area of impact (check all that apply):
Nursing Professional Development
Patient Outcome
Other – Describe:
H. Qualified Planners/Presenter(s)/Author(s)/Content Review (s)
Attach “Qualified Planners/Presenter(s)/Author(s)/Content Review(s)” grid.
[see “Guidelines” – page 5]
I. – L. Education Documentation Form(s) (EDFs) and Reference List
Attach an “Education Documentation Form” (EDF) and “Reference List” for each presentation.
[see “Guidelines” – page 8]
M.Successful Completion (Criteria for awarding contact hours. This information will be reflected on the “Disclosure to Participants”). [see “Guidelines” – page 10]
Criteria for successful completion: (Check all that apply.)
Attendance at entire activity.
Attendance for at least % of the activity.
Attendance at one (1) or more sessions (partial credit).
Completion/submission of evaluation form.
Successfully completing a post-test.
Return skill demonstration/competency assessment.
Completion of a Learner-Paced packet/module.
Other:
Describe:
N. Awarding Contact Hours[see “Guidelines” – page 10]
Number of contact hours to be awarded:(Up to the 1/100th as appropriate)
1.Provider-Directed:
Presentation time plus evaluation time divided by 60 minutes equals total number of contact hours.
divided by 60 minutes = . contact hours
Total number of minutesDo not round
from column J of the
Education Documentation Form
2.Learner-Paced:
Pilot Study
Historical Data
Word Count (Mergener Formula)
Other:
Describe:
Describe the method and rationale used in determining the number of contact hours to be awarded for successful completion of this Learner-Paced activity. Contact hours must be calculated in a logical, defensible manner. Show evidence (math calculation) of how contact hours were determined. Do not round.
3.Blended-Activity:
+ =
Provider-DirectedLearner-PacedTotal Number of
Contact hoursContact hoursContact hours
Do not round
O.Evaluation/Outcome Measure [see “Guidelines” – page 11]
(Check all thatapply.)
1.Describe the method(s) of evaluation to be used to evaluate a change in knowledge, skill and/or practice based on the learning outcome: (Tie back to section F) (check all that apply)
Short-Term
Knowledge
Post-test
Intent to change practice as reflected on the post-activity evaluation tool
Active participation during learning activity
Case study/case scenario analysis
Debriefing
Other:
Describe:
Skill
Direct observation of skill performance/return demonstration
Role playing
Other:
Describe:
AND/OR
Long-Term
Practice
Self-reported change in practice
Longitudinal study of changes in practice
Data collection related to quality outcome measures
Observation of performance in practice
3-6 months post-program survey/test
Other:
Describe:
2.Additionally, an evaluation of the overall activity is required.
A COPY OF YOUR CNE ACTIVITY EVALUATION TOOL MUSTBE INCLUDED WITH THIS ACTIVITY TOOL.
3.Describe how evaluation data will be used:
Make revisions to this activity
Make revisions to future activities
Reviewed by the planning committee members and presenter/author/content reviewer
Future planning of education activities
Other:
Describe:
P.Promotional Materials[see “Guidelines” – page 12]
Type of advertising to be used: (Check all that apply. Include a copy of each with this application.)
Flyer (Page #:)Brochure (Page #:)
Memo/Letter (Page #:)Meeting Notice (Page #:)
Email (Page #:)Website (Page #:)
Calendar (Page #:)Social Media (Page #:)
Other: Describe: Page #: Save-the-date (Page #:)
Q. Documentation of Successful Completion[see “Guidelines” – page 12]
A copy of your proposed certificate of successful completion mustBE INCLUDED WITH this activity TOOL with the correct statement.
R.Commercial Support(if applicable)[see “Guidelines” – page 13]
Does this activity receive any commercial support? Yes No
If “no”, proceed to Section S.
If “yes”, attach “Commercial Support Agreement(s)” Pages
S.Disclosures Provided to Activity Participants– Methods[see “Guidelines” – page 14]
Disclosures / Promotional Material / Handout / AV Slide1. Requirements for Successful Completion
2. Absence or Presence of Conflicts of Interest
Disclosures required if applicable:
3. Commercial Support / YesN/A / Yes
N/A / Yes
N/A
4. Joint Provider Statement / Yes
N/A / Yes
N/A / Yes
N/A
5. Expiration Date for Awarding Contact Hours(Enduring Materials Only) / Yes
N/AFor PD activity / Yes
N/AFor PD activity / Yes
N/AFor PD activity
A COPY OF THE DOCUMENTATION OF THE WRITTEN DISCLOSURE(S) THAT ADDRESSES ALL OF THE ABOVE COMPONENTS MUST BE INCLUDED WITH THIS TOOL.
T.Joint Providership(if applicable)[see “Guidelines” – page 15]
Will the activity be joint provided? Yes No
If yes, complete the following grid:
Name of joint providing organization(s) / Joint Provider agreement Page #Summative Evaluation:
1.______Nurse Planner initials (required): Upon completion of the activity, a summative evaluation will be generated and kept on file for six (6) years.
2. ______Nurse Planner initials (required): The Nurse Planner in conjunction with the planning committee will review the Summative Evaluation(s) to assess the education activity’s effectiveness and to identify how results may be used to guide future education activities.
Attachments
Please provide evidence of the following:
Attachment 1 / Names and credentials of all individuals in a position to control content (must identify the individuals who fill the roles of Nurse Planner and content expert(s)).Attachment 2 / Conflict of interest documentation from all individuals in a position to control content (e.g. planners, presenters/ authors, and/or content reviewers) and resolution.
Attachment 3 / Education Documentation Form (EDF) for each presentation and an associated Reference List.
Attachment 4 / Post-activity evaluation tool
Attachment 5 / Promotional material(s)
Attachment 6 / Certificate of Successful Completion
Attachment 7 / Commercial Support Agreement(s)with signature(s) and date (if applicable)
Attachment 8 / Joint Provider Agreement(s) with signature(s) and date (if applicable)
Attachment 9 / Disclosures to Participants
- Activity approval statement as issued by the accredited approver
- Criteria for successful completion in order to receive contact hours
- Presence or absence of conflicts of interest for all individuals in a position to control content (e.g. the Planning Committee, presenters, authors and content reviewers)if COI is present, disclosure must include name of person, type of relationship, and name of commercial entity.
- Commercial support (if applicable)
- Expiration date (Learner-Paced materials only)
- Name(s) of Joint Provider(s) (if applicable)
Attachment 10 / Summative evaluation – included in CNE activity file.
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