CO-CURRICULAR ACTIVITY (Patient Care) DOCUMENTATION FORM
This form is completed at the conclusion of the co-curricular event and submitted via the on-line MACH Form Link along with submission via the Co-Curricular ePortfolio portal (E-Campus) to
Dr. Simi Gunaseelan no later than 5 p.m. the following business day.
☐ Class of 2022 ☐ Class of 2023 ☐ Class of 2024 ☐ Class of 2025
STUDENT NAME:
Date:
☐ P1
☐ P2
☐ P3
☐ P4
Co-curricular Event Name:
Facility Name:
Street Address:
City:
Associated Student Organization Name/Other Name For This Event:
Description of Event:
Interprofessional Education (IPE) Event:
☐ Yes
☐ No
Record time spent in the co-curricular event
Time In
Time Out
Total Time
If Yes, Indicate IPE Partners:
Record the number of individuals served within each activity (in designated column)
B/P
BG
A1c
Lipid
Panel
Education
Immunization
BMI
Supervisor Title
Supervisor Name
Other
Please Specify
Topic
Supervisor Signature
Comments (Reflect any concerns associated with this event):
The activities from this co-curricular event meets the following Educational Outcome(s) of ACPE Standards 2016 (please check all that apply):
☐ 1.1. Foundational knowledge
☐ 2.4. Population-based care
☐ 3.4. Interprofessional collaboration
☐ 4.2. Leadership
☐ 2.1. Patient-centered care
☐ 3.1. Problem solving
☐ 3.5. Cultural sensitivity
☐ 4.3. Innovation and entrepreneurship
☐ 2.2. Medication use systems management
☐ 3.2. Education
☐ 3.6. Communication
☐ 4.4. Professionalism
☐ 2.3. Health and wellness
☐ 3.3. Patient advocacy
☐ 4.1. Self-awareness
Select the level(s) achieved via the co-curricular activity (Select all that apply):
☐ Level 1: I participated in this experience
☐ Level 2: I will reflect on this experience by writing a guided reflection
☐ Level 3: I will be assessed by a health professional (Faculty/Preceptor) on my learning from this experience
Revision v.2 8/28/19 Gunaseelan
Definition of Educational Outcomes of ACPE Standards 2016
1.1. Foundational Knowledge - Develop, integrate and apply knowledge from the foundational sciences (i.e., pharmaceutical,
social/behavioral/administrative, and clinical sciences) to evaluate the scientific literature, explain drug action, solve
therapeutic problems and advance population health and patient-centered care. (Learner)
2.1. Patient-centered care - Provide patient-centered care as the medication expert (collect and interpret evidence, prioritize,
formulate assessments and recommendations, implement, monitor and adjust plans, and document activities). (Caregiver)
2.2. Medication Use Management System - Manage patient healthcare needs using human, financial, technological, and
physical resources to optimize the safety and efficacy of medication use systems. (Manager)
2.3. Health and Wellness - Design prevention, intervention, and educational strategies for individuals and communities to
manage chronic disease and improve health and wellness. (Promoter)
2.4. Population-based care - Describe how population-based care influences patient-centered care and influences the
development of practice guidelines and evidence-based best practices. (Provider)
3.1. Problem-solving - Identify problems; explore and prioritize potential strategies; and design, implement and evaluate a
viable solution. (Problem Solver)
3.2. Education - Educate all audiences by determining the most effective and enduring ways to impart information and assess
understanding. (Educator)
3.3. Patient Advocacy - Assure that the patients’ best interests are represented. (Advocate)
3.4. Interprofessional collaboration - Actively participate and engage as a healthcare team member by demonstrating mutual
respect, understanding and values to meet patient care needs. (Collaborator)
3.5. Cultural Sensitivity - Recognize social determinants of health to diminish disparities and inequities in access to quality
care. (Includer)
3.6. Communication - Effectively communicate verbally and nonverbally when interacting with an individual, group, or
organization. (Communicator)
4.1. Self-awareness - Examine and reflect on personal knowledge, skills, abilities, beliefs, biases, motivation, and emotions
that could enhance or limit personal and professional growth. (Self-aware)
4.2. Leadership - Demonstrate responsibility for creating and achieving shared goals, regardless of position. (Leader)
4.3. Innovation and Entrepreneurship - Engage in innovation activities by using creative thinking to envision better ways of
accomplishing professional goals. (Innovator)
4.4. Professionalism - Exhibit behaviors and values that are consistent with the trust given to the profession by patients, other
healthcare providers and society. (Professional)