Revalidation pack
This is a pack of templates to support the revalidation process, including:
Practice hours record log
2-3
Template Continuing Professional Development (CPD) record log
4-7
Template: Reflective accounts record log
8 - 14
Professional development discussion (PDD) form
15 - 16
Confirmation from a third party form
17 - 19
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1
Practice hours record log
Dates
1st April 2015
–
st
31 March
2016
1st April 2014
–
st
31 March
2015
Name and
address of
organisation
Wirral University
Teaching
Hospital
Arrowe Park
Hospital
Wirral
CH495PE
Wirral University
Teaching
Hospital
Clatterbridge
Hospital
Wirral
CH63 4JY
Type of
organisation
Hospital
Hospital
Scope of
practice
Number
of hours
 Management
 Education
 Direct Patient
Care
1650
 Management
 Education
 Direct Patient
Contact
1650
#PROUD TO CARE FOR YOU
Registration
Brief description of work
Nurse
Working within general medical ward
duties include:
Medicine administration including IV
Cannulation, venepuncture, urinary
catheter insertion and care, care to
support activities of daily living, care
assessments (various), referral and
support to multidisciplinary team both
internal and outside agencies,
safeguarding, emergency care, advocacy,
support of nursing and medical students,
Instructor for ALS and support clinical
training on the ward.
Nurse
Working within general medical ward
duties include:
Medicine administration including IV
Cannulation, venepuncture, urinary
catheter insertion and care, care to
support activities of daily living, care
assessments (various), referral and
support to multidisciplinary team both
internal and outside agencies,
safeguarding, emergency care, advocacy,
support of nursing and medical students,
Instructor for ALS and support clinical
training on the ward.
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2
1st April 2013
–
st
31 March
2014
Wirral University
Teaching
Hospital Arrowe
Park Hospital
Wirral
CH495PE
Guide to completing practice
hours log:
Hospital
 Management
 Education
 Direct Patient
Contact
1650
To record you hours of practice as a registered nurse and/or midwife, please enter you most recent practice first and then any other
practice until you reach 450 hours. You do not necessarily need to record individual practice hours. You can describe your practice
hours in team of standard working days or weeks. For example if you work full time, please just make one entry of hours. If you have
worked in a range of setting please set these out individually. You may need to print additional pages to add more periods of
practice.. if you are both a nurse and midwife you will need to provide information to cover 450 hours of practice of these registrations
Work settings (select appropriate setting:
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Nurse
Working within general medical ward
duties include:
Medicine administration including IV
Cannulation, venepuncture, urinary
catheter insertion and care, care to
support activities of daily living, care
assessments (various), referral and
support to multidisciplinary team both
internal and outside agencies,
safeguarding, emergency care, advocacy,
support of nursing and medical students,
Instructor for ALS and support clinical
training on the ward
Ambulance service
Care home sector
Care inspectorate
Cosmetic/aesthetic sector
District nursing
Education
Governing body or leadership role
GP practice or other primary care
Health Visiting
Hospital or other secondary care
Insurance/legal
Military
Occupational health
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Your scope of practice:
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Other community services
Overseas
Policy
Prison
Private domestic setting
Private health care
Public health
Research
School
Specialist (tertiary) care
Telephone or e0health advice
Trade union or professional body
Voluntary sector
Other
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Commissioning
Consultancy
Education
Management
Policy
Direct patient care
Quality assurance or inspection
Registration:
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Nurse
Midwife
Nurse/SCPHN
Midwife/SCPHN
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3
Continuing Professional Development (CPD) record log
Please provide the following information for each learning activity, until you reach 35 hours of CPD (of which 20 hours must be participatory).
For examples of the types of CPD activities you could undertake, and the types of evidence you could retain, please refer to Guidance sheet 3
in ‘How to revalidate with the NMC’.
Dates
12th December
2013
4th January
2014
Method
Please describe the
methods you used for
the activity.
Course attendance
Course attendance
Link to Code
Topic(s)
Clinical Champions Course – theory and
practical
 Infection control
 MRSA Bacteraemia
 Blood Cultures (post course assessment
within ward)
 Venepuncture
 Cannulation
 Urinary Catheter Insertion and care
 PICC line care
Practise effectively
Preserve safety
Mandatory Basic Life Support
 Adult & Paediatric BLS
 Adult & Paediatric Choking
 Unified Do Not Attempt Cardiopulmonary
Resuscitation Policy overview
 Emergency Equipment Familiarisation
 Modified Early Warning Score overview and
audit feedback
 Sepsis
Practise effectively
Preserve safety
Promote
professionalism and
trust
#PROUD TO CARE FOR YOU
Number of
Number of
participatory
hours
hours
6 ½ hours
6 hours
1 ½ hours
1 ½ hours
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4
Dates
June 2014
November
2014
February 2015
Method
Online Learning
Independent
Learning
Course Attendance
Topic(s)
Link to Code
Dementia Awareness Tier 1 Training
 Awareness & understanding symptoms,
recognising signs, challenging behaviour
 Knowledge of the condition – types of
dementia, differences between dementia,
delirium, depression etc.
 Communications, listening skills and
supporting people with dementia;
 Person centred care – sign posting to advice
and guidance, medication, ethics, impact on
families
Pressure Sore Management
 Prevention
 Grading & assessment
 Pain management
 Pressure area management treatments and
devices
 Nutrition
Safer Use of Medicines
 Theory & Practice of Safer Use of Medicine
Administration
 Anticoagulants
 Insulin
 Injectable medications
 Calculation
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Number of
Number of
participatory
hours
hours
Prioritise people
Practise effectively
Preserve safety
Promote
professional ism
and trust
20 minutes
0
Prioritise people
Practise effectively
Preserve safety
Promote
professionalism and
trust
4 hours
0
Practise effectively
Preserve safety
Promote
professional ism
and trust
7 hours
7 hours
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5
Dates
June 2015
November
2015
January 2016
Method
Topic(s)
Link to Code
Number of
Number of
participatory
hours
hours
Course attendance
Mandatory Basic Life Support
 Adult & Paediatric BLS
 Adult & Paediatric Choking
 Unified Do Not Attempt Cardiopulmonary
Resuscitation Policy overview
 Emergency Equipment Familiarisation
 Modified Early Warning Score overview and
audit feedback
 Sepsis
Practise effectively
Preserve safety
Promote
professional ism
and trust
1 ½ hours
1 ½ hours
Online Learning
SN@P Education Training Package – linked to
Safer Use of Medicines
 Drug calculation practice
Practise effectively
Preserve safety
2 hours
0
BSc Module – Infection Control
 ..
 ..
 ..
 ..
 ..
 ..
 ..
 ..
Prioritise people
Practise effectively
Preserve safety
Promote
professional ism
and trust
150
15
Total:
Total:
175 hours
20 minutes
34 hours
Course attendance &
Independent
Learning
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6
Guide to completing CPD record log
Examples of learning method
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

Online learning
Course attendance
Independent learning
What was the topic?
 Give a brief outline of the key points of the
learning activity
 How it is linked to your scope of practice
 What you learnt
 How you have applied what you learnt to
your practice
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Link to Code
Please identify the part or parts of the Code relevant
to the CPD
 Prioritise people
 Practice effectively
 Preserve safety
 Promote professionalism and trust
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7
Reflective Accounts Form
You must use this form to record five written reflective accounts on you CPD and/or practice
related feedback and/or an event or experience in you practice and how this relates to the
Code. Please fill in a page for each of you reflective accounts, making sure you do not
include any information that might identify a specific patient, service user or colleague.
Please refer to the NMC guidance on preserving anonymity in Guidance sheet 1 in ‘How to
revalidate with the NMC’.
Reflective account:
What was the nature of the CPD activity and/or practice-related feedback and/or
event or experience in you practice?
I received a letter that was sent to my ward Sister thanking me for the care I had given to
their relative during the End stages of life.
What did you learn from the CPD activity and/or feedback and/or event or
experience in you practice?
Several years ago I undertook an end of life training course and this has impacted upon
my practice ever since. Is it nice to know that this course and consequently the skills &
knowledge I have gained from it have made a difference to both patient and their relatives
experiences during the end stages of the patient’s life and their death.
How did you change or improve your work as a result?
I am thinking that I may try and access a more advanced end of life course to enhance
and develop my skills further which will directly affect patient and their relatives care.
Even though I have had positive feedback there is always room for improvement and I
strive for this as end of life care is of upmost importance. This will enable me to teach and
support others dealing with clients’ needs.
How is this relevant to the Code?
Select one or more themes: Prioritise people - Practice effectively - Preserve safety Promote professionalism and trust
Prioritise people
Practice effectively
Preserve safety
Promote professionalism and trust
#PROUD TO CARE FOR YOU
wuth.nhs.uk
@wuthnhs #proud
8
Reflective Accounts Form
You must use this form to record five written reflective accounts on you CPD and/or practice
related feedback and/or an event or experience in you practice and how this relates to the
Code. Please fill in a page for each of you reflective accounts, making sure you do not
include any information that might identify a specific patient, service user or colleague.
Please refer to the NMC guidance on preserving anonymity in Guidance sheet 1 in ‘How to
revalidate with the NMC’.
Reflective account:
What was the nature of the CPD activity and/or practice-related feedback and/or
event or experience in you practice?
I attended Cardiopulmonary resuscitation training in January 2014 where the
implementation of the North England North West Unified Do Not Attempt Cardiopulmonary
Resuscitation policy was introduced. During the session they explained how the policy
practically worked within clinical practice and the new documentation (Lilac form), the
Mental Capacity documentation and the patient information leaflet.
What did you learn from the CPD activity and/or feedback?
That the policy is now Northwest Regional and not just Trust based. The documentation
(Lilac form) is given to the patient / relative / caregiver on discharge. What to do in relation
to the Mental Capacity assessments and documentation (in relation to UDNACPR)
The use of patient / relative information leaflets
Other key documentation that may influence uDNACPR decisions such as Advanced
Directive to Refuse Medical Treatment (ADRT) and Power of Attorney Health and Welfare.
How did you change or improve your work as a result?
I know feel that I understand the process of uDNACPR and have a more comprehensive
understanding of the policy which I can utilise in clinical practice which directly affects
patient care.
I also went away from the training session and accessed the policy and read it in full which
has explained things further. I also feel that I can now manage affectively patient / relative /
caregivers questions and those of colleagues.
How is this relevant to the Code?
Select one or more themes: Prioritise people - Practice effectively - Preserve safety Promote professionalism and trust
Prioritise people
Practice effectively
Preserve safety
Promote professionalism and trust
#PROUD TO CARE FOR YOU
wuth.nhs.uk
@wuthnhs #proud
9
Reflective Accounts Form
You must use this form to record five written reflective accounts on you CPD and/or practice
related feedback and/or an event or experience in you practice and how this relates to the
Code. Please fill in a page for each of you reflective accounts, making sure you do not
include any information that might identify a specific patient, service user or colleague.
Please refer to the NMC guidance on preserving anonymity in Guidance sheet 1 in ‘How to
revalidate with the NMC’.
Reflective account:
What was the nature of the CPD activity and/or practice-related feedback and/or
event or experience in you practice?
I received practice feedback in the form of a thank you letter (see attached)
What did you learn from the CPD activity and/or feedback?
The feedback thanked me for supporting a junior doctor during their clinical skills induction
and assessing their clinical competence within the classroom setting.
How did you change or improve your work as a result?
This has made me feel more confident about my role as a teacher and I feel better
equipped to support new staff in developing their clinical skills.
How is this relevant to the Code?
Select one or more themes: Prioritise people - Practice effectively - Preserve safety Promote professionalism and trust
Practice effectively
Preserve safety
Promote professionalism and trust
#PROUD TO CARE FOR YOU
wuth.nhs.uk
@wuthnhs #proud
10
Reflective Accounts Form
You must use this form to record five written reflective accounts on you CPD and/or practice
related feedback and/or an event or experience in you practice and how this relates to the
Code. Please fill in a page for each of you reflective accounts, making sure you do not
include any information that might identify a specific patient, service user or colleague.
Please refer to the NMC guidance on preserving anonymity in Guidance sheet 1 in ‘How to
revalidate with the NMC’.
Reflective account:
What was the nature of the CPD activity and/or practice-related feedback and/or
event or experience in you practice?
I attended clinical champions’ course in December 2013 which is a one-day course
focused on how clinical skill can influence patient safety in relation to infection control.
What did you learn from the CPD activity and/or feedback?
I learned about the risks of catheter associated urinary tract infections and how to
correctly perform this procedure.
How did you change or improve your work as a result?
I had never catheterised a male patient before so following the course (where I had
practiced both female and male catheterisation) I undertook supervised practice (with
patient consent) in this skill (see attached competency.
How is this relevant to the Code?
Select one or more themes: Prioritise people - Practice effectively - Preserve safety Promote professionalism and trust
Prioritise people
Practice effectively
Preserve safety
Promote professionalism and trust
#PROUD TO CARE FOR YOU
wuth.nhs.uk
@wuthnhs #proud
11
Reflective Accounts Form
You must use this form to record five written reflective accounts on you CPD and/or practice
related feedback and/or an event or experience in you practice and how this relates to the
Code. Please fill in a page for each of you reflective accounts, making sure you do not
include any information that might identify a specific patient, service user or colleague.
Please refer to the NMC guidance on preserving anonymity in Guidance sheet 1 in ‘How to
revalidate with the NMC’.
Reflective account:
What was the nature of the CPD activity and/or practice-related feedback and/or
event or experience in you practice?
I attended Cardiopulmonary resuscitation training in January 2014 where we were
instructed and practiced Adult and Paediatric Basic Life Support
What did you learn from the CPD activity and/or feedback?
Within the training session I refreshed my knowledge of the current national
resuscitation guidance and the instructor linked this with practice and the clinical
environment. I also gained refreshed knowledge and information regarding audit finding
on local issues and policies. These included MEWS and Sepsis.
How did you change or improve your work as a result?
Emergency situations are generally quite daunting however require immediate action
which involves having the knowledge and confidence to sure safe and best practice.
Through regular refresher training this allows me to practice the skills and ask questions
in a safe environment to ensure that the care I deliver in such moments remains based
on current guidance and best practice. The training reassures that the care I deliver is
accurate and appropriate and I feel better equipped to deal.
How is this relevant to the Code?
Select one or more themes: Prioritise people - Practice effectively - Preserve safety Promote professionalism and trust
Prioritise people
Practice effectively
Preserve safety
Promote professionalism and trust
#PROUD TO CARE FOR YOU
wuth.nhs.uk
@wuthnhs #proud
12
Reflective Accounts Form
You are required to record a minimum of five written reflections on the Code, your CPD and
practice-related feedback, as outlined in ‘How to revalidate with the NMC’. Please fill in a
page for each of your reflections, ensuring you do not include any information that might
identify a specific patient or service user. You must also discuss these reflections as part of a
professional development discussion (PDD) with another NMC registrant and may be
required to upload a signed PDD form.
Reflective account:
What was the nature of the CPD activity and/or practice-related feedback and/or
event or experience in you practice?
I completed 2 modules, Clinical Examination skills & Diagnostic Health Assessment
over a 4 month period.
What did you learn from the CPD activity and/or feedback?
I completed 2 modules, Clinical Examination skills & Diagnostic Health Assessment
over a 4 month period.
How did you change or improve your work as a result?
I learnt how to obtain a comprehensive history from the patient. Also, how to examine
different systems and provide a differential diagnosis. I was also able to write several
assignments & written examination at Level 7. It provided me with the underpinning
knowledge to interpret physiological and clinical data to determine a differential
diagnosis and management plan.
How is this relevant to the Code?
Select one or more themes: Prioritise people - Practice effectively - Preserve safety Promote professionalism and trust:
Prioritise people
Practice effectively
Promote professionalism and trust
#PROUD TO CARE FOR YOU
wuth.nhs.uk
@wuthnhs #proud
13
Reflective Accounts Form
You are required to record a minimum of five written reflections on the Code, your CPD and
practice-related feedback, as outlined in ‘How to revalidate with the NMC’. Please fill in a
page for each of your reflections, ensuring you do not include any information that might
identify a specific patient or service user. You must also discuss these reflections as part of a
professional development discussion (PDD) with another NMC registrant and may be
required to upload a signed PDD form.
Reflective account:
What was the nature of the CPD activity and/or practice-related feedback and/or
event or experience in you practice?
The patient was newly diagnosed with end stage renal failure and had been finding it
hard to come to terms with the constraints on his lifestyle. I made time to sit and chat to
the patient, to go through his concerns and to check that he fully understood about the
diet and fluid restrictions. But, to also explain that the situation will get better and he
may well be able to return to work and go on holiday again. I explained that the staff
are here to help and there is a patient support network. The patient came to time the
next week to say that he really appreciated the time that I had spent with him. He felt
much better about everything. He also had a better understanding of his diet and fluid
restrictions which were making him feel better. He had also been chatting to a couple
of the other patients, some of whom were able to hold down a job, and the other had
been on a cruise.
What did you learn from the CPD activity and/or feedback?
It made me feel really pleased that I was able to make difference to the patient. It is so
nice to have positive feedback from a patient making my role worthwhile. Although, at
times the pace on the ward can be really fast it is important to make time to chat to the
patients allowing them time to voice their concerns and give them guidance to improve
their quality of life. It is important that patients are able to trust the healthcare
professionals.
How did you change or improve your work as a result?
Although it is a busy period of time when the patient is being ‘hooked up’ to the machine
I will try and discuss any concerns they have, but I will always ensure that I spend some
time with them later on in the dialysis session. Also, as a result of the patients having
many common concerns and questions I have decided to start up a patient newsletter
with the help of my colleagues. Patients will also be encouraged to contribute to the
newsletter to provide hints, tips and personal experiences. We could also look at recipe
ideas, and contact details for advice.
How is this relevant to the Code?
Select one or more themes: Prioritise people - Practice effectively - Preserve safety Promote professionalism and trust:
Prioritise people , Practice effectively, Promote professionalism and trust
#PROUD TO CARE FOR YOU
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14
Reflective Discussion Form
You must use this form to record your reflective discussion with another NMC-registered
nurse or midwife about your five written reflective accounts. During your discussion you
should not discuss patients, service users or colleagues in a way that could identify them
unless they expressly agree, and in the discussion summary section below make sure you do
not include any information that might identify a specific patient or service user. Please refer
to Guidance sheet 1 in ‘How to revalidate with the NMC’ for further information. This form
should be completed, stored and shared in manual paper form, as opposed to electronically.
This is important because creating, storing or sharing these data electronically may trigger an
obligation to register with the Information Commissioner.
To be completed by the nurse or midwife:
Name:
Ernie Jones
NMC Pin number:
99I123456E
To be completed by the nurse or midwife with whom you had the discussion
Name:
NMC Pin number:
Email address:
Date of discussion:
Number of reflections discussed:
Short summary of discussion:
George Formby
99I56789E
George.formby1925@nhs.net
31st March 2014
2
We discussed the reflection regarding the thank
you card and CPR training. We discussed the need
for individualised care and to keep current with all
guidance and continuation of training and
development to improve patient care and safety.
I have discussed the number of
reflective accounts listed above
with the named nurse or midwife
as part of a reflective discussion.
I agree to be contacted by the NMC
to provide further information if
necessary for verification
purposes.
Goerge Fornby
31st March 2014
#PROUD TO CARE FOR YOU
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15
Reflective Discussion Form
You must use this form to record your reflective discussion with another NMC-registered
nurse or midwife about your five written reflective accounts. During your discussion you
should not discuss patients, service users or colleagues in a way that could identify them
unless they expressly agree, and in the discussion summary section below make sure you do
not include any information that might identify a specific patient or service user. Please refer
to Guidance sheet 1 in ‘How to revalidate with the NMC’ for further information. This form
should be completed, stored and shared in manual paper form, as opposed to electronically.
This is important because creating, storing or sharing these data electronically may trigger an
obligation to register with the Information Commissioner.
To be completed by the nurse or midwife:
Name:
Ernie Jones
NMC Pin number:
99I123456E
To be completed by the nurse or midwife with whom you had the discussion
Name:
George Formby
NMC Pin number:
99I78910E
Email address:
Rebecca.smith1976@nhs.net
31st January 2015
Date of discussion:
Number of reflections discussed:
Short summary of discussion:
3
We discussed clinical champions training, support
to training for junior doctors and the dialysis
patient. We have discussed the importance of
training and passing on our experience and
knowledge to others whether patients or
colleagues as this improves patients care directly.
I have discussed the number of
reflective accounts listed above
with the named nurse or midwife
as part of a reflective discussion.
I agree to be contacted by the NMC
to provide further information if
necessary for verification
purposes.
Rebecca Smith
31st January 2015
#PROUD TO CARE FOR YOU
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16
Confirmation Form
You must use this form to record your confirmation. This form should be completed,
stored and shared in manual paper form, as opposed to electronically. This is important
because creating, storing or sharing these data electronically may trigger an obligation to
register with the Information Commissioner. Please refer to Guidance sheet 1 in How to
revalidate with the NMC for further information.
To be completed by the nurse or midwife:
Name:
Ernie Jones
NMC pin number:
99I123456E
Date of last renewal of registration
or joined the register:
2nd April 2013
I have received confirmation from (select applicable):

A line manager who is also an NMC registered nurse or midwife
A line manager who is not an NMC registered nurse or midwife
Another NMC registered nurse or midwife
A regulated health care professional
An overseas regulated health care professional
Other professional in accordance with the NMC’s online confirmation tool
To be filled in by your confirmer:
Name:
Eric Twinge
Job Title:
Ward Charge Nurse (manager)
Email address:
eric.twinge99@nhs.net
Wirral University Teaching Hospital
Arrowe Park Hospital,
CH495PE
Professional address including
postcode:
31st March 2016
Date of confirmation discussion:
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17
If you are an NMC registered nurse or midwife please provide:
NMC Pin Number:
99E12345E
If you are a regulated health care professional please provide:
Profession:
ID of membership for regulatory body:
If you are an overseas regulated health care professional please provide:

Country:

ID of membership for regulatory
body:

Profession:
If you are another professional please provide:

Profession:

Registration number for regulatory
body:
Confirmation checklist of revalidation requirements
Practice hours

You have seen written evidence that satisfies you that the nurse or midwife has
practised the minimum number of hours required for their registration.
Continuing professional development

You have seen written evidence that satisfies you that the nurse or midwife has
undertaken 35 hours of CPD relevant to their practice as a nurse or midwife.

You have seen evidence that at least 20 of the 35 hours include participatory learning
relevant to their practice as a nurse or midwife.

You have seen accurate records of the CPD undertaken.
Practice-related feedback

You are satisfied that the nurse or midwife has obtained five pieces of practicerelated feedback.
Written reflective accounts
You have seen five written reflective accounts on the nurse or midwife’s CPD
 and/or practice-related feedback and/or an event or experience in their practice
and how this relates to the Code, recorded on the NMC form.
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18
Reflective discussion

You have seen a completed and signed form showing that the nurse or midwife
has discussed their reflective accounts with another NMC-registered nurse or
midwife (or you are an NMC-registered nurse or midwife who has discussed these
with the nurse or midwife yourself).
I confirm that I have read ‘Information for confirmers’, and that the above named
NMC-registered nurse or midwife has demonstrated to me that they have complied
with all of the NMC revalidation requirements listed above the three years since
their registration was last renewed or they joined the registered as set out in
‘Information for confirmers’.
I agree to be contracted by the NMC to provide further information if necessary for
verification purposes. I am aware that if I do not respond to a request for
verification information I may put the nurse or midwife’s revalidation application
at risk.
Signature:
Rebecca Smith
Date:
31ST March 2016
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19