CME – Instructions for Monitors

Continuing Medical Education
3020 Children’s Way, Mc-5021, San Diego, CA  92123
(858) 966-4072; Fax: (858) 966-8587

Rady Children’s Hospital-San Diego CME Department is required to monitor every program that is granted Category 1 credit for compliance to ACCME Standards, Federal and state laws.

The monitor for CME Certified Educational Activities (Course, Regularly Scheduled Series, Internet or Enduring Material CME), CANNOT be the Physician Coordinator. Each Physician Coordinator can appoint a monitor on a meeting-by-meeting basis, if a monitor assignment cannot be made on a more regular basis of said meeting.

The Accreditation Council for Continuing Medical Education (ACCME) requires monitoring reports on 10-25% of all sessions of a certified activity each year. Our Certification year runs from April 1st to March 31st.


Live Courses/Webinars: need to be monitored each time one is held.

Regularly Scheduled Series: We would prefer CME-certified meetings be monitored each time, however, we realize this may not be possible. We suggest a minimum of six (6) meetings be monitored each year, unless the meeting is only held quarterly, in which case, we recommend monitoring each meeting.

Explanation of the Items to be Monitored (See the Monitor Form):
Be sure to mark each question section as it applies: Y (Yes), N (No) or NA (Not Applicable). Fill out the items as best you can.

  1. Sign-In Sheet(s): Sign-in sheets are to be made available and signatures are required for attendance. This is the only way attendees get credit. If the sign-in sheet form is absent, note this and remind the coordinator to obtain it for future sessions.
  2. Monitor Review: When handout material is provided, attach a copy to the Monitor form and forward to the CME Department, MC 5021, by: interoffice mail, or, if available, scan and e-mail to All course brochures, syllabus, flyer, schedule / agenda and other documents must include the following accreditation statement:
    Rady Children’s Hospital-San Diego is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
    CME Credit: The Rady Children’s Hospital-San Diego designates this live activity for a maximum of__.__ AMA PRA Category 1 Credit(s) TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  3. Certification Document (CD): This document contains the Needs, Objectives, and Target Audience, as well as staff participation disclosures and other important information (Residents, students, etc. do not need to provide disclosure). Please have this document available, at each meeting, for attendees’ review at Registration (placed at or near sign-in sheet), or posted permanently in venue. If missing, note on Monitor Form and draw to the attention of the Coordinator to correct.
  4. CME Credit Certificate: Record of Attendance for participants to keep for their own record. CME is no longer tracking any physician’s CME credit as of January 2010.
  5. Content: Document any specific references to the following: Cultural/Linguistic Diversity; Patient Outcomes; Performance Improvement Measures and/or Practice Gaps addressed.
  6. ACGME Competencies addressed: Indicate any competencies this activity focused on.
  7. Faculty Disclosure: Each Speaker needs to disclose their or their partner’s relevant financial relationships’ (Pharmaceutical Industry) associations.
  8. Grant Support: If known, please list. The ACCME, our accreditation agency, requires CME have a Letter of Agreement (LOA) on file. Is there evidence of commercial support [(i.e., drug advertising, gifts (other than pens or note paper)]? If so, note on Monitor Form and document how they were acknowledged for their grant support.
  9. Exhibitors: Exhibitors can attend meeting, but any drug advertising or gifts, as mentioned in #8, has to be displayed outside the educational activity meeting room.
  10. Exhibits: Exhibits should be held outside of where the educational activity occurred.
  11. Food Service: Document if food was served and who provided it.
  12. Monitor’s Notes/Documentation: Indicate if you have notes and where you documented them.
  13. Outcomes Measurement Survey: In October, CME will provide Survey for each participant to complete (conducted 1x per year). CME will provide instructions.
  14. Conference is: Compliant when steps #1-#7 are marked “Yes,” including steps #8-#10, if applicable. If any steps are missing, there is Non-Compliance. Try to take care of any issues during/at the actual meeting being monitored; otherwise, CME will document non-compliance. (The CME Department will determine Compliance.)
  15. Deficiency memo to be generated by CME: The CME Department will deal directly with the Coordinator if the non-compliant issues could not be taken care of at the actual meeting.

Contact CME with any questions (858) 966-4072 or

Return Forms to: CME, MC-5021. Thank you.