Informal Continuing Medical Education Documentation Record

For Compliance With Section 166.2 of the Texas Medical Practice Act

Do not submit this form to the Texas Medical Board unless specifically requested.

This form represents only one format which may be useful for physicians to record their CME hours. This is NOT an official form of the Texas Medical Board and is NOT required for compliance with the CME requirements. If used, this form should be retained as a personal record only.

Informal CME Activities Completed

Name: ____________________________________ 

Lic. Number _______________________________

From:___________________, 200____ To: ______________________, 200 ____
(date of current license)                              (date of next registration)

Physicians may complete up to 12 hours (of the required total 24 hours every 12 months). Informal activities are not always provider verifiable. If available, retain brochures, computer transcripts or certificates of attendance. If not available, maintain a personal log of activities completed. The following may be reported as informal hours:

  • Conferences, seminars, grand rounds, case conferences, journal clubs, etc. not designated for formal credit. Record activity title; date; and clock hours expended.
  • Self instructional materials or courses not designated for formal credit and self-assessment examinations and reviews. Record activity/course title; date of use; and clock hours expended.
  • Reading clinically relevant medical journals or articles and use of literature search databases in connection with the provision of patient care. Record name of publication or data base utilized; date read/used; clock hours expended.
  • Participation in patient care review activities (peer review or hospital quality of care review committees); research/preparation time for medical presentations delivered to health professionals; Up to 10 hours may be claimed for: publication of a medical or medically related article; for each chapter of a medical or medically related book or other medical education materials; preparation of an exhibit displayed at a scientific medical meeting or other CME activity.
    Articles must be published in a recognized medical journal that is primarily read by physicians or other health professionals. Credit may be claimed only once for publications or exhibits even if it is reissued in a changed format. Record the type of activity; date completed; and clock hours expended.
  • Up to 6 hours may be claimed for volunteer services at a site serving medically underserved populations, as defined in the Medical Practice Act. The volunteer hours should be a site other than the physician's primary practice location.

 

Activity Title Date Clock Hours
   
   
   
   
   
   
   
   
   
   
   

Return to Rules for Reporting CME
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