Completed Revalidation Forms and Templates

1 Completed Forms and Templates Contents The Forms and Templates in this pack are examples of how a nurse or midwife may record how they meet the requirements of Revalidation . These include real life examples taken from nurses or midwives who have already revalidated. This is not a sample portfolio of one individual nurse or midwife. The pack includes a variety of Forms and Templates , designed to reflect multiple practice settings and different ways of approaching the process. 1. Practice hours log Secondary care - Dual registered nurse and midwife 3. University Nursing lecturer 4. Primary care - Practice nurse 5. 2. Continuing professional development log Secondary care Staff nurse 6. 3. Feedback log Secondary care Midwife 8. 4. Reflective accounts form (mandatory). Community District nurse 10. Community Health visitor 12. Cosmetic sector self-employed aesthetic nurse 14. 5. Reflective discussion form (mandatory).

2 Care home Staff nurse 16. 6. Confirmation form (mandatory). Care home Staff nurse 17. The reflective accounts, reflective discussion and confirmation Forms are all mandatory for Revalidation . Guide to completing practice hours log Work setting Maternity unit or birth centre Scope of practice Military To record your hours of practice as a registered nurse Ambulance service Commissioning Occupational health and/or midwife, please fill in a page for each of your Care home sector Consultancy Police periods of practice. Please enter your most recent Community setting (including Education Policy organisation practice first and then any other practice until you reach district nursing and community Management psychiatric nursing) Prison 450 hours. You do not necessarily need to record Policy Private domestic setting individual practice hours. You can describe your Consultancy Direct patient care Public health organisation practice hours in terms of standard working days or Cosmetic or aesthetic sector Quality assurance or inspection School weeks.

3 For example if you work full time, please just Governing body or other leadership Specialist or other tertiary care Registration make one entry of hours. If you have worked in a range including hospice GP practice or other primary Nurse of settings please set these out individually. You may care Telephone or e-health advice Midwife need to print additional pages to add more periods of Trade union or professional Hospital or other secondary Nurse/SCPHN. practice. If you are both a nurse and midwife you will body care Midwife/SCPHN. need to provide information to cover 450 hours of University or other research Inspectorate or regulator Nurse and Midwife (including practice for each of these registrations. facility Insurance or legal Nurse/SCHPN and Voluntary or charity sector Midwife/SCPHN). Other Dates: Name and Your work Your scope Number Your Brief description of your work: address of setting of practice of hours: registration organisation: (choose from list above): (choose from list above): (choose from list above): 10/12/2010 London Hospital, Hospital Direct patient Full time Nurse and Midwife on labour and PN ward, also rely Current London Road, care hours per week midwife on nursing skills, knowledge &.

4 London. experience every day. Caring for women and babies in labour and postpartum period; caring for women post- operatively; CTG monitoring; suturing;. breastfeeding support; examination of the new born. Page 3 of 19. Guide to completing practice hours log Work setting Maternity unit or birth centre Scope of practice Military To record your hours of practice as a registered nurse Ambulance service Commissioning Occupational health and/or midwife, please fill in a page for each of your Care home sector Consultancy Police periods of practice. Please enter your most recent Community setting (including Education Policy organisation practice first and then any other practice until you reach district nursing and community Management psychiatric nursing) Prison 450 hours. You do not necessarily need to record Policy Private domestic setting individual practice hours. You can describe your Consultancy Direct patient care Public health organisation practice hours in terms of standard working days or Cosmetic or aesthetic sector Quality assurance or inspection School weeks.

5 For example if you work full time, please just Governing body or other leadership Specialist or other tertiary care Registration make one entry of hours. If you have worked in a range including hospice GP practice or other primary Nurse of settings please set these out individually. You may care Telephone or e-health advice Midwife need to print additional pages to add more periods of Trade union or professional Hospital or other secondary Nurse/SCPHN. practice. If you are both a nurse and midwife you will body care Midwife/SCPHN. need to provide information to cover 450 hours of University or other research Inspectorate or regulator Nurse and Midwife (including practice for each of these registrations. facility Insurance or legal Nurse/SCHPN and Voluntary or charity sector Midwife/SCPHN). Other Dates: Name and Your work Your scope Number Your Brief description of your work: address of setting of practice of hours: registration organisation: (choose from list above): (choose from list above): (choose from list above): June 2013 Norwich University Education 1600 hrs per year Nurse Teaching pre-registration nurses, and June 2016 University, teaching post qualifying courses at under Norwich Road, and post graduate level.

6 Norwich. Link lecturer, practice liaison and associated activities, marking. Page 4 of 19. Guide to completing practice hours log Work setting Maternity unit or birth centre Scope of practice Military To record your hours of practice as a registered nurse Ambulance service Commissioning Occupational health and/or midwife, please fill in a page for each of your Care home sector Consultancy Police periods of practice. Please enter your most recent Community setting (including Education Policy organisation practice first and then any other practice until you reach district nursing and community Management psychiatric nursing) Prison 450 hours. You do not necessarily need to record Policy Private domestic setting individual practice hours. You can describe your Consultancy Direct patient care Public health organisation practice hours in terms of standard working days or Cosmetic or aesthetic sector Quality assurance or inspection School weeks.

7 For example if you work full time, please just Governing body or other leadership Specialist or other tertiary care Registration make one entry of hours. If you have worked in a range including hospice GP practice or other primary Nurse of settings please set these out individually. You may care Telephone or e-health advice Midwife need to print additional pages to add more periods of Trade union or professional Hospital or other secondary Nurse/SCPHN. practice. If you are both a nurse and midwife you will body care Midwife/SCPHN. need to provide information to cover 450 hours of University or other research Inspectorate or regulator Nurse and Midwife (including practice for each of these registrations. facility Insurance or legal Nurse/SCHPN and Voluntary or charity sector Midwife/SCPHN). Other Dates: Name and Your work Your scope Number Your Brief description of your work: address of setting of practice of hours: registration organisation: (choose from list above): (choose from list above): (choose from list above): 6 January Heatherfield GP GP practice Direct patient 12 hours per Nurse Part of primary healthcare team, with duties 2008 - Practice, Leeds care week = approx.

8 Including: Current Road, Leeds. 560 hours per - Venepuncture year - Travel health advice and vaccinations - Smoking cessation - Family planning & women's health Page 5 of 19. Guide to completing CPD record log Examples of learning method What was the topic? Link to Code Please provide the following information for each Online learning Please give a brief outline of the key Please identify the part or parts of the Code relevant learning activity, until you reach 35 hours of CPD Course attendance points of the learning activity, how it to the CPD. (of which 20 hours must be participatory). For Independent learning is linked to your scope of practice, Prioritise people what you learnt, and how you have Practise effectively examples of the types of CPD activities you could applied what you learnt to your Preserve safety undertake, and the types of evidence you could practice. Promote professionalism and trust retain, please refer to Guidance sheet 3 in How to revalidate with the NMC.

9 Dates: Method Topic(s): Link to Code: Number of Number of Please describe the methods you used for the activity: hours: participatory hours: Independent learning online course Clinical mandatory training Practise 0. Update for all clinical aspects relevant to my effectively role, including blood transfusion, manual Preserve safety handling and safeguarding. Some of what we covered I already knew, but it was good to refresh. I learned that there was a new blood transfusion policy and a new procedure for collecting blood from the fridge. I haven't done this in practice for a while so it was important that I learnt this. Page 6 of 19. Course attendance IV Therapy. This course enabled me to learn Practise the theory and practice behind IV therapy. Also effectively got to practise aseptic non touch technique Preserve safety (ANTT). I have increased my knowledge and am now able to deliver IV therapy safely. Independent learning reading article Caring for people who are dying: Prioritise people 2 0.

10 Priorities at the end of life. Read CPD. article in Nursing Standard. Gained new ideas which I will reflect on and discuss with my team, with a view to making changes to our practice. Meeting attendance Mentor update. Face to face session Prioritise people 3 3. which informed me of recent changes to student nurse training and reminded me of the standards I need to achieve as a mentor. Allowed me to reflect on my role as a mentor and role model to students in the last six months. Conference attendance RCN Education Conference. Attended Practise 15 15. two-day conference. Presentations on effectively quality surgical nursing and its impact on Preserve safety clinical practice were particularly relevant to me. I will present these ideas to the team at our next meeting, and have gained some ideas on implementing more training in my area. Total: Total: 35 Page 7 of 19. Guide to completing a feedback log Examples of sources of feedback Examples of types of feedback Please provide the following information for each of Patients or service users Verbal your five pieces of feedback.