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Bridges to Excellence Experience Roster and Exemplar
Form Instructions: Please complete all fields below. To obtain continuing education contact hours remember to submit evaluation and appropriate roster
* Required
Your Information
*1. Today's Date:
*2. Name ( Last, First)
*3. PPS/Badge #:(ex: UC000111999)
*4. Department/Unit
*5. Observational Unit/Department:
Roster
Section Instructions: First select the appropriate course roster to reflect the actual number of hours you performed an observation visit (4, 8, or 12 hours). Each visit (shift) is treated as a separate continuing education contact hour award. Time includes 1 hour to write exemplar. Then document the dates you spent for each visit.
*6. Select the appropriate course roster to reflect the actual number of hours you visited (4, 8, or 12 hours). Each visit (shift) is treated as a separate event.
*7. Date(s) completed above experience:
Exemplar Information
Section Instructions: Exemplar should discuss your entire experience. You can copy and paste your exemplar from Word document, or type directly your exemplar in Text Box below. For additional information on writing an exemplar see handout on "Writing an Exemplar" on the Bridges website.
8. Which area below describes the setting of the exemplar?
*9. Provide a short ~2500 word exemplar on your experiences detailing:
A procedure and/or equipment used that was a new experience for you.
Evaluate how patient care differed from your home unit; use of primary nursing, over all focus, difference if in supervisory role, etc. Did you face any nursing challenges? How did you meet your personal objectives? Discuss a patient's care you observed, and how differed in role.
Review handout on "Writing an Exemplar" on website.
Max Characters: 2500
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