CME Claim Form

Fundamentals CME Claim Form

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) is accredited by the Accreditation Council for Continuing Medical Education (A.C.C.M.E.) to provide Continuing Medical Education for physicians.
The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) designates this enduring material for a maximum of 12 AMA PRA Category 1 Credits™.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and Self-Assessment requirements of the American Board of Surgery’s Continuous Certification program. It is SAGES' responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

You must pass the tests in the FUSE materials with a grade of 80% or higher, and complete the CME credit request and evaluation to obtain CME credits. Please allow 4-6 weeks for delivery of credit letter.

Credit may only be claimed once. If you intend to take the FUSE exam, you should wait to claim credit until after you pass that exam so that you may receive 12 credits. If you do not intend to take the exam, you may claim 10.5 credits.

Who is claiming the credit?
I certify that*
- I am a Physician
- I am a Nurse
- Other Medical Professional
What is your License Number?*
Other Medical Professional*

Explain Other Medical Professional
SAGES Member?*
- Yes
- No
Indicate whether or not you are a SAGES member
Name*
First Last
As you wish it to appear on the credit letter
Degree(s)*

MD, PhD, etc as you wish it to appear on the credit letter
Date of Birth (MM/DD)*

Month and Date ONLY (MM/DD)
Licensing State*
Licensing ID or NPI*
Email Address*
Phone*
Best contact number to reach you at
Institution/Organization*
Department*
Number of Credits Claimed*
Please enter a number from .25 to 12.0.
Check this box if you want a copy of the certificate emailed to you

In order to evaluate the learning experience provided by the FUSE Program, all participants must complete the following evaluation.
1. As a result of this program, do you plan to make a change(s) in your practice?*
- No (reaffirmed my practice)
- N/A (not practicing, in training, retired)
- Yes
2. FUSE Practice Change*
- No changes intended
- I have taught others in the operating room about the function of electrosurgical instruments
- Modified the way I use argon plasma coagulation
- Changed the type of advanced energy that I use. Please describe below
- Changed the way I establish hemostasis during endoscopy. Please describe below
- Modified my use of energy in patients with pacemakers/defibrillators
- Changed the settings I use most of the time on the monopolar electrosurgical unit (formerly known as Bovie)
- Other
Other changes or describe change more:*
Please explain your Other selection or provide further details on selected changes.
3. Please describe any barriers to incorporating these changes into practice, if any:*
4. Did you note any commercial bias in the FUSE program?*
- Yes
- No
If Yes, Please Explain:*
5. Please let us know how you would improve the FUSE Online Didactic content or format:*
CEU Evaluation Questions
Objective 1: Do you feel that, as a result of the activity, you are better able to:
1. Define Proper electrosurgery terms
2. Given a clinical situation, identify the application of Ohm's Law, power equation, and energy
3. Identify the function (input and output) of a radiofrequency (RF) electrosurgical generator
4. Identify the characteristics and differences between monopolar and bipolar instruments
5. Identify the characteristics of the RF electromagnetic spectrum and why it is used for surgical applications

6. Identify how RF electrical energy causes effects in cells and tissue

7. Identify the different effects of ranges of temperature on cells and tissue
Objective 1: Response*
Not at all Neutral Significantly Better
Objective 2: Do you feel that, as a result of the activity, you are better able to:

1. Identify general patient protection measures for the electrosurgical unit

2. Identify various mechanisms whereby electrosurgical injuries may occur

3.Identify circumstances, mechanisms, and prevention of: dispersive electrode-related injury, direct coupling-related injury, insulation failure-related injury, injury due to unintentional activation of the active electrode, injury due to direct thermal extension from the active electrode, alternate site-related injury, capacitive coupling/induced current-related injury, injury from residual heat from the instrument tip, energy-related single port access injury, the operative team can suffer a burn injury

4. Identify the hazards of the byproducts and smoke produced during electrosurgery

5. Identify circumstances which promote OR fires and identify prevention strategies

6. Identify circumstances, mechanisms, and prevention of tracheotomy-related fires

7. Identify circumstances, mechanisms and prevention of alcohol prep-related fires

8. Identify how to respond to an OR fire

9. Identify problems that can occur when simultaneously using multiple energy devices

10. Identify how to report and handle an adverse device event and meet regulatory requirements
Objective 2 Response:*
Not at all Neutral Significantly better
Objective 3: Do you feel that, as a result of the activity, you are better able to:

1. Maximize the use of current density to achieve the desired tissue effects

2. Describe the clinical effects of changing current densities

3. Identify the mechanism of action, the proper use of and potential complications of using argon beam coagulation in electrosurgery

4. Identify the strategies for the risk reduction for prevention of argon gas embolism
Objective 3 Response:*
Not at all Neutral Significantly better
Objective 4: Do you feel that, as a result of the activity, you are better able to:

1. Identify the characteristics of basic and advanced bipolar electrosurgical instruments

2. Identify clinical scenarios when basic bipolar instruments are indicated and identify appropriate power settings for use

3. Identify performance optimization methods for advanced bipolar instruments

4. Identify the differences between basic bipolar and monopolar instrumentation as it relates to coupling underwater use, current density, and lateral thermal spread

5. Identify tissue charactersitics that reduce the effectiveness of advanced bipolar instruments
Objective 4 Response:*
Not at all Neutral Significantly better
Objective 5: Do you feel that, as a result of the activity, you are better able to:

1. Identify the differences between typical radiofrequency electrosurgical and radiofrequency ablation (RFA) systems

2. Identify the indications for application of radiofrequency energy for volumetric ablation

3. Identify the underlying principles of the volumetric thermal coagulation RFA system

4. Identify circumstances, mechanisms and prevention of RFA related injury
Objective 5 Response:*
Not at all Neutral Significantly better
Did the activity meet the stated learning objectives for Modules 6-10?*
- Yes
- No
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Fundamentals CME Claim Form

Who is claiming the credit?

CEU Evaluation Questions

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Fundamentals CME Claim Form

Who is claiming the credit?

CEU Evaluation Questions

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FUSE Videos

Resources

Contact Information