SLIDEREAD

Completed formsand templates

ContentsThe forms and templates in this pack are examples of how a nurse or midwifemay record how they meet the requirements of revalidation. These include reallife examples taken from nurses or midwives who have already revalidated.This is not a sample portfolio of one individual nurse or midwife. The packincludes a variety of forms and templates, designed to reflect multiple practicesettings and different ways of approaching the process.1. Practice hours logSecondary care - Dual registered nurse and midwifeUniversity – Nursing lecturerPrimary care - Practice nurse3452. Continuing professional development logSecondary care – Staff nurse63. Feedback logSecondary care – Midwife84. Reflective accounts form (mandatory)Community – District nurseCommunity – Health visitorCosmetic sector – self-employed aesthetic nurse1012145. Reflective discussion form (mandatory)Care home – Staff nurse166. Confirmation form (mandatory)Care home – Staff nurse17The reflective accounts, reflective discussion and confirmation forms are allmandatory for revalidation.

Guide to completing practice hours logWork settingTo record your hours of practice as a registered nurseand/or midwife, please fill in a page for each of yourperiods of practice. Please enter your most recentpractice first and then any other practice until you reach450 hours. You do not necessarily need to recordindividual practice hours. You can describe yourpractice hours in terms of standard working days orweeks. For example if you work full time, please justmake one entry of hours. If you have worked in a rangeof settings please set these out individually. You mayneed to print additional pages to add more periods ofpractice. If you are both a nurse and midwife you willneed to provide information to cover 450 hours ofpractice for each of these registrations. Dates:10/12– Current Ambulance serviceCare home sectorCommunity setting (includingdistrict nursing and communitypsychiatric nursing)ConsultancyCosmetic or aesthetic sectorGoverning body or otherleadershipGP practice or other primarycareHospital or other secondarycareInspectorate or regulatorInsurance or legalName andaddress oforganisation:Your worksettingYour scopeof practice(choose from list above):(choose from list above):London Hospital,London Road,London.HospitalDirect patientcare Maternity unit or birth centreMilitaryOccupational healthPolicePolicy organisationPrisonPrivate domestic settingPublic health organisationSchoolSpecialist or other tertiary careincluding hospiceTelephone or e-health adviceTrade union or professionalbodyUniversity or other researchfacilityVoluntary or charity sectorOtherNumberof hours:YourregistrationScope of practice irect patient careQuality assurance or inspectionRegistration NurseMidwifeNurse/SCPHNMidwife/SCPHNNurse and Midwife (includingNurse/SCHPN andMidwife/SCPHN)Brief description of your work:(choose from list above):Full time 37.5hours per weekNurse andmidwifeMidwife on labour and PN ward, also relyon nursing skills, knowledge &experience; every day. Caring for womenand babies in labour and postpartumperiod; caring for women postoperatively; CTG monitoring; suturing;breastfeeding support; examination ofthe new born.Page 3 of 19

Guide to completing practice hours logWork settingTo record your hours of practice as a registered nurseand/or midwife, please fill in a page for each of yourperiods of practice. Please enter your most recentpractice first and then any other practice until you reach450 hours. You do not necessarily need to recordindividual practice hours. You can describe yourpractice hours in terms of standard working days orweeks. For example if you work full time, please justmake one entry of hours. If you have worked in a rangeof settings please set these out individually. You mayneed to print additional pages to add more periods ofpractice. If you are both a nurse and midwife you willneed to provide information to cover 450 hours ofpractice for each of these registrations. Dates:Name andaddress oforganisation:June – NorwichJune University,Norwich Road,Norwich. Ambulance serviceCare home sectorCommunity setting (includingdistrict nursing and communitypsychiatric nursing)ConsultancyCosmetic or aesthetic sectorGoverning body or otherleadershipGP practice or other primarycareHospital or other secondarycareInspectorate or regulatorInsurance or legalYour worksettingYour scopeof practice(choose from list above):(choose from list above):UniversityEducation Numberof hours:Maternity unit or birth centreMilitaryOccupational healthPolicePolicy organisationPrisonPrivate domestic settingPublic health organisationSchoolSpecialist or other tertiary careincluding hospiceTelephone or e-health adviceTrade union or professionalbodyUniversity or other researchfacilityVoluntary or charity sectorOtherYourregistrationScope of practice irect patient careQuality assurance or inspectionRegistration NurseMidwifeNurse/SCPHNMidwife/SCPHNNurse and Midwife (includingNurse/SCHPN andMidwife/SCPHN)Brief description of your work:(choose from list above):1600 hrs per year NurseTeaching pre-registration nurses, andteaching post qualifying courses at underand post graduate level.Link lecturer, practice liaison andassociated activities, marking.Page 4 of 19

Guide to completing practice hours logWork settingTo record your hours of practice as a registered nurseand/or midwife, please fill in a page for each of yourperiods of practice. Please enter your most recentpractice first and then any other practice until you reach450 hours. You do not necessarily need to recordindividual practice hours. You can describe yourpractice hours in terms of standard working days orweeks. For example if you work full time, please justmake one entry of hours. If you have worked in a rangeof settings please set these out individually. You mayneed to print additional pages to add more periods ofpractice. If you are both a nurse and midwife you willneed to provide information to cover 450 hours ofpractice for each of these registrations. Dates:6 January Current Ambulance serviceCare home sectorCommunity setting (includingdistrict nursing and communitypsychiatric nursing)ConsultancyCosmetic or aesthetic sectorGoverning body or otherleadershipGP practice or other primarycareHospital or other secondarycareInspectorate or regulatorInsurance or legalName andaddress oforganisation:Your worksettingYour scopeof practice(choose from list above):(choose from list above):Heatherfield GPPractice, LeedsRoad, Leeds.GP practiceDirect patientcare Maternity unit or birth centreMilitaryOccupational healthPolicePolicy organisationPrisonPrivate domestic settingPublic health organisationSchoolSpecialist or other tertiary careincluding hospiceTelephone or e-health adviceTrade union or professionalbodyUniversity or other researchfacilityVoluntary or charity sectorOtherNumberof hours:YourregistrationScope of practice irect patient careQuality assurance or inspectionRegistration NurseMidwifeNurse/SCPHNMidwife/SCPHNNurse and Midwife (includingNurse/SCHPN andMidwife/SCPHN)Brief description of your work:(choose from listabove):12 hours perweek approx.560 hours peryearNursePart of primary healthcare team, with dutiesincluding:- Venepuncture- Travel health advice and vaccinations- Smoking cessation- Family planning & women’s healthPage 5 of 19

Guide to completing CPD record logExamples of learning methodWhat was the topic?Link to CodePlease provide the following information for eachlearning activity, until you reach 35 hours of CPD(of which 20 hours must be participatory). Forexamples of the types of CPD activities you couldundertake, and the types of evidence you couldretain, please refer to Guidance sheet 3 in How torevalidate with the NMC. Please give a brief outline of the keypoints of the learning activity, how itis linked to your scope of practice,what you learnt, and how you haveapplied what you learnt to yourpractice.Please identify the part or parts of the Code relevantto the CPD.Prioritise people Practise effectively Preserve safety Promote professionalism and trustDates:Online learningCourse attendanceIndependent learningMethodTopic(s):Link to Code:Number ofhours:Number ofparticipatoryhours:Clinical mandatory trainingUpdate for all clinical aspects relevant to myrole, including blood transfusion, manualhandling and safeguarding. Some of what wecovered I already knew, but it was good torefresh. I learned that there was a new bloodtransfusion policy and a new procedure forcollecting blood from the fridge. I haven’t donethis in practice for a while so it was importantthat I learnt this.PractiseeffectivelyPreserve safety7.50Please describe the methods you used for the activity:4.4.14Independent learning – online coursePage 6 of 19

27.5.14Course attendanceIV Therapy. This course enabled me to learnthe theory and practice behind IV therapy. Alsogot to practise aseptic non touch technique(ANTT). I have increased my knowledge andam now able to deliver IV therapy safely.PractiseeffectivelyPreserve safety3.6 Independent learning – reading articleCaring for people who are dying:priorities at the end of life. Read CPDarticle in Nursing Standard. Gained newideas which I will reflect on and discusswith my team, with a view to makingchanges to our practice.Prioritise people.6.14Meeting attendanceMentor update. Face to face sessionwhich informed me of recent changes tostudent nurse training and reminded meof the standards I need to achieve as amentor. Allowed me to reflect on my roleas a mentor and role model to students inthe last six months.Prioritise people 331.3.16Conference attendanceRCN Education Conference. Attendedtwo-day conference. Presentations onquality surgical nursing and its impact onclinical practice were particularly relevantto me. I will present these ideas to theteam at our next meeting, and havegained some ideas on implementing moretraining in my area.PractiseeffectivelyPreserve safety1515Total:35Total:25.57.57.5Page 7 of 19

Guide to completing a feedback logExamples of sources of feedbackExamples of types of feedbackPlease provide the following information for each ofyour five pieces of feedback. You should not recordany information that might identify an individual,whether that individual is alive or deceased.Guidance Sheet 1 in How to revalidate with theNMC provides guidance on how to make sure thatyour notes do not contain any information that mightidentify an individual. Patients or service usersColleagues – nurses midwives, otherhealthcare professionalsStudentsAnnual appraisalTeam performance reportsSerious event reviewsVerbalLetter or cardSurveyReportYou might want to think about how your feedbackrelates to the Code, and how it could be used inyour reflective accounts.Date1.7 10.8 Source of feedbackType of feedbackWhere did this feedbackcome from?How was the feedbackreceived?StudentWoman I looked after on PNwardVerbal, in a meeting to reviewplacement documentationThank you letterContent of feedbackWhat was the feedback about and how has it influenced your practice?The student found it valuable when I let her take the lead in apostnatal baby check. I will encourage my students to take the leadmore often and try to only provide direction when they need it.Linked to ‘promote professionalism and trust’ in the Code.Thanking me for supporting her and her partner throughout thedischarge process. Highlighted the importance of taking time to makesure women feel confident and comfortable before they are senthome with their new baby. Linked to ‘prioritise people’ in the Code.Page 8 of 19

12.11 3.2 7.5 Annual appraisalPatientColleagueVerbalWritten complaintVerbalGave me feedback on my leadership style. We discussed what workswell, and areas where I could improve. We also talked about aleadership course which I am going to attend next month.A complaint was received about the ward, from a woman who felt shereceived poor care, inadequate support with breastfeeding and wasnot kept in the loop about discharge process. Will reflect on this in oneof my reflective accounts. Linked to ‘prioritise people’ in the Code.I asked a more experienced midwife on the ward to observe abreastfeeding support session I lead, and give me feedback. Wetalked about what I did well, and some new ideas and techniques Icould include in my session. Will reflect on this in one of my reflectiveaccounts.Page 9 of 19

You must use this form to record five written reflective accounts on your CPD and/or practice-related feedbackand/or an event or experience in your practice and how this relates to the Code. Please fill in a page for eachof your reflective accounts, making sure you do not include any information that might identify a specificpatient, service user or colleague. Please refer to our guidance on preserving anonymity in Guidance sheet 1in How to revalidate with the NMC.Reflective account: Community – District nurseWhat was the nature of the CPD activity and/or practice-related feedbackand/or event or experience in your practice?CPD participatory activity. Attending a Manual Handler Transfer Specialist course.What did you learn from the CPD activity and/or feedback and/or event orexperience in your practice?As an experienced community nurse I have had to adapt to various environments to delivercare safely and effectively. Working within the community team we provide care for patientswith complex health care needs at home, most presenting with limited ability to mobiliseand transfer independently. I participated in the manual handling transfer specialist trainingcourse to develop the team’s knowledge and skills in patient ha