PPR-NL Practice Profile Questionnaire
PPR-NL Practice Profile Questionnaire – Family Medicine
Step
1
of
7
– About You & Training
0%
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)
Family Medicine
Walk-in or Episodic Care
Emergency Medicine
Community-based Specialist other than Family Medicine
Hospital-based practice
Residential or Long-term Care Facility
House calls
Occupational Medicine
Government agency
Other
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
Add
Remove
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)
Add
Remove
List up to FIVE medical procedures that you commonly perform in your main clinical practice
(Required)
Add
Remove
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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