PPR-NL Practice Profile Questionnaire - CPSNL

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PPR-NL Practice Profile Questionnaire

CPSNL>Quality>Physician Peer Review (PPR-NL)>PPR-NL Practice Profile Questionnaire

PPR-NL Practice Profile Questionnaire

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PPR-NL Practice Profile Questionnaire - Family Medicine

Step 1 of 7 - About You & Training

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Section 1: About You

Name(Required)

Surname First Name

Gender(Required)

Male

Female

Other

Date of Birth(Required)

MM slash DD slash YYYY

Current Email(Required)

Section 2: Training

Medical School(Required)

Date(Required)

MM slash DD slash YYYY

Postgraduate Certification(Required)

Date(Required)

MM slash DD slash YYYY

Postgraduate Certification

Date

MM slash DD slash YYYY

Postgraduate Certification

Date

MM slash DD slash YYYY

Postgraduate Certification

Date

MM slash DD slash YYYY

Current Licence Type(Required)

Primary Specialty or Practice Type(Required)

Languages used in practice and record keeping (choose all that apply)(Required)

English

French

Other (specify)

If OTHER, please list(Required)

Practice Description

Approximately how many hours per week do you spend in the practice of medicine?

Consider the past 12 months, excluding holidays and leaves of absence.
Respond in terms of a typical or average week.
Provide the number of hours per week for ALL activities related to the practice of medicine, including non-clinical roles.

Clinical Practice (Patient Care)
(including direct and indirect patient care, documentation, review of related communications and laboratory results)

Hours of Clinical Practice per Week(Required)

Please enter a number greater than or equal to 0.

Professional Development (Personal)
(e.g., continued medical education, quality improvement and assurance activities)

Hours of Professional Development per Week(Required)

Please enter a number greater than or equal to 0.

Education (of Others)
(e.g., clinical and non-clinical teaching or assessment of other health professionals, curriculum development and program oversight, etc)

Hours of Education (of others) per Week(Required)

Please enter a number greater than or equal to 0.

Administration
(e.g., non-clinical administrative duties for a practice, practice group, health care facility, government or non-governmental health agency, etc)

Hours of Administration per Week(Required)

Please enter a number greater than or equal to 0.

Research
(including all aspects of clinical or non-clinical medical research)

Hours of Research per Week(Required)

Please enter a number greater than or equal to 0.

Other (specify)

Hours per Week

Please enter a number greater than or equal to 0.

Section 4: Clinical Practice

Please indicate ALL the clinical practice locations in which you provide care.

Indicate the approximate number of hours per week you spend in each location.
Include both permanent and locum positions.

Family Medicine
(primary care, typically by appointment)

Hours of Family Medicine per Week(Required)

Please enter a number greater than or equal to 0.

Walk-in or Episodic Care
(primary care, typically without appointment )

Hours of Walk-in or Episodic Care per Week(Required)

Please enter a number greater than or equal to 0.

Emergency Medicine
(Emergency Department or Collaborative Emergency Centre)

Hours of Emergency Medicine per Week(Required)

Please enter a number greater than or equal to 0.

Community-based Specialist other than Family Medicine
(office practice or private facility)

Hours of Community Based Specialty per Week(Required)

Please enter a number greater than or equal to 0.

Hospital-based practice
(including out-patient clinics, consultation, in-patient care, laboratory or diagnostic imaging)

Hours of Hospital Based Practice per Week(Required)

Please enter a number greater than or equal to 0.

Residential or Long-term Care Facility

Hours of Residential or Long-term Care per Week(Required)

Please enter a number greater than or equal to 0.

House calls
(to patients in a private resident, excluding long-term care facilities)

Hours of House Calls per Week(Required)

Please enter a number greater than or equal to 0.

Occupational Medicine
(Workplace based)

Hours of Occupational Medicine per Week(Required)

Please enter a number greater than or equal to 0.

Government agency
(e.g., Department of Justice, Public Health, etc.)

Hours Government Agency Work per Week(Required)

Please enter a number greater than or equal to 0.

Other (specify)

Hours per Week

Please enter a number greater than or equal to 0.

Select the one practice location that you consider to be your main clinical practice(Required)

Section 4: Clinical Practice (continued)

Do you provide locum coverage to other physicians?(Required)

Yes

No

If YES, choose ONE of the following that best describes your locum practice:(Required)

I provide locum coverage in addition to having my own established clinical practice

I provide exclusively locum coverage (1-2 locum sites per year)

I provide exclusively locum coverage (3 or more locum sites per year)

With respect to your clinical practice, do you typically share patient care responsibilities with colleagues of the same specialty?(Required)

Yes

No

If YES, what would be the nature of this shared care (choose ALL that apply):(Required)

I make entries in a shared patient record

I share on call responsibilities with other physicians in my discipline or specialty

I regularly participate in formal patient handover with colleagues

I regularly collaborate with physicians in my discipline or specialty when planning patient care

I provide consultation services to physicians in other disciplines or specialties

Other

If OTHER, please specify:(Required)

With respect to your clinical practice, do you directly work with other health care professionals, excluding administrative staff?(Required)

Yes

No

If YES, indicate ALL that apply:(Required)

Physicians

Nurses

Nurse Practitioners

Licensed Practical Nurses

Physiotherapists

Occupational Therapists

Paramedics

Physician Assistants

Other

If OTHER, please specify:(Required)

Do you have a formal agreement with MUN's Faculty of Medicine to provide regular clinical (bedside) teaching to Undergraduate (Medical Students)?(Required)

Yes

No

If YES, approximately how many hours per week?(Required)

Do you have a formal agreement with MUN's Faculty of Medicine to provide regular clinical (bedside) teaching to Postgraduate Trainees (Residents)?(Required)

Yes

No

If YES, approximately how many hours per week?(Required)

Do you currently have privileges to a provincial hospital?(Required)

Yes

No

If YES, list the name of each facility and the privileges you hold below:(Required)

Name of Facility

Types of Privileges

What type of Medical Record do you use in your main clinical practice?(Required)

Paper-based record

Electronic Medical Record

Hospital Record (any type)

If EMR, please specify type:(Required)

What arrangement(s) do you currently have in place to ensure that urgent medical advice is available to patients outside of regular office/clinic hours? (e.g., a schedule of on-call coverage outside of regular office hours arranged with colleagues, etc.)(Required)

Do you provide care where you are required to stay overnight in a hospital or facility?(Required)

Yes

No

If YES, for how many nights per month on average?(Required)

2 or fewer nights per month

3-4 nights per month

5 or more nights per month

Section 5: Patients

How large is the community in which you practice?(Required)

Fewer than 5,000 people

Between 5,000 and 20,000 people

More than 20,000 people

Approximately how large is your personal patient roster in your primary practice?(Required)

< 1000 patients

1000-2000 Patients

over 2000 patients

N/A (Episodic or Emergency Care only)

Describe your approximate Patient Distribution (by gender)

Male(Required)

Female(Required)

Other(Required)

Describe your approximate Patient Distribution (by age group)

Infant (Birth - 1 Year)(Required)

Child (1 - 11)(Required)

Adolescent (12 - 18)(Required)

Adult (19 - 64)(Required)

Geriatric (over 65)(Required)

Describe your approximate Patient Distribution (by visit type)

Preventative or Continuing Care(Required)

Acute Care (new complaint)(Required)

Do you work in an outpatient or clinic setting?(Required)

Yes

No

If YES, approximately how many patients would you care for in one hour, on average?(Required)

Section 6: Scope of Practice

List the TEN most common conditions that you encounter in your main clinical practice(Required)

List up to FIVE medical procedures that you commonly perform in your main clinical practice(Required)

Since completing your postgraduate medical training, have you significantly restricted or focused your scope of practice? (e.g., a Family Physician who no longer practices intra-partum obstetrics or an Orthopedia Surgeon who mainly focuses on joint replacement)(Required)

Yes

No

If YES, please describe:(Required)

Is your primary practice in a field for which you were NOT originally trained? That is, do you have a specific practice focus that would not have been considered the main focus of your original postgraduate training? (e.g., A family Physician who practices mainly Emergency Medicine or a General Surgeon who practices cosmetic medicine)(Required)

Yes

No

If YES, how did you prepare for the transition to the new scope of practice? (check ALL that apply)(Required)

Training program offered by CCFP or RCPSC

Formal Hospital or University-based Fellowship

Informal clinical placement or mentorship

Self-study

Other

If OTHER, please specify:(Required)

Are you planning a significant change in your practice over the next five years(Required)

Yes

No

If YES, choose one or more of the following:(Required)

Increase my scope of practice

Reduce my scope of practice

Partial Retirement

Full Retirement

Other

If OTHER, please specify:(Required)

Do you currently have a formal administrative role with a publicly run health care facility, government health department, university, medical training body or regulator?(Required)

Yes

No

If YES, please describe:(Required)

Section 7: Continuing Professional Development

Are you currently enrolled and in compliance with the professional development framework or either the College of Family Physicians of Canada (Mainpro+) or Royal College of Physicians and Surgeons of Canada (MOC)?(Required)

I am enrolled and compliant. That is, I have met the minimum requirements in my current 5 year cycle

I am enrolled, but have missed some requirements for my current cycle

I am not enrolled in either program

I am not sure

I attest that this is an accurate representation of my practice.(Required)

I acknowledge that I have read and understand the above statement.

Full Name(Required)

First

Date(Required)

MM slash DD slash YYYY

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(709) 726-4725

Email

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