Advanced Practice Pain Management Nurse (AP-PMN)

Recognition PortfolioRenewal Application

September 2019

2019 Advanced Practice CommissionChair

Jennifer Surprise, MSN, APRN, ACNS-BC, RN-BC, AP-PMN

ASPMN® Board of Director LiaisonKimberly Wittmayer, MS, APRN, PCNS-BC, AP-PMN

MembersCarrie A. Brunson MSN, RN-BC, APRN, ACNS-BC, AP-PMN

Michelle L. Czarnecki, MSN, RN-BC, CPNPMary T. Lyons, MSN, APN/CNS, RN-BC ONC, AP-PMNSharon K. Wrona, DNP, RN-BC, PNP, PMHS, AP-PMN

● This document was originally developed by the ASPMN® Advanced Practice (AP) Task Force: Patricia Bruckenthal, PhD, APRN-BC, FAAN and Helen N. Turner, DNP, APRN, PCNS-BC, AP-PMN, FAAN and updated July 2019.

● All materials contained in this publication are the property of the ASPMN® and may not be copied for purposes other than submission of an AP portfolio.

Table of ContentsPREFACE...............................................................................................................................................MISSION STATEMENT............................................................................................................................OBJECTIVES..........................................................................................................................................ELIGIBILITY REQUIREMENTS..................................................................................................................INSTRUCTIONS......................................................................................................................................HOW TO ACCRUE AP POINTS................................................................................................................APPLICATION FORM..............................................................................................................................POINT LOG INSTRUCTIONS/SAMPLE POINT LOG....................................................................................POINT LOG............................................................................................................................................CATEGORY A: CONTINUING EDUCATION – INSTRUCTIONS....................................................................CATEGORY A: CONTINUING EDUCATION – VERIFICATION FORM...........................................................CATEGORY B: PROGRAM OR PROJECT ACTIVITIES – INSTRUCTIONS......................................................8, 9CATEGORY B: PROGRAM OR PROJECT ACTIVITIES - VERIFICATION FORM.............................................CATEGORY C: RESEARCH ACTIVITIES – INSTRUCTIONS.........................................................................CATEGORY C: RESEARCH ACTIVITIES - VERIFICATION FORM.................................................................CATEGORY D: EDUCATION/PUBLICATION ACTIVITIES – INSTRUCTIONS.................................................CATEGORY D: EDUCATION/PUBLICATION ACTIVITIES - VERIFICATION FORM.........................................CATEGORY E: TEACHING ACTIVITIES – INSTRUCTIONS..........................................................................CATEGORY E: TEACHING ACTIVITIES – VERIFICATION FORM E1-3.........................................................CATEGORY E: TEACHING ACTIVITIES – VERIFICATION FORM E4............................................................CATEGORY E: TEACHING ACTIVITIES – VERIFICATION FORM E5............................................................CATEGORY F: PROFESSIONAL ORGANIZATION INVOLVEMENT – INSTRUCTIONS...................................CATEGORY F: PROFESSIONAL ORGANIZATION INVOLVEMENT – VERIFICATION FORM...........................CATEGORY G: ACADEMIC EDUCATION/ PROFESSIONAL CERTIFICATIONS – INSTRUCTIONS..................CATEGORY G: ACADEMIC EDUCATION/ PROFESSIONAL CERTIFICATIONS - VERIFICATION FORM..........CATEGORY H: PRE-APPROVAL FOR PROJECTS OR ACTIVITES NOT DEFINED ABOVE – INSTRUCTIONS...CATEGORY H: PRE-APPROVAL FOR PROJECTS OR ACTIVITES NOT DEFINED ABOVE – VERIFICATION FORM....................................................................................................................................................PORTFOLIO CHECKLIST/PAYMENT FORM...............................................................................................APPENDIX A - DEFINITION OF TERMS....................................................................................................

MISSION STATEMENTASPMN® is committed to promoting the highest standard of professionalism in Pain Management Nursing (PMN), consumer care and safety by providing recognition of Advanced Practice (AP) in PMN. The ASPMN® AP Commission grants recognition to individuals who have met predetermined standards demonstrating an elite level of practice and professional contribution.

OBJECTIVES

The objectives of the ASPMN® AP recognition program are to affirm excellence by:

1. Formally recognizing individuals who meet the standards of the ASPMN® AP program.2. Encouraging continued professional growth in PMN.3. Providing a standard of advanced professionalism required for recognition, thereby assisting the

employer, public and members of healthcare professions in the assessment of the AP Pain Management Nurse.

ASPMN® established the AP recognition program at the request of Advanced Practice Nurses specializing in pain management. Activities required for AP-PMN recognition go beyond routine, entry-level PMN practice, and challenge individual applicants to contribute to the art and science of the specialty. The applicant’s AP portfolio will demonstrate their achievements in AP. Therefore, each packet will be unique and reflect the interests and contributions of each individual practitioner.

RENEWAL REQUIREMENTS

The applicant must:1. Hold a current APRN license or advanced practice nursing position.2. Maintain current entry-level ANCC Pain Management certification.3. Demonstrate professional contributions to the advancement of AP-PMN (not all areas

listed below are required) within the previous 5 year period as an APRN:A. Continuing educationB. Programs or projectsC. ResearchD. Education/PublicationE. TeachingF. Involvement in professional organizationsG. Academic education/AP certificationsH. Projects/Activities not defined

4. Submit renewal fee ($150).5. Submit a current copy of CV or resume.

Renewal of AP recognition every five (5) years by completing the renewal process is required.

1

PREFACE

READ THESE INSTRUCTIONS CAREFULLY BEFORE STARTING YOUR PORTFOLIO!

1. Online submissions are preferred.2. Complete the renewal application.3. Scan (if you’ll be submitting on line) or copy (if you’ll be sending your portfolio via US mail) the necessary

items (e.g. licenses, certifications) as required. A complete listing is available in the portfolio checklist later in this packet.

4. You must complete 75 AP points demonstrating your professional contributions to PMN. This portfolio is organized with instructions for each AP category followed by the appropriate verification form. Complete verification forms only for the activities you choose to submit; only one activity per form. Not all available verification forms will be used by all applicants.

5. Complete the AP point log to summarize the allocation of the AP points in your portfolio. 6. Keep a copy of your portfolio for your records; submit either on-line or via US mail.7. If you have questions during your application process, please contact the ASPMN® Executive Office at

ASPMN@kellencompany.com.

HOW TO ACCRUE AP POINTS

There are eight categories below in which you can accrue AP points; some categories have mandatory requirements. Each category is assigned a letter (A-H below) and each approved activity within each category is assigned a number. A total of 75 points must be earned during the past 5 year period

o 50 points must directly relate to PMN. o The remaining 25 points do not have to directly relate to pain management, but must reflect

professional topics that specifically impact APRN pain management practice.o Please refer to “Definitions of Terms” at the end of this packet for complete description and examples

of activities.

POINT DISTRIBUTION

FOR EACH CATEGORY

Category Minimum Points Required Maximum Points

Allowed

A. Continuing education 20 related to pain management 40

B. Program or project 10 40C. Research None 40D. Education/Publication 10 50E. Teaching 10 50F. Professional organizations None 30

G. Professional Certifications/Academic education

None 25

H. Project / Activity not defined None 25

2

INSTRUCTIONS

Name: Click or tap here to enter text. ASPMN® Member ID # (if applicable): Click or tap here to enter text.Mailing Address: ☐ Home ☐ Work

Line 1 Click or tap here to enter text.

Line 2 Click or tap here to enter text.

City: Click or tap here to enter text. State: Click or tap here to enter text. Zip: Click or tap here to enter text.

Telephone: Work: Click or tap here to enter text. Home: Click or tap here to enter text.

E-mail: Click or tap here to enter text.---------------------------------------------------------------------------------------------------------------------------------------------------RN State Licensure: Click or tap here to enter text.

If licensed in multiple states as RN: ☐ RN State: Choose an item. ☐ RN State: Choose an item.

APRN State Licensure: Click or tap here to enter text.

If licensed in multiple states as APRN: ☐ APRN State: Choose an item. ☐ APRN State: Choose an item.---------------------------------------------------------------------------------------------------------------------------------------------------

Education (check all that apply; click appropriate box, right click, properties, checked):

☐ MS ☐ MSN ☐ DNP ☐ PhD ☐ Other: Click or tap here to enter text.

---------------------------------------------------------------------------------------------------------------------------------------------------Area of practice (check all that apply; click appropriate box, right click, properties, checked):

☐ Acute ☐ Homecare ☐ Outpatient ☐ Extended Care ☐ Industry ☐ Private☐ Education ☐ Research ☐ Administration ☐ Other: Click or tap here to enter text.

Years in Nursing: Click or tap here to enter text.

Years as Certified Pain Management Nurse: Click or tap here to enter text.

---------------------------------------------------------------------------------------------------------------------------------------------------☐ I attest that all statements on this application are true. If statements are found to be false, certification

may be suspended or revoked. (Signature required below)

Signature: Click or tap here to enter text. Date: Click or tap to enter a date.

Filling in your name serves as your signature for the AP-PMN portfolio process.

3

ASPMN® AP-PMN RENEWAL APPLICATION

The Point Log will contain a summary of what is included in your portfolio, with the total points for each activity you’ve submitted.

75 points are required. Minimum points needed for each activity must be met; any excess points are not included in the review.

o Total 75 points from the following: Continuing Education- min 20 pts, max 40 pts. Any of the activities in categories B, C, D, or E- min. 30 pts, max 40 pts. Any of the activities in categories F, G or H- no min., max 40 pts.

Each submitted activity will require the appropriate verification form (forms follow).

SAMPLE POINT LOG

Category Activity Description Date(s) Total Points

A 1 CE Total 2017-2019 20

B 3 Establish Team 2018 10

C 3 Research ToolTesting

2018 10

D 22 Patient EducationTool

2018 5

E 1 Conference Presentation

2018 10

G 1APRN National Certification 2019 10

TOTAL POINTS 75

4

POINT LOG INSTRUCTIONS

Name: Click or tap here to enter text.

Category Activity #

Description Date(s) Total Points Check Here

☐ Required documentation included

☐ Required documentation included

☐ Required documentation included

☐ Required documentation included

☐ Required documentation included

☐ Required documentation included

☐ Required documentation included

☐ Required documentation included

☐ Required documentation included

☐ Required documentation included

☐ Required documentation included

☐ Required documentation included

Total Points:

5

POINT LOG

20 points from clinically focused pain management (PM) continuing education (CE) are required; up to 40 points are allowed.

o The additional 20 points may be obtained in topics related to pain management, or professional practice (PP), directly related to pain management nursing.

o Professional practice is defined as courses or activities that are not clinically related to pain management but impact or enhance the role of AP-PMN. Examples of PP topics would be “Pain Management Legal Issues,” “Preceptor Workshop.” CEs related to such topics as domestic violence, safety, HIPPA, CPR, etc., are not

acceptable because they are not specific to pain management practice.

To earn points for CE, it is important you submit a complete listing of each individual educational session you attended during a conference or program. For example, if you attend ASPMN®’s National Conference and earn 18 contact hours, you must individually list each session title on the Category A verification form.

CE programs, including home-study or self-study programs must be sponsored by accredited or approved providers such as a state nursing association, the American Nurses Credentialing Center, American Academy of Nurse Practitioners, or other professional associations.

Contact Hour (CME, CNE, CEU) = 60 minutes = 1 AP Point

It is not necessary to submit a copy of the CE certificate. However, the ASPMN® AP Commission reserves the right to selectively audit portfolios and request documentation of programs attended and CE’s awarded. Therefore, applicants are advised to keep the certificate of attendance or completion that includes your name, date, program title and the number of contact hours awarded.

6

CATEGORY A: CONTINUING EDUCATIONINSTRUCTIONS

Name: Click or tap here to enter text.

Program Date(s) Title of

Session/CourseSession/Course

Provider

Approved Accrediting

Organization

Pain Managemen

t (PM)

Professional Practice

(PP)

8/2017 Example: Management of Pain related to Cancer Treatments

Cancer Society Ohio Nurses Association

3

9/2018 Example: Creating a Business Plan

SB University NYS Nursing Association 5

Total Points(Transfer this total to Point Log)

**No additional documentation is required for Category A**

7

CATEGORY A: CONTINUING EDUCATIONVERIFICATION FORM

10 points are required; up to 40 points are allowed.

To receive points in this category, your documentation must demonstrate having had the primary responsibility for developing, implementing and evaluating the program, conducting the project, or case.

Activities in this category more clearly demonstrate the achievement of AP and include more complex activities requiring multiple steps for completion and/or significant preparation. This is reflected in the larger number of points assigned to these activities.

Some of these activities may be performed due to employer directives but some are independent of employment status.

One activity (e.g. QI project resulting in a clinical pathway development and data collection/analysis) may be used for multiple activities (e.g. B5, B6, B7). A separate verification form is required for each activity (e.g. B5, B6 and B7).

* Please refer to “Definitions of AP Terms” at the end of this packet for complete description and examples of activities.

**ACTIVITIES, POINTS AND REQUIRED DOCUMENTATION ARE LISTED ON THE FOLLOWING PAGE**

8

CATEGORY B: PROGRAM OR PROJECT ACTIVITIESINSTRUCTIONS

Category B Activities AP Points Required DocumentationB1: Establish a nursing* or multidisciplinary pain management* service

o Write a proposal 10 Provide a copy of the document

o Develop initial policies and procedures

5 Provide a copy of the document

o Develop billing procedure(s) 10 Provide a copy of the documentB2: Establish an independent (self-employed) pain management practice or consulting business

25 Complete information on following page

B3. Team/Committee/Task Force focused on pain management

o Establish 10 Complete information on following pageo Chair (do not include member if

choosing chair)10 Complete information on following page

o Member 5 Complete information on following pageB4: Public health policy development* 10 Provide a copy of the documentB5: Quality improvement (QI) project* 10 Complete information on following pageB6: Clinical pathway development* 10 Provide a copy of the documentB7: Collecting and analyzing outcome data or case study data(Derived from clinical practice and not part of a formal research project)

10 Complete information on following page

B8: Policy/procedures(including updated references)

o Develop original 10 Provide a copy of the documento Major revisions to existing 5 Provide a copy the original and revised

B9: Competency based tools*Original or major revision

5 Original: Provide a copy of the documentRevisions: Include original and revised

B10: Standardized Care PlansOriginal or major revision

5 Original: Provide a copy of the documentRevisions: Include original and revised documents

B11: Arranging and participating in a Product Fair

10 Complete information on following page

B12: Product Formularyo Develop original 10 Provide a copy of the documento Major revisions to existing 5 Provide a copy the original and revised

B13: Webmaster (electronic information system related to pain management nursing)

o Develop website content

10 Provide a copy of the content and the name of the website

B14: Grant Activities* (non-research based) (e.g., grant money for educational development; or to obtain equipment)

o Write and submit

10 Provide a copy of the document

B15: Expert consultation on a legal case related to pain management

10 Provide a letter from the law firm for whom the consultation was performed explaining your contributions.

B16: Provide item writing services for ASPMN® certification exam

10 Provide a letter from the ASPMN® Exam Committee Liaison

9

CATEGORY B: PROGRAM OR PROJECT ACTIVITIESVERIFICATION FORM

Name: Click or tap here to enter text.

Check one activity number per form (click appropriate box, right click, properties, checked):

☐ B1 ☐ B2 ☐ B3 ☐ B4 ☐ B5 ☐ B6 ☐ B7 ☐ B8 ☐ B9

☐ B10 ☐ B11 ☐ B12 ☐ B13 ☐ B14 ☐ B15 ☐ B16

For B 1 , 4, 6, 8, 9, 10, 12, 13, 14, 15 or 16 submit this form with the required documentation listed in instruction packet.

For B 2, 3, 5, 7 or 11 complete the following : 1. Title:

2. Date activity completed:

3. Summarize purpose and/or assessment of need for program, project, or case as it relates to pain management. Include what the clinical challenge and how it was identified.

4. Provide an overview of the implementation of program / project as it relates to pain management.

5. Describe the program/project’s evaluation process (implications for clinical practice) as it relates to pain management.

6. What were the results of the project?

TOTAL POINTS CLAIMED FOR CATEGORY B: Click or tap here to enter text.(Transfer this total to Point Log)

10

No points are required; up to 40 points are allowed.

Research activities must relate to pain management and must be Institutional Review Board (IRB) approved. You must include the IRB approval letter with your required documentation.

It is expected these activities would include a thorough literature review and reflect translation of research into practice.

Category C Activities AP Points

Required DocumentationIn addition to the IRB letter of approval:

C1: Develop a study proposal 25 A copy of the study proposal

C2: Write a grant 25 A copy of grant application

C3: Research Tool (Develop or test)

Development of a new tool 10 Complete information on following page and a copy of the research tool

Testing of a new or existing tool

10 Complete information on following page, a copy of the research tool and results of testing

C4: Data Collection 10 Complete information on following pageAnalysis 10 Complete information on following page

C5: Publish a report of research findings in a peer reviewed journal

10 A copy of the research report

C6: Serve as a site Principle Investigator or Co-Investigator of a multi-site Research Project

25 A copy of the study summary/abstract and documentation of your role

11

CATEGORY C: RESEARCH ACTIVITIESINSTRUCTIONS

Name: Click or tap here to enter text.

Check one activity number per form (click appropriate box, right click, properties, checked):

☐ C1 ☐ C2 ☐ C3 ☐ C4 ☐ C5 ☐ C6

For C 1 , 2, 5 or 6 submit this form with the required documentation listed in instruction packet.

For C 3 or 4 complete the following:

Date activity completed: Click or tap to enter a date.

1. Describe the purpose of the study, as it relates to AP-PMN.

2. Summarize the results of the data that supported the project. Provide information regarding data analysis (e.g. which statistical tests were used)

3. Describe how the data/study improved (or will improve) practice or patient outcomes.

AP POINTS CLAIMED FOR CATEGORY C ACTIVITIES: Click or tap here to enter text.

(Transfer this total to Point Log)

12

CATEGORY C: RESEARCH ACTIVITIES VERIFICATION FORM

CATEGORY D: EDUCATION/PUBLICATION ACTIVITIESINSTRUCTIONS

10 points are required, up to 50 points are allowed. These activities must be related to PMN and you must serve in the role for which you are claiming

points (e.g. lead author or co-author or reviewer, etc.). *Please refer to “Definitions of Terms” at the end of this packet for description and examples of

activities.

**ACTIVITIES, POINTS AND REQUIRED DOCUMENTATION ARE LISTED ON THE FOLLOWING PAGE**

13

Category D Activities AP Points

Required Documentation

TEXTBOOKD1: Editor or co-editorD2: Section editor

4030

Complete table on following page and include a copy of the title page, page showing date of publication, and table of contents

D3: Lead authorD4: Co-author*

3020

Complete table on following page and include a copy of the title page, page showing date of publication, and table of contents

D5: Reviewer * 15 Complete table on following page and submit a copy of your review

CHAPTERD6: Lead author D7: Co-author* or Contributing author*

2010

Complete table on following page and include a copy of the title page, page showing date of publication, and table of contents

D8: Reviewer * 5 Complete table on following page and submit a copy of your review

JOURNAL ARTICLED9: Lead author D10: Co Author*

2010

Submit a copy of your publicationSubmit a copy of your publication

D11: Reviewer for peer reviewed journal

5 Submit a copy of the journal article and a copy of your review

CASE STUDYD12: Author D13: Co-author*

105

Submit a copy of your publicationSubmit a copy of your publication

ABSTRACTD14: Lead author or co-author* 5 Submit a copy of your publication

EDITORIALD15: Lead author or co-author * 5 Submit a copy of your publication

NEWSLETTERD16: Editor

D17: Contributor* of newsletter item

10

5

Submit a copy of your publication and title page indicating you as editorSubmit a copy of your publication

AUTHOR FOR OTHER PUBLICATIONSD18: Newspaper article D19: Best practice document D20: Online module

55

10

Submit a copy of your publicationSubmit a copy of your publicationSubmit a copy of your publication

DEVELOPMENT OF EDUCATIONAL TOOLS

D21: Healthcare professional fact sheet *D22: Patient education tool *D23: Learning module *

D24: Brochure/pamphlet *

55

10

10

Submit a copy of your publicationSubmit a copy of your publicationComplete the table on the following page and submit title page indicating you as authorSubmit a copy of your publication

CREATE PAIN MANAGEMENT DOCUMENTATION SYSTEM

D25: Original or major revision 5Submit a copy of your publicationFor major revision: submit the original and revised

14

CATEGORY D: EDUCATION/PUBLICATION ACTIVITIES

VERIFICATION FORM

Name: Click or tap here to enter text.

Check one activity number per form (check appropriate box):

☐ D1 ☐ D2 ☐ D3 ☐ D4 ☐ D5 ☐ D6 ☐ D7 ☐ D8 ☐ D9 ☐ D10 ☐ D11 ☐ D12

☐ D13 ☐ D14 ☐ D15 ☐ D16 ☐ D17 ☐ D18 ☐ D19 ☐ D20 ☐ D21 ☐ D22 ☐ D23 ☐ D24 ☐ D25

For D 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24 or 25 submit this form with the required documentation listed in instruction packet.

For D 1, 2, 3, 4, 5, 6, 7, 8 or 23 complete the following:

Table below is required for D 1-8, and D23

Example Your WorkJanuary 2017 Date of publication

Promoting Self-Management for Chronic Pain

Title of work/publication

Article written that presents current evidenced based interventions to manage persistent pain

Synopsis of material

Peer reviewed journal article Type of work (book, chapter, article)

Pain Management Nursing Where was it published?

Provide clinicians with research based evidence to increase access to strategies for self-management of pain

Review available technologically enhanced tools for self-management of pain

Objectives of the work

Importance of self-management for pain

Barriers to pain self-management

Strategies to increase self-management of pain

Technological advances for self-management strategies for pain control.

General content outline

AP POINTS CLAIMED FOR THIS ACTIVITY: (Transfer this total to Point Log)

15

CATEGORY E: TEACHING ACTIVITIESINSTRUCTIONS

10 points are required, up to 50 points are allowed.

Category E activities are split between 3 verification forms since activities differ in the documentation required. You need only to complete the appropriate verification form for each program or project you choose (copy as needed).

To receive points, teaching activities must occur in the classroom or clinical area. You must be the instructor with a structured framework of teaching/learning.

You may be awarded points for activities (e.g. lectures) that are repeated, but only if the content is altered to meet the needs of the learner. You may only claim points once if giving the same exact lecture to multiple audiences.

Category E Activities AP Points Required Documentation

E1: PRESENTATION/LECTURE/WORKSHOP NOT OFFERING CEUS

National/Regional Conference Local (e.g. in your organization)

105

Information on verification form E1-3

E2: PRESENTATION/LECTURE/ WORKSHOP OFFERING CEUS

National/Regional Conference Local (e.g. in your organization)

1510

Information on verification form E1-3

E3: Expert consultation at a medical event (i.e., health fair, screening clinic) 5

Information on verification form E1-3

E4: POSTER PRESENTATION Lead author Co-Author

105

Information on verification form E4 and a copy of the poster

E5. Preceptor or clinical education (i.e., mentoring, orientation, job shadowing)

1 point for every 8 hours.

Maximum 30 points

Information on verification form E5 and a letter from the faculty coordinator (information on verification form E5)

E5: Preceptees may include:

Resident/Interns/Physicians Physical Therapists Physician’s Assistants Pain Management Students Graduate/Doctoral Nursing Students Nurse Practitioners/Clinical Nurse Specialists

16

CATEGORY E: TEACHING ACTIVITIES(LECTURES AND PRESENTATION)

VERIFICATION FORM E 1- 3

Name: Click or tap here to enter text.

Check one activity number per form (check appropriate box):

☐ E1 ☐ E2 ☐ E3

Title of presentation/lecture/medical event:

Date Offered: Click or tap to enter a date.

Conference or event: Click or tap here to enter text.

City/State: Click or tap here to enter text.

Objectives (list 3):1.

2.

3.

Outline of Teaching Content:

TOTAL AP POINTS CLAIMED FOR THIS ACTIVITY Click or tap here to enter text.

(Transfer this total to Point Log)

17

Name: Click or tap here to enter text.

Complete a separate form for each poster presentation.

Title of poster presentation:

Date Offered: Click or tap to enter a date. Conference or event: Click or tap here to enter text.

City/State: Click or tap here to enter text.

☐ Attach proof of acceptance of the poster.

☐ Attach a copy of the actual poster.

TOTAL AP POINTS CLAIMED FOR THIS ACTIVITY Click or tap here to enter text.

(Transfer this total to Point Log)

18

CATEGORY E: POSTER PRESENTATIONVERIFICATION FORM E 4

Your Name: Click or tap here to enter text.

Complete a separate form for each precepting activity.

I affirm that I have served as a preceptor for (which institution?):

Number of students: Click or tap here to enter text.

Type of student: Click or tap here to enter text.

Dates of preceptorship (if precepting for an extended period of time, indicate date range e.g. January – May 2018):

Total hours: Click or tap here to enter text. Divided by 8 = Total AP Points Click or tap here to enter text.

-------------------------------------------------------------------------------------------------------------------------Submit letter of support from faculty substantiating preceptorship and accomplishments (e.g. hours, projects, evaluations) including the following information:

Faculty Coordinator Faculty’s Institution Your name Hours of preceptorship your provided Area in which you provided preceptorship (e.g. nursing, advanced practice nursing) Name of educational institution and program (E.g. XX University, DNP Program) The dates for the preceptorship Faculty Coordinator name: Address: Phone:

AP POINTS CLAIMED FOR THIS ACTIVITY Click or tap here to enter text. (Transfer this total to Point Log)

19

CATEGORY E:PRECEPTING/CLINICAL EDUCATION

VERIFICATION FORM E 5

No minimum number of points are required, up to 30 points are allowed.

Examples of acceptable organizations include (but are not limited to those listed):o American Society for Pain Management Nursing® (ASPMN®)o American Academy of Pain Medicine (AAPM)o Oncology Nursing Society (ONS)o American Association of Rehabilitation Nurses (AARN)o The International Nurses Society on Addictions (IntNSA) o Forum or Advisory Panels*

Participating in national / regional / state / affiliate and local professional nursing organizations related to the pain management specialty provides a mechanism for contributing to growth of the specialty and is designated for AP points. Participation in other nursing specialty organizations whose mission is directly related to the care and/or support of pain management patients is also acceptable for AP points. Examples of these acceptable organizations are the, American Society for Pain Management Nursing® (ASPMN®), American Academy of Pain Management (AAPM), American Academy of Pain Medicine (AAPM), Oncology Nursing Society (ONS), American Association of Rehabilitation Nurses (AARN), or the International Nurses Society on Addictions (IntNSA). AP Points are awarded for each year of office served and can be used for AP points only in the specialty for which the organization is noted. Serving on institutional or agency committees is not acceptable for earning AP points.

*Public health policy activities may involve representation of professional organizations at the national, regional or state level, e.g. participation in consensus groups meetings, testimony for regulatory bodies, and development of documents related to public health policy decisions.

20

CATEGORY F:PROFESSIONAL ORGANIZATION INVOLVEMENT

INSTRUCTIONS

Name: Click or tap here to enter text.

Please complete the information below and submit a summary of your contributions to the committee along with the name and contact information of a committee peer who can validate your involvement.

Acceptable ActivityName of Task

Force, Committee, or Organization

# of Years

ServedPoints per

YearTotal Points

F1. Officer at a national level 20

F2. Committee or Task Force Chair at a national level 15

F5. Committee member at the national level 10

F3. Officer at the regional/state/local level

15

F6. Committee or Task Force Chair at the regional/state/ local level

10

F7. Committee member at the regional/state/ affiliate/ local level

5

Total AP Points(Transfer this total to Point Log)

21

CATEGORY F:PROFESSIONAL ORGANIZATION INVOLVEMENT

VERIFICATION FORM

No minimum number of points are required, up to 25 points are allowed.

Post-graduate credits must be from an accredited college or university. Credits must relate to nursing, or be credits related to health care, management, teaching or the biopsychosocial knowledge base of human services.

o Examples of acceptable courses (others may apply): Advanced Physical Assessment Advanced Pharmacology Advanced Anatomy and Physiology Business Ethics Education classes (e.g. Adult Learning Theory) Health Care Management

o Examples of unacceptable classes (others may apply) may include computer sciences, culinary arts.

Category G Activities AP Points Required Documentation

G1: APRN National Certification (Initial or Renewal)

10 Complete appropriate section on the table on following page. Submit copy of certificate.

G2: Attaining / Maintaining Prescriptive Authority

5 Complete appropriate section on the table on following page.

G3:Academic Education (Transcript(s) required)

5 points per each semester credit

hour

Complete appropriate section on the table on following page. Submit transcript(s).

G4: Professional national certifications for fields related to pain management (e.g. Hospice/Palliative care nursing; Orthopedic nursing; mental health)

*Do NOT include your ANCC pain management certification in this category*

10 Complete appropriate section on the table on following page. Submit copy of certificate.

22

CATEGORY G: ACADEMIC EDUCATION/ PROFESSIONAL CERTIFICATIONS

INSTRUCTIONS

CATEGORY G: ACADEMIC EDUCATION/APRN CERTIFICATION

VERIFICATION FORM

G1: National APRN Certification

Activity Certifying Organization Date of initial or renewal Certification number

G1

G2: Prescriptive Authority

Activity Prescriptive Authority License number

Date of initial or renewal

G2

G3: Academic Education

Activity Number School or Activity Dates of

attendanceSemester/ Quarter

Credit Hours Points

5 pts per semester

credit hourG3

G3

G3

G4: Professional Organization Certification

Activity Certifying Organization Date of initial or renewal Certification number

G4

TOTAL AP POINTS FOR CATEGORY G: Click or tap here to enter text.(Transfer this total to point

log)

23

T

No minimum number of points are required, up to 25 points are allowed.

Projects and activities not defined in the above sections must be submitted to the AP commission for pre-approval. The request for pre-approval should be sent prior to submission of the AP portfolio, and must be at least one (1) month prior to AP application deadline.

The AP Commission will review the request for pre-approval, make a decision of acceptability, and notify applicant.

It is required you use this pre-approval for projects/activities not defined verification form to summarize the project or activity. Other documentation is not acceptable.

24

CATEGORY H: PRE-APPROVAL FOR PROJECTS ORACTIVITES NOT DEFINED ABOVE

INSTRUCTIONS

Name: Click or tap here to enter text. Date: Click or tap here to enter text.

Complete this form for each project or activity for which you are requesting pre-approval.

1. Date activity completed: Click or tap to enter a date.

2. Summarize activity as it relates to AP-PMN.

3. Provide an overview of the implementation of program / project as it relates to AP-PMN.

4. Evaluation of program / project (implications for clinical practice) as it relates to AP-PMN.

AP POINTS REQUESTED FOR THIS ACTIVITY: Click or tap here to enter text.

(Transfer this total to Point Log)

25

CATEGORY H: PRE-APPROVAL FOR PROJECTS/ACTIVITES NOT DEFINED ABOVE

VERIFICATION FORM

Include the following documents with your completed application portfolio (click on box, right click, properties, checked when completed). All materials must be computer generated (not hand written):☐ Application ☐ Copy of ANCC Pain Management Certification☐ Copy of APRN Certification (if applicable) ☐ Point Log ☐ Most recent performance evaluation or peer letter of recommendation☐ Curriculum Vitae or resume, including current position summary to reflect

your AP role☐ Complete all necessary information required on each verification form ☐ Keep a copy of your materials☐ Submit fee ☐ Submit all materials either on-line (coming soon), email to

aspmn@kellencompany.com, or mail hard copy to the addresses below.

Renewal Fee: $150

All funds MUST be submitted from a U.S. bank in U.S. funds. ASPMN® does not accept purchase orders or invoice for services.

☐ Check made payable to ASPMN® check #Click or tap here to enter text.☐ Credit CardASPMN® no longer accepts credit card numbers on paper forms. All credit card payments must be made online. If you elect to pay by credit card you will receive an invoice and instructions on how to access your online account and how to make your payment.

Payment type submission information

Credit Card: email application to aspmn@kellencompany.com

Check: Mail completed application, supporting documentation and check to:

AP PortfolioASPMN® Executive Office4400 College BlvdSuite 220Overland Park, KS 66211

*NOTE: The ASPMN® AP Commission is not responsible for correspondence lost in the mail. If submitting hard copy, it is advisable to send your application by traceable means that require a signature, such as UPS or Federal Express. Please note that certified mail is only traceable when you request and pay for tracking. For online submission, scan and upload required documents.

The entire application review process may take up to 60 days from date of receipt. If you have not received notification of receipt within 2-3 weeks, please contact the ASPMN®AP Commission. Applications can be submitted at any time. Only completed applications will be reviewed. Successful applicants will receive a certificate and may use the title "Advanced Practice-Pain Management Nurse" AP-PMN.

26

PORTFOLIO CHECKLIST

The following definitions have been developed to explain the intent of some of the terms used in this portfolio. If you have additional questions after you have reviewed the terms, please contact aspmn.org.

Brochure/Pamphlet: Summary of information regarding a product or service. Example: You develop a tri-fold marketing piece outlining the Pain Management Services offered at your hospital.

Clinical Pathway: A clinical pathway is intended to be a multidisciplinary patient plan of care. These pathways are disease/condition specific and usually include standing orders, policy and procedures, patient education, ongoing patient assessment criteria, etc. Typically, there are multidisciplinary meetings held to determine what must be in the pathway. Activities in this category require multiple steps for completion.

Co-author: Listed as one of two or more authors of a journal article or other publication. Not listed as the 1st or lead author.

Competency Based Tool: An educational activity that measures the pain management skills and knowledge of the nursing staff.

Example: You develop a pain management competency test for the nursing staff that consists of a scenario to evaluate a pain management patient when the patient is not able to self-report pain. The nursing staff then completes a CPOT scale, and documents the results and proposed treatment plan in the patient record.

Contributing Author: Name is cited as a contributing author in the published textbook or chapter.

Forum or Advisory Panel: Providing a voluntary role as a consultant on various Pain Management issues, i.e., Manufacturers advisory panels, new product development/advancing products, reviewing manufacturers literature, etc.

Grant Activities (non-research based): Grant applications for activities such as: education programs for your facility, equipment, or other "non-research based activities" which would not go before an IRB. Grant activity that only requires institution approval since the application does not involve human subjects or informed consent.

Example: Institution approved grant proposal submitted to a University or company that supports nursing education (such as Lippincott Williams & Wilkins, etc.) to request funding for educational program at your facility.

Healthcare Professional Fact Sheet: Factual clinical information intended for the healthcare professional.

Example: You develop a clinical fact sheet for nursing students which shows the difference between acute and chronic pain treatment options.

IRB (Institutional Review Board): A committee/group that is given the responsibility by an institution to review research projects involving human subjects. The purpose and role of the IRB is to assure the protection and safety, rights and welfare of research participants (human subjects).

Example: Institution and IRB approved grant proposal submitted to the NIH Institute of Nursing Research to request funding for a research study at your facility.

Lead Author: Listed as 1st named author on a journal article or other publication.

27

APPENDIX ADEFINITION OF TERMS

Learning Module: A pain management course in a written, electronic, or video format. The module must include objectives, learning activities and competency evaluation (post-test, return demonstration, etc.).

Example: During RN Orientation, you are asked to complete a written learning course on the Pain Management Policies and successfully pass a written test on the subject.

Multidisciplinary Pain Management Service: Establishing a pain management practice that includes various disciplines. For example: a team consisting of a Pain Management Nurse, a Physical Therapist, a Pain Management physician, and a Psychologist, etc., who are involved in caring for pain patients.

Patient Education Tool: Factual information developed and written for patients.Example: You develop a one page handout on “Safely storing your Pain Medications”

Public health policy activities may involve representation of professional organizations at the national, regional or state level, e.g. participation in consensus groups meetings, testimony for regulatory bodies, and development of documents related to public health policy decisions.

Professional Practice: Courses or activities, other than topics clinically related to pain management, that impact or enhance the role of a Pain Management Nurse.

Examples: “Marketing Your Business”, “Legal Issues”, “Integrating Technology into your Practice”, “Preceptor Workshop”, “Out-patient Billing/Reimbursement”, or any of the Professional Practice courses offered at the ASPMN Conference.

Quality Improvement Project: An activity in which a problem is identified, solutions to the problem are identified, and a corrective program is implemented. After an initial period of utilizing the program, the solutions are reevaluated to identify the results and success of the program.

Example: Through chart audits you find that pain re-assessments are not being charted consistently and correctly on patient records. You develop a “Pain Re-assessment Documentation Record” that provides nurses with a rational pain re-assessment guideline after either pharmacological or non- pharmacological pain management interventions. After in-servicing the form and using it for three months an audit is performed and shows that correct documentation was found on 90% of the charts.

Pain Management Nursing Service: Establishing a pain management nursing practice in which the Pain Management Nurse is responsible for the pain management issues within a healthcare setting.

Example: You take a newly created hospital position as a Pain Management Nurse. Your responsibilities are to define your Pain Management nursing role and responsibilities, establish the hospital's policy and procedures for pain management.

Prevalence and/or Incidence Study: An observational study that analyzes data from a population or subset at a specific point in time (cross sectional data).

Reviewing Textbook, Chapter, or Journal Article: Analyzes content related to Pain Management practices and edits content as appropriate.

Revising an Education Program: The program must have revisions of content, and updated references.

END

28