Goals of Care Conversations and Advanced Care Planning

Program Evaluation

We appreciate your participation in our continuing education activity. Your responses will allow us to improve our program offerings and services. Thank you for your time.

SECTION 1
Please use the scale below to rate the questions:
1= Not at all confident
2= Somewhat confident
3= Mostly confident
4= Fully confident

Question Title

* 1. Evaluation of Training
Using the rating key, how confident were you BEFORE in your ability to:

	1	2	3	4
Discuss methods to help patients identify a surrogate decision maker.	Discuss methods to help patients identify a surrogate decision maker. 1	Discuss methods to help patients identify a surrogate decision maker. 2	Discuss methods to help patients identify a surrogate decision maker. 3	Discuss methods to help patients identify a surrogate decision maker. 4
Describe advance care planning billing codes and when to use them.	Describe advance care planning billing codes and when to use them. 1	Describe advance care planning billing codes and when to use them. 2	Describe advance care planning billing codes and when to use them. 3	Describe advance care planning billing codes and when to use them. 4
Summarize how and when to fill out a MOLST	Summarize how and when to fill out a MOLST 1	Summarize how and when to fill out a MOLST 2	Summarize how and when to fill out a MOLST 3	Summarize how and when to fill out a MOLST 4
Apply best language for talking with patients about serious illness and goals of care	Apply best language for talking with patients about serious illness and goals of care 1	Apply best language for talking with patients about serious illness and goals of care 2	Apply best language for talking with patients about serious illness and goals of care 3	Apply best language for talking with patients about serious illness and goals of care 4

Question Title

* 2. Evaluation of Training
Using the rating key, how confident are you AFTER in your ability to:

	1	2	3	4
Discuss methods to help patients identify a surrogate decision maker.	Discuss methods to help patients identify a surrogate decision maker. 1	Discuss methods to help patients identify a surrogate decision maker. 2	Discuss methods to help patients identify a surrogate decision maker. 3	Discuss methods to help patients identify a surrogate decision maker. 4
Describe advance care planning billing codes and when to use them.	Describe advance care planning billing codes and when to use them. 1	Describe advance care planning billing codes and when to use them. 2	Describe advance care planning billing codes and when to use them. 3	Describe advance care planning billing codes and when to use them. 4
Summarize how and when to fill out a MOLST	Summarize how and when to fill out a MOLST 1	Summarize how and when to fill out a MOLST 2	Summarize how and when to fill out a MOLST 3	Summarize how and when to fill out a MOLST 4
Apply best language for talking with patients about serious illness and goals of care	Apply best language for talking with patients about serious illness and goals of care 1	Apply best language for talking with patients about serious illness and goals of care 2	Apply best language for talking with patients about serious illness and goals of care 3	Apply best language for talking with patients about serious illness and goals of care 4

Question Title

* 3. Evaluation of Presenter
To what extent did the presenter accomplish the following:

	1	2	3	4
a. Presented information clearly	a. Presented information clearly 1	a. Presented information clearly 2	a. Presented information clearly 3	a. Presented information clearly 4
b. Knowledge of Subject	b. Knowledge of Subject 1	b. Knowledge of Subject 2	b. Knowledge of Subject 3	b. Knowledge of Subject 4
c. Quality of Material	c. Quality of Material 1	c. Quality of Material 2	c. Quality of Material 3	c. Quality of Material 4
d. Practical applicability or relevance of topic	d. Practical applicability or relevance of topic 1	d. Practical applicability or relevance of topic 2	d. Practical applicability or relevance of topic 3	d. Practical applicability or relevance of topic 4

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* 4. What was the most significant thing(s) you learned today?

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* 5. Do you intend to implement at least one practice improvement learned as a result of this learning activity?

Yes

N/A

If yes, please describe:

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* 6. What could we do to improve this training session? Please feel free to share any additional comments and suggestions. Your feedback is extremely valuable to us.

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* 7. Are you interested in receiving continuing education credits?

Yes

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* 8. If yes, what type of continuing education credit are you interested in?

Social Work

Medicine (CME)

Certificate of Attendance

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* 9. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Roger Williams Medical Center and the Rhode Island Geriatric Education Center. Roger Williams Medical Center is accredited by the Rhode Island Medical Society to provide continuing medical education for physicians.

Roger Williams Medical Center designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Please claim credit based on the time you spent in this activity.

I claim _____credit(s).

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* 10. Please enter your information (below) so we may send you a certificate

Full Name and Credentials

Preferred Email address

Organization

State

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* 1. Evaluation of TrainingUsing the rating key, how confident were you BEFORE in your ability to:

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* 2. Evaluation of TrainingUsing the rating key, how confident are you AFTER in your ability to:

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* 3. Evaluation of PresenterTo what extent did the presenter accomplish the following:

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* 4. What was the most significant thing(s) you learned today?

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* 5. Do you intend to implement at least one practice improvement learned as a result of this learning activity?

Question Title

* 6. What could we do to improve this training session? Please feel free to share any additional comments and suggestions. Your feedback is extremely valuable to us.

Question Title

* 7. Are you interested in receiving continuing education credits?

Question Title

* 8. If yes, what type of continuing education credit are you interested in?

Question Title

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* 10. Please enter your information (below) so we may send you a certificate

* 1. Evaluation of Training
Using the rating key, how confident were you BEFORE in your ability to:

* 2. Evaluation of Training
Using the rating key, how confident are you AFTER in your ability to:

* 3. Evaluation of Presenter
To what extent did the presenter accomplish the following: