VIHC - Patient Physician Communicate Near End of Life
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Agreement
By completing this form, you attest that you have attended the activity in its entirety.
I agree
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Please rate the following:
The program was relevant to my work.
Strongly Agree
Agree
I don't know
Disagree
Strongly Disagree
Content matched stated objectives.
Strongly Agree
Agree
I don't know
Disagree
Strongly Disagree
Usefulness of handouts/AV.
Excellent
Very Good
Good
Fair
Poor
Quality of facilities.
Excellent
Very Good
Good
Fair
Poor
How well did the educational sessions give a balanced view of therapeutic options, including the use of generic names?
Excellent
Very Good
Good
Fair
Poor
If you rated any of the above questions with 'fair,' 'poor,' 'disagree,' or 'strongly disagree' please explain in detail (e.g. session title, speaker name, situation):
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Objective 1: Comfortably and empathically initiate conversations about goals of care
By meeting the above objective my professional competence will increase because I have acquired new strategies to use in my practice.
Strongly Agree
Agree
I don't know
Disagree
Strongly Disagree
By meeting the above objective my professional performance will improve because I should be able to implement the new strategies.
Strongly Agree
Agree
I don't know
Disagree
Strongly Disagree
By meeting the above objective my patient outcomes should improve due to the implementation of newly-learned strategies.
Strongly Agree
Agree
I don't know
Disagree
Strongly Disagree
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Objective 2: Utilize and apply prognostic indicator tools to assist them to identify patients who may not be well-served by continued efforts to prolong life in preference to an emphasis on comfort and prevention of suffering
By meeting the above objective my professional competence will increase because I have acquired new strategies to use in my practice.
Strongly Agree
Agree
I don't know
Disagree
Strongly Disagree
By meeting the above objective my professional performance will improve because I should be able to implement the new strategies.
Strongly Agree
Agree
I don't know
Disagree
Strongly Disagree
By meeting the above objective my patient outcomes should improve due to the implementation of newly-learned strategies.
Strongly Agree
Agree
I don't know
Disagree
Strongly Disagree
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Objective 3: Identify what services hospice can offer to benefit patients with end stage illnesses and their families
By meeting the above objective my professional competence will increase because I have acquired new strategies to use in my practice.
Strongly Agree
Agree
I don't know
Disagree
Strongly Disagree
By meeting the above objective my professional performance will improve because I should be able to implement the new strategies.
Strongly Agree
Agree
I don't know
Disagree
Strongly Disagree
By meeting the above objective my patient outcomes should improve due to the implementation of newly-learned strategies.
Strongly Agree
Agree
I don't know
Disagree
Strongly Disagree
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Please answer the following:
Do you believe this activity was appropriate for the scope of your professional activities?
Yes
No
NA
Was the educational content scientifically sound?
Yes
No
NA
Was the mode of education effective for learning?
Yes
No
If you answered 'No' to any of the above questions, please explain:
Did you perceive any product/service/company/commercial bias in any educational session you attended or materials you received?
Yes
No
If you answered "Yes" to the above question, please detail the situation below (e.g. session title, speaker name):
Were you solicited by sales personnel in an
educational room
(other areas do not matter) while you attended this educational activity?
Yes
No
If you answered 'Yes' to the above question, please explain in detail (e.g. who, when, where):
How much did you learn as a result of this educational program?
Great deal
Quite a bit
Some
Very little
Nothing
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What specifically did you learn during this activity that you intend to integrate into your practice?
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What questions have arisen in your practice for which you need answers/strategies that you can implement?
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What patient/client problems or patient/client challenges do you feel you are not able to address appropriately or to your satisfaction?
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What problems are your patients/clients communicating to you that need attention or follow-up?
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Are you interested in basic, intermediate or advanced level trainings?
Basic
Intermediate
Advanced
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What barriers might you have that would interfere with implementation of new information learned from this training?
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How could
this
training (the overall meeting) be improved to better impact competence, performance and/or patient/client outcomes?
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Additional comments:
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