SAMPLE Category 2/Self Report CME Log for Physicians
For the biennial PA Medical Licensure Period Ending
(MD’s – December 31 of even years; DO’s October 31 of even years)
TYPE OF ACTIVITY
DATE
NUMBER
DESCRIPTION
OF
HOURS
.50
Met w/ Drs. Smith & Smith; discussed Patient X.
Consult with peers
1/1/2012
Read Journal Article
1/1/2012
.50
Teaching
1/4/1012
2
Resident teaching; rounds – LGH
Professional conduct and
ethics
1/1/2012
1
Attended a Medical Ethics lecture at LGH that did not
offer Category 1.
Mediasite Archived Video
Lecture
1/1/2012
1
Reviewed 1 hour Pediatric Grand Rounds on
Immunization updates.
Lecture
1/1/2012
1
Presented 1 hour on “CHF” to residents that did not offer
Category 1.
Total Category 2 Credits
RM/PS
X
Read article in JAMA; Mortality Among Hospitalized
Medicare Beneficiaries in the First 2 Years Following
ACGME Resident Duty Hour Reform
JAMA. 2007;298:975-983
X
Total RM/PS Credits
Address_______________________________________________
Signature______________________________
City_________________State_____________Zip______________