Download FRI BOOK 10/24/2013 1

FRI BOOK
10/24/2013
Palm Beach State College – Paramedic Program
1
FRI
Table of Contents
PARAMEDIC CLINICAL .............................................................................................................. 1
STUDENT CLINICAL BOOK ........................................................................................................ 2
Typhon – Non-Compliance ................................................................................................. 3
CLINICAL DO’S AND DON’TS .................................................................................................... 4
SEMESTER SKILLS ................................................................................................................... 5
CARDIO-PULMONARY / ICU DEPARTMENT OBJECTIVES ............................................................. 6
ALS UNIT OBJECTIVES ............................................................................................................. 7
EMERGENCY DEPARTMENT OBJECTIVES ................................................................................... 8
PEDIATRIC DEPARTMENT OBJECTIVES ...................................................................................... 9
CODE OF CONDUCT OFFENSE .................................................................................................10
REQUIRED SKILLS / CLINICALS - 2ND SEMESTER........................................................................11
REQUIRED SKILLS / CLINICALS - GRADUATION .........................................................................12
SIGNIFICANT EXPOSURE OR INJURY IN A CLINICAL/LAB SETTING: .............................................15
DECLINATION OF POST-EXPOSURE EVALUATION .....................................................................16
PHYSICIAN NOTIFICATION OF SIGNIFICANT EXPOSURE ..............................................................17
PARAMEDIC STUDENT CLINICAL OBJECTIVE WORKSHEET ........................................................19
ONGOING PRECEPTOR TRAINING PROGRAM.............................................................................20
PRECEPTOR EVALUATION OF STUDENT CLINICAL EXPERIENCE .................................................21
PRECEPTOR FEEDBACK TOOL .................................................................................................22
CLINICAL SIGN IN SHEET .........................................................................................................23
STUDENT SHIFT LOG...............................................................................................................24
PATIENT CARE REPORT ..........................................................................................................25
STUDENT EQUIPMENT COMPETENCY CHECK LIST - LP .............................................................28
STUDENT EQUIPMENT COMPETENCY CHECK LIST – MED BAG ..................................................29
PAYROLL REPORT – CLINICAL .................................................................................................30
PARAMEDIC ASSISTANCE LAB REFERRAL ....................................................................31
Paramedic Student Assistance Lab Referral Guidelines .................................................33
CLINICAL EVALUATION - PROGRESS REPORT .....................................................................34
CLINICAL EVALUATION - COVER FOR LONG FORM ....................................................................35
CLINICAL EVALUATION - LONG FORM ......................................................................................36
Team Leadership ........................................................................................................39
Palm Beach State College – Paramedic Program
FRI
PARAMEDIC CLINICAL
Book Attestation Page
I hereby attest that the reports and documentation contained
within this Student Clinical Book for:
Are complete, accurate and reflect the student’s Typhon
entries.
Fire Rescue Instructor Printed Name:
_______________________________________________
Fire Rescue Instructor Signature:
_______________________________________________
Date of Submission:
_______________________________________________
CLASS SHIFT: ____________
Palm Beach State College – Paramedic Program
1
FRI
PALM BEACH STATE COLLEGE
PARAMEDIC PROGRAM
STUDENT CLINICAL BOOK
□ EMS 2664 – CLINICAL 1
□ EMS 2665 – CLINICAL 2
□ EMS 2658 – CLINICAL 3
□ EMS 2659 – Internship
STUDENT NAME________________________________
HOSPITAL INSTRUCTOR_________________________
FIRE RESCUE INSTRUCTOR______________________
CLASSROOM INSTRUCTOR______________________
Palm Beach State College – Paramedic Program
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FRI
PALM BEACH COMMUNITY COLLEGE
EMS Academy - Paramedic Program
Typhon – Non-Compliance
□ EMS 2664 – CLINICAL 1
□ EMS 2665 – CLINICAL 2
□ EMS 2658 – CLINICAL 3
□ EMS 2659 – Internship
Class Shift:
______
Clinical Shift: ______
Date of Non-compliance:
Clinical instructor:
Student Name (Print):
I am aware that skills tracking and documentation are integral components of my paramedic
training and is used for recording and verification of skills observed and performed while at
clinicals. Entries must be made within 72 hours of occurrence. Non-compliance will affect
the Documentation section of my Clinical long-form evaluation and may result in receiving an
Unsatisfactory grade for that given semester.
 Entries not made within 72 hours
 Narrative deficiency
Student Acknowledgement (signature):
Palm Beach State College – Paramedic Program
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FRI
Palm Beach State College EMS
Academy
CLINICAL DO’S AND DON’TS
The following is provided to you with the intent of making your
clinical experiences amiable. Remember: you are a guest at Fire
Rescue and the Hospital.
This is your Clinical Code of Conduct
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
×
×
×
×
×
×
×
×
×
Sit in a recliner
Adjust the AC
Leave work area early
Be unprofessional
Use TV remote control
Use cell phone
Eat what is not yours
Go into bunkroom or offices
Perform medical procedures
without
× Preceptor approval
× Falsify any documents or
evaluations
× Be Late!!
Use good hygiene
Study textbook during slow time
Be part of the team
Help with patient lifting
Help with truck washing
Help with station chores
Ask questions
Show enthusiasm
Be professional
Thank the crew
Contribute $$ for food
Offer to cook & clean
Ask for help
Participate in truck checks
Clean up your mess
Have safety goggles, HEPA mask, vest
Palm Beach State College – Paramedic Program
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FRI
SEMESTER SKILLS
PARAMEDIC STUDENT FIRST SEMESTER SKILLS:
•
All EMT-B Skills
•
IV Set Up and Insertion
•
Ventilation of Unintubated Patients
•
Encoding
•
Medication Administration, IV, IM, SQ, PO
•
Endotracheal Intubation
•
Student must demonstrate the ability to serve as the Team Leader in a variety of
prehospital emergency situations. The student should serve as the Team Leader for at
least 35 prehospital emergency responses.
PARAMEDIC STUDENT SECOND SEMESTER SKILLS:
•
ACLS, PHTLS
•
Comprehensive Assessments on all patient types including: OB, Trauma, Psychiatric,
Cardiac, Geriatric, etc.
•
Formulate and Implement Treatment Plans on Chest Pain, Dyspnea, Syncope,
Abdominal, and Altered Mental Status Patients.
•
Student must demonstrate the ability to serve as the Team Leader in a variety of
prehospital emergency situations. The student should serve as the Team Leader for at
least 35 prehospital emergency responses.
PARAMEDIC STUDENT THIRD SEMESTER SKILLS:
•
Student must demonstrate the ability to serve as the Team Leader in a variety of
prehospital emergency situations. The student should serve as the Team Leader for at
least 35 prehospital emergency responses.
•
PALS
Palm Beach State College – Paramedic Program
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Revised Fall 2010
Paramedic Student Clinical Rotations:
CARDIO-PULMONARY / ICU DEPARTMENT OBJECTIVES
During clinical rotations in this area, the paramedic student should have the opportunity to gain
experience and develop proficiency in the following skills:
1.
Perform oral and sterile endotracheal suctioning. (2-1.89)
2.
Using bag-valve-mask device to ventilate patients. (2-1.43d)
3.
Apply and/or monitor oxygen therapy devices such as mask and cannula. (2-1.100)
4.
Identify uses and side effects of the various respiratory treatment drugs. (5-1.7, 5-1.8)
5.
Identify uses and side effects of the various respiratory treatment drugs. (5-1.7, 5-1.8)
6.
Identify lung sounds including: wheezing, rales, rhonchi. (3-2.28, 5-1.10)
7.
Identify sounds and symptoms of respiratory distress. (2-1.26, 5.15)
8.
Observe ABG procurement and use of blood gas machine (intern will not perform arterial
punctures) Interpret ABG’s and relate to specific signs and symptoms and treatment.
(2.1.9, 2-1.10, 2-1.12, 2.1.13)
9.
Assist in respiratory treatments and use of mechanical ventilators. (1.8.38, 2-1.95f, 5-1.7)
10. Use a pulse oximetry device. (2-1.81)
11. Define, identify and describe a tracheostomy, stoma, and tracheostomy tube. (2-1.52.
12. Maintains a professional demeanor throughout this clinical rotation. (1-1.39, 1-1.46)
13. Paramedic Student will be under direct supervision during clinical rotations.
**Detailed documentation must accompany this referral
Palm Beach State College – Paramedic Program
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Revised Fall 2010
Paramedic Intern Clinical Rotations:
ALS UNIT OBJECTIVES
During this rotation, as experience, exposure, and knowledge level permits, the paramedic intern:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
Determines safety for self and adequacy of work environment and intakes appropriate
action (1*1.38, 3-3.64)
Initiates appropriate crowd control maneuvers. (3-3.64)
Establishes and maintains rapport while providing emotional support to patients, family,
and bystanders. (1-9.3)
Performs primary assessment and intervenes as indicated. (3-3)
Obtains relevant and accurate patient history in a systematic manner. (3.1.1, 3-1.2, 3-1.5,
3-1.6 0
Performs an appropriate physical exam. (3-3.81)
Recognizes patients that need further attention and transports at appropriate point in run.
(3-3.28, 3-3.29)
Recognizes the need to make hospital contact. (1-1.24, 1-4.28, 3-5.23)
Obtains vital signs quickly and accurately. (2-1.19, 3-2.32, 3-2.81)
Recognizes arrhythmias. (5-2.35)
Interprets assessment information clearly and takes appropriate action. (3-4, 7-1.1)
Accurately reports all pertinent information in a systematic manner. (1-4.28, 3-5.29, 71.13)
Speaks clearly and concisely and is easily understood. (3-5.5, 7-1.13)
Repeats all orders and reports patient response to therapy. (1-4.28, 3-6.18)
Keeps accurate, complete and legible written records. (1-4.28, 1-4.29, 7-1.13)
Anticipates orders, and the needs of other team members. (1-1.16)
Establishes appropriate working relationships with all team members. (1-1.16)
Assumes leadership role and directs team members appropriately. (1-1.16, 7-1.8, 7-1.18,
7-1.19)
Communicates information appropriately to all team members. (1-1.6,7-1.13)
Performs well under stress, uses good judgment. (1-1.46, 1-2.26, 3-4.9)
Is able to accept constructive criticism and guidance. (1-1.1L, 3-4.7)
Maintains adequate airway control. (2-1.1, 2-1.29.2-1.42, 2-1.43d, 2-1.58)
Properly uses the antishock trousers. (4-2.40)
Applies splints and bandages appropriately. (4-3.35a & b, 4-9.44)
Provides proper care to burn patient. (4-4.80-.84)
Performs CPR correctly and effectively. (5-2.125, 5-2.205a)
Safely and effectively performs defibrillation/cardioversion. ( 5-2.205b, 5-2.205c)
Displays proper knowledge and skill level when using drug therapy. (1-7.24, 1-8.20, 18.21, 1-8.41)
Demonstrates knowledge and ability in emergency Childbirth. (5-14.13)
Efficiently performs ET, Nasal Tracheal and EOA procedures. (2-1.58, 2-1.69, 2-1.104a-c)
Initiates or directs extrication of patient. (8-3.34)
Aseptic and proficient insertion of IV and monitoring IV therapy. (1-8.8, 1-8.34)
Performs needle thoracostomy. (4-7.50A)
Proficiently administers oxygen therapy. (2-1.43d, 2-1.51)
Spinal immobilizes patient correctly. (4-6.15, 4-6.31)
Demonstrates ability to suction patient. (2-1.88, 2-1.89)
Maintains assigned ambulance inventory. (8-1.2)
Demonstrates the ability to correctly operate all electronic equipment. (3-5.29, 2-1.31, 21.46, 5-1.15, 5-2.199, 5-4.12
Critiques runs with preceptor. (1-1.1L, 3-4.7)
Maintains a professional demeanor throughout this clinical rotation. (1-1.16, 1-1.17, 11.39)
Palm Beach State College – Paramedic Program
7
FRI
Revised Fall 2010
Paramedic Student Clinical Rotations:
EMERGENCY DEPARTMENT OBJECTIVES
During clinical rotations in this area, the paramedic student should have the
opportunity to gain experience and develop proficiency in the following skills:
1.
Triage (8-2.17, 8-2.20, 8-2.21)
2.
Vital and diagnostic signs-recognition and significance. (3-2.6, 3-2.28, 3-281)
3.
Physical assessment, patient history, documentation in compliance with
for all age groups. (3.3, 3-1.1, 3-6.1)
4.
Peripheral IV insertion and drip rate calculation. (1-8.16, 1-8.17, 1-8.19, 1-8.21)
5.
Drug therapy-IM,IV,SQ,PO,SL,ET, dosage calculation. (1-8.16, 1-8.17, 1-8.19, 1-8.21)
6.
Aseptic techniques and universal precautions. (1-8.28, 1-8.30)
7.
Cardiac arrest procedures. (5-2.124, 5-2.125, 5-2.129, 5-2.2056).
8.
NG tube and urinary catheter insertion (2-1.40, 6-6.29).
9.
Airway management including insertion of airways, suctioning, oxygen therapy,
intubation (under direct physician supervision). (2-1.100, 2-1.104a, 2-1.37, 2-1.88)
hospital policy
10. Use of cardiac monitors and interpretation of rhythms. (5-2.35, 5-2.200)
11. Venipunture for blood specimens. (1-8.23, 1-8.42)
12. Emotional support of patient and families. (1-1.44)
13. Use of IV pumps. (1-8.21)
14. Recognition of safety hazards to patients; implementation of safety procedures including
side rail use and needle safety. (12.45, 1-2.46)
15. Interpretation of ABG’s. (2-1.9, 2-1.10)
16. Wound care and bandaging. (4-3.31)
17. Maintains a professional demeanor throughout this rotation. (1-1.39, 1-1.46)
18. Paramedic Student will be under direct supervision during clinical rotations
Palm Beach State College – Paramedic Program
8
FRI
Revised Fall 2010
Paramedic Student Clinical Rotation:
PEDIATRIC DEPARTMENT OBJECTIVES
During clinical rotations in this area, the paramedic student should have the opportunity to
experience and develop proficiency in the following skills:
1.
Perform pediatric patient assessment including, at a minimum, a review of the patient’s
chart, taking vital signs, and auscultation of lung and bowel sounds. (6-2.8, 6-2.94).
2.
Prepare and administer IM and IV medications, if allowed by the department. (6-2.107).
3.
Monitor IV infusions; assist with IV insertions (some pediatric departments will allow
intern IV insertion in selected cases, check with instructor or charge nurse) (6-2.50, 62.106).
4.
Estimate pediatric ages, and weights in kilograms and verify with documented
measurements. (6.2.95).
5.
Perform history-taking using information from patient and parents. (3-1.1).
6.
Relate history and assessment to pathological conditions, treatments, and medications. (62.1).
7.
Perform isolation procedures. (1.2.30, 5-11.59).
8.
Provide emotional support to patients and families. (6-2.90).
9.
Assist with nursing care and treatments (including feeding and changing diapers). (62.91, 6-2.9).
10. Maintains a professional demeanor throughout this clinical rotation. (1-139, 1.1-46).
11. Observe the following procedures as they occur
•
•
•
Spinal tap
Oxygen therapy using tents, etc.
Intraosseous infusions
• Other procedures performed on pediatric patients
Please bring any problem to the attention of the clinical instructor\
Paramedic Students will be under direct supervision during clinical rotations
Palm Beach State College – Paramedic Program
9
FRI
Revised Fall 2010
PALM BEACH STATE COLLEGE
Paramedic Program - Clinicals
CODE OF CONDUCT OFFENSE
Please refer to PBSC Health Sciences/EMS Disciplinary Procedures for a complete listing of offenses
Date:
Instructor:
Student Print Name:
Class Shift
Signature:
Group 1 Offense**
Inappropriate language
Dress Code Violation
Failure to follow chain of command
Failure to act in a professional manner
Absence Non-Notification
Arrive late without notification
Smoke or chew tobacco at hospital or fire rescue setting
Conduct inconsistent to good order and discipline
Other:
Group 2 Offense**
Commit academic dishonesty.
“Any student who knowingly helps or is present when another student violates
academic behavior standards is also in violation.”
Behave with intent to detract from the education of another student.
Leave assigned area (hospital or fire rescue setting) without notifying instructor.
Perform duties outside the scope of practice.
Perform as a firefighter while participating in a paramedic student capacity.
Respond to a fire/rescue call while in a PBSC lecture/lab/hospital setting.
Examine a patient without an instructor or preceptor present.
Not properly maintaining BSI and/ or properly utilizing PPE.
Show disrespect or be abusive to any instructor, hospital or fire rescue personnel.
Use a cellular telephone without the consent on an instructor.
Other:
Group 3 Offense**
Immediate phone call to Clinical Coordinator required
Possess or be under the influence of controlled substance or alcohol
Perform skills on which s/he has not yet been signed-off in lab
Failure to comply with HIPAA
Conduct perceived to be sexual harassment
Conduct which threatens the health or safety of others
Other:
Palm Beach State College – Paramedic Program
10
FRI
PALM BEACH STATE COLLEGE
Paramedic Program
DATE:
August 2011
PATH:
REQUIRED SKILLS / CLINICALS - 2ND SEMESTER
Evidence of progression of clinical skills is required for success in the paramedic program.
In order to receive a Satisfactory grade in EMS2665 Paramedic Clinical II, the student must have
the following minimum skills accurately reflected in Typhon:
Skill
Med Administration
ET Intubation
IV Success
Bag-Valve-Mask
Team Lead
Minimum # LIVE Skills Required
10
2
15
4
10
The numbers utilized for this benchmark will be the accumulation of Typhon numbers from
EMS2664 and EMS2665, Paramedic Clinicals I & II.
Regardless of any other evaluations in clinicals, the student will not be allowed to progress to
EMS2658 Paramedic Clinical III without the accomplishment of the above live skills.
These minimum goals are not meant as your target goals; they are at the lowest end of the
acceptable spectrum. We recommend that the students get as much possible experience while in
the program to be best prepared to enter their chosen field of EMS.
Palm Beach State College – Paramedic Program
11
FRI
PALM BEACH STATE COLLEGE
Paramedic Program
DATE: August 2011
PATH:
REQUIRED SKILLS / CLINICALS - GRADUATION
Evidence of progression of clinical skills is required for success in the paramedic program.
In order to receive a satisfactory grade in EMS2659 Paramedic Internship, and therefore
graduate, the student must have met all of the required minimum clinical goals in each category:
• Mandatory Skills
• Assessments by Patient Age
• Assessments and Plans
• Assessments by Patient Type
The numbers utilized for this benchmark will be the accumulation of Typhon numbers from
EMS2664, EMS2665, EMS2658 (Paramedic Clinicals I, II, & III) and EMS2659 Paramedic
Internship.
Students MUST obtain, and accurately document, 15 Team Leads solely within EMS2659
Paramedic Field Internship, with a total of 35 to graduate.
These minimum goals are not meant as your target goals; they are at the lowest end of the
acceptable spectrum. We recommend that the students get as much possible experience while in
the program to be best prepared to enter their chosen field of EMS.
Students will utilize the current paramedic
Required Clinical Goals (see policies).
Palm Beach State College – Paramedic Program
12
FRI
Mandatory LIVE Skills
Minimum
Category
15
5
Assessments by Patient Age
Minimum
Age
*Med Administration
1
*ET
25
*IV Success
3:1 Make-up Ratio (SimMan)
20
1
5
*Bag-Valve-Mask
5:1 Make-up Ratio (SimMan)
5
35
*Team Lead
1:1 Make-up Ratio
2
2
35
35
15 Live MUST be during EMS2659
Cardiac
1
Obstetric
5
Respiratory
10
Trauma
5
Syncope
35
2
Medical
10
5
0-1mo
1m -1yr
1-3yr
4-5yr
6-12yr
13-17yr
18-65yr
>65yr
Assessment by Patient Type
Minimum
Encounter
Assessment and Plan
Minimum
Encounter
15
Newborn
Infant
Toddler
Pre School
School Age
Adolescent
Adult
Geriatric
Abdominal
Psychiatric
AMS / Neuro
Palm Beach State College – Paramedic Program
13
FRI
Medication Administration
Live ET Intubations
Successful IV's
Ventillation with BVM
Assessment of Newborn
(0-1mo)
Assessment of Infant
(1mo-1yr
Assessment of Toddler
(1-3yr)
Assessment of Preschooler
(4-5yr)
Assessment of School Age
(6-12yr)
Assessment of Adolescents
(13-17yr
Assessment of Adults
(18-65yr)
Assessment of Geriatrics
(>65yr)
Assessment of Obstetric Patients
Assessment of Trauma Patients
Assessment of Medical Patients
Assessment of Psychiatric Patients
Assessment and Plan of Cardiac Patients
Assessment and Plan of Respiratory Patients
Assessment and Plan of Syncope Patients
Assessment and Plan of Abdominal Patients
Assessment and Plan of AMS/Neuro Patients
Total Field Team Leads
Field Internship Team Leads in EMS2659
Palm Beach State College – Paramedic Program
14
15
5
25
20
1
1
5
5
2
2
35
35
1
10
35
2
15
5
5
10
5
35
15
FRI
SIGNIFICANT EXPOSURE OR
INJURY IN A CLINICAL/LAB SETTING:
An exposure can be defined as a percutaneous injury (e.g., needlestick or cut with a sharp object)
or contact of mucous membrane or nonintact skin (e.g., exposed skin that is chapped, abraded, or
with dermatitis) with blood, saliva, tissue, or other body fluids that are potentially infectious.
Exposure incidents might place health care personnel at risk for hepatitis B virus (HBV),
hepatitis C virus (HCV), or human immunodeficiency virus (HIV) infection, and therefore
should be evaluated immediately following treatment of the exposure site by a qualified health
care professional.
(Centers for Disease Control and Prevention)
The following is a recommended approach for student reporting and instructor action should
a significant exposure or injury occur during a clinical setting.
1. Student shall notify Clinical/Lab instructor.
2. Clinical instructor to notify Infection Control Nurse (exposures only)
3. Student proceeds to facility’s Emergency Department, signs in as a patient
for treatment. If off site, the student should go to nearest hospital emergency
department.
4. Clinical/Lab instructor to notify the Clinical Coordinator / Program Manager
via Voice Mail. 868-3418.
5. Clinical/Lab instructor to call Palm Beach State College Security for an
incident report to be completed. 561-868-3600, day or night.
6. Clinical Coordinator/Program Manager notifies Safety and Security 8683487.
7. (Optional) Clinical instructor to call or page Dr. Landman for student
counseling and follow up care for exposures only. 561-969-7900, day or
night.
8. Student shall send a detailed e-mail to Clinical Coordinator / Program
Manager regarding incident specifics.
9. Clinical instructor to provide a copy of the insurance form to emergency
registration upon student registration.
Palm Beach State College – Paramedic Program
15
FRI
PALM BEACH STATE COLLEGE
EMS PROGRAM
DECLINATION OF POST-EXPOSURE EVALUATION
On___________________, I experienced an incident while participating in a Palm Beach State
College EMS Program, which may have caused my exposure to bloodborne pathogens. An
Accident-Incident Report was filed at that time.
I have been advised that I may be evaluated by a physician pursuant to this incident, which may
include serologic testing for HIV and HBV, and that there will be no cost to me for this
evaluation. However, I choose to decline having the evaluation performed, with the
understanding that I may have blood drawn at this time but not tested until a later time of my
choosing (up to 90 days following the date of the incident).
_________________________________________
Printed Name
_________________________________________
Signature
__________________________________________
Date
Palm Beach State College – Paramedic Program
16
FRI
Palm Beach State College
PHYSICIAN NOTIFICATION OF SIGNIFICANT EXPOSURE
To:
From:
Subject:
Emergency Room Physician
Dr. Ken Scheppke, MD
Significant Exposure to Bloodborne Pathogens
The student before you has sustained a significant exposure to a potentially infectious body fluid
during the course of medical treatment of ________________________________________
(patient name)
Per Florida State Statute 381.004(10), this medical personnel (student) has the right to know the
HIV status of this source patient. Florida law allows you to perform a HIV test on this patient
either with their consent or without their consent if blood specimens have been obtained for other
purposes.
In addition, it is not mandated by the state but if the source patient consents, we are also
requesting a Hepatitis B and C test be performed.
Please have your staff contact the hospitals Infection Control Coordinator and advise them of the
incident. They will forward the results to Palm Beach State College, 4200 Congress Avenue,
Risk Management Department, Lake Worth Florida, 33461. Thank you for your cooperation.
Ken Scheppke, MD
Medical Director
Palm Beach State College EMS Programs
Student Name ______________________________________________________
Date ____________
Student Signature ___________________________________________________
Blood specimen obtained from source patient (check one)
□Yes
□No
Source patient HIV testing (per state statute 381.004)
□ With consent
□ Without consent
Palm Beach State College – Paramedic Program
□ Refused
17
FRI
Palm Beach State College – Paramedic Program
18
FRI
PARAMEDIC STUDENT CLINICAL OBJECTIVE WORKSHEET
Date:
Shift:
Student Name:
Course:
Fire Department and Station#:
Fire Rescue Instructor Name and Contact Number:
Goals and objectives to be accomplished today (areas of focus):
•
•
•
Preceptor Signature:
Palm Beach State College – Paramedic Program
19
FRI
F.R.I. __________________
Palm Beach State College
ONGOING PRECEPTOR TRAINING PROGRAM
Preceptor Name
Date
Website
Was Viewed
Department
Name
Station
Preceptor
Understands what,
where student should
st
nd
rd
be in 1 , 2 , 3
semester Yes Or No
Preceptor Signature
1.
2.
3.
4.
5.
6.
7.
8.
9.
Palm Beach State College – Paramedic Program
20
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PRECEPTOR EVALUATION OF STUDENT CLINICAL EXPERIENCE
AFFECTIVE DOMAIN:
● Preparedness: the student arrived on time with ink pen, stethoscope, eye
protection, pen light, and required paper work and identification.
● Professional appearance: the student is dressed in proper uniform and is
neat in appearance.
● Initiative: student demonstrates interest in EMS through actions and
interactions with evaluator
● Conduct: Student interacts with patients, families & co-workers in a
respectful and empathetic manner. Demonstrates respectability
and professional ethics.
● Careful Delivery of Service: Student follows policies, procedures &
protocols. Uses appropriate safeguards in the performance of duties.
PSYCHOMOTOR DOMAIN:
●Student demonstrates proficiency in skills performed.
COGNITIVE DOMAIN:
● Knowledge: The student can recall common terms, facts, principles and
basic concepts in EMS.
● Problem Solving: the student uses knowledge to solve a previously
unencumbered situation.
● Evaluation: the student can judge the appropriateness of actions and can
defend his/her decisions.
Palm Beach State College – Paramedic Program
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Student Name:
Clinical Shift
Preceptor Name:
Class Shift
Station:
Date:
Palm Beach State Paramedic Student
PRECEPTOR FEEDBACK TOOL
Place an X
Checklist:
Yes
No
Comments:
Student arrives on time and stays
entire length of clinical?
Student has clean uniform, PBSC ID,
and uses good hygiene?
Student asks questions and studies
during down time?
Demonstrates professionalism to
patients and crew?
Exercises caution in the performance
of duties and policies?
How much prompting was required
for student to perform required
tasks?
Outstanding recall of principles and
theories?
Identifies problems and
independently devises a plan to solve
problem?
Student can provide a sound
rationale for decisions and actions?
What % of the call does student
manage without direction of
preceptor?
Would you want this student as your
partner someday?
Student should receive an “S” or “U”
grade for this evaluation period?
Palm Beach State College – Paramedic Program
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CLINICAL INSTRUCTOR_______________________________
FIRE RESCUE INSTRUCTOR____________________________
INSTRUCTOR PHONE # ________________________________
Clinical Shift ___________
Class Shift _____________
PALM BEACH STATE COLLEGE
PARAMEDIC STUDENT
CLINICAL SIGN IN SHEET
STUDENT: Fill out this sheet every time you attend a clinical function. Fill out the dates you are absent.
Keep this sheet in your Clinical Book.
Student Name
Date
Palm Beach State College – Paramedic Program
Time In
Time Out
Site
Instructor Printed Name
23
Instructor Signature
Calls
Reports
FRI
STUDENT SHIFT LOG
Class:
Student Name:
Month:
Section: □ EMS 2664
□ EMS 2665
□ EMS 2658
□ EMS 2659
FRI: ______________________________
Date
Station
Preceptor Call Visit
Palm Beach State College – Paramedic Program
Comments
24
FRI
PALM BEACH STATE COLLEGE
EMT/Paramedic Program
PATIENT CARE REPORT
Student:
_________________________
EMT
Paramedic
Date: ____/____/_____
Time of Call: _______________
Hospital/Agency: ____________
Unit: ____________
□ I accompanied this patient to the hospital during transport.
Instructor/Preceptor Name: ______________________
Instructor/Preceptor Signature: ______________________
ETHNICITY
M
F
Chief MEDICAL COMPLAINT
African American
American Indian
Asian
Caucasian
Hispanic
Abdominal
Cardiac
CVA
Diabetic
OB/GYN
OD-Poison
Psychiatric
Respiratory
Seizure
Sepsis
Other ___________________
Other: ___________________
Chief TRAUMA COMPLAINT
Abdomen
Chest
Extrem.
Muscular
Neck/Back
Pelvic
Head/Face
Multisystem
Other ___________________
MECHANISM OF INJURY
Driver MVA
Passenger MVA
Auto-Pedestrian
Motorcycle
Fall/Jump
Airbag
Seatbelt
Entrapment
Ejection
Rollover
Blunt
Penetrating Injury – Type: _____________________
Other: ______________________________________
None
ALLERGIES:
MEDICATIONS:
PAST MEDICAL HX:
Time
BP
Eyes Open→
_________
Verbal→
None 1
Motor→
None 1
Pulse
Resp
Spontaneous 4
AVPU
Pupils
To Voice 3
Orient 5
Obey Com. 6
BLS AIRWAY
@ ______L/Min
NC
ALS AIRWAY
Surgical
Pulse Ox on room air ⇒ ________
Palm Beach State College – Paramedic Program
Lungs
To Pain 2
Confused 4
Pain/Local 5
NRB
Drug/Tx
None 1
Nasal airway
Nasal ET
Oral ET
Attempts X: ____
% After O2 ⇒ ________
25
Route
Glasgow Score =
Inappropriate 3
Pain/Withdraw 4
Dose
Garbled 2
Pain/Flexion 3
Pain/Ext 2
Oral airway
Success Y N
ET size: ___
% Glucometer ⇒ __________
FRI
BVM
Success:
N
IV / IO Attempts X: _____
ELECTRICAL
THERAPY
ENERGY
LEVELS
Y
Site: ________
OBS.
PERF.
MANUAL
DEFIBRILLATION
SYNCHRONIZED
CARDIOVERSION
TRANSCUTANEOUS
PACING
Gauge: ______
Solution: ______
EKG INTERPRETATION
OBS
PERF
Rhythm 1:
Rhythm 2:
Rhythm 3:
PHTLS CARE
BLS CARE
OBS
PERF
OBS PERF
PATIENT
W ITNESSED ARREST
INTERVIEW
VITAL SIGNS
SUCTION
02
CHEST
ADMINISTRATION
COMPRESSIONS
BANDAGING
VENTILATIONS
TRACTION SPLINT
BLS airway adjunct
C-SPINE
AIRWAY ADJUNCT TYPE:
IMMOBILIZATION
ALS CARE – OTHER
LONG BACKBOARD
DESCRIBE
LONG BONE
# PERFORMED
IMOBILIZATION
STUDENT
PHYSICALLY
INVOLVED IN
LIFTING PATIENT
YES
CHEST
NO
DECOMPRESSION
CRICOTHYROIDOTOMY
12 LEAD ECG
PULSE OXIMETRY
BLOOD GLUCOSE
Field Diagnosis:
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS / INJURY: (include pertinent negatives / positives as indicated)
ONSET (i.e. slow, sudden, etc.):
PROVOCATION:
QUALITY:
RADIATION:
SEVERITY:
TIME:
LAST ORAL INTAKE:
ASSESSMENT: (include pertinent negatives / positives for each area if indicated)
SKIN COLOR / CONDITION:
CAP REFILL:
HEAD:
EYES:
EARS:
NOSE:
MOUTH:
Palm Beach State College – Paramedic Program
26
FRI
Obs Per
NECK:
CHEST:
LUNGS SOUNDS:
ABDOMEN:
PELVIS:
GENITALIA:
EXTREMITIES:
BACK:
IMPRESSIONS (rule out):
RX: TREATMENT, RESPONSE AND REASSESSMENT:
TRANSPORT / TRANSFER: Verbal and written report given to: Time of transfer:
E: EXCEPTIONS:
Palm Beach State College – Paramedic Program
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STUDENT EQUIPMENT COMPETENCY CHECK LIST - LP
Student Name:
Station/Shift:
School / Institution:
The student will locate and show knowledge of the CPAP
Yes No
Preceptor
Date
Preceptor
Date
Preceptor
Date
Preceptor
Date
The student can identify the location of the CPAP
The student can identify the location of all accessories for equipment
The student can show and apply the proper procedure for the CPAP
The student will locate and show knowledge of the Carevent
Yes No
The student can identify the location of the CAREVENT
The student can identify the location of all accessories for equipment
The student can show and apply the proper procedure for the C AREVENT
The student will locate and show knowledge of the Suction Unit
Yes No
The student can identify the location of the Suction Unit
The student can identify the location of all accessories for equipment
The student can show and apply the proper procedure for the Suction Unit
The student will identify the location of items in the LifePack 15
Yes No
The student can identify the location of the LifePack 15
The student can identify the location of all accessories for equipment
The student can show and apply the proper procedures for the LifePack 15
Palm Beach State College – Paramedic Program
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STUDENT EQUIPMENT COMPETENCY CHECK LIST – MED BAG
Student Name:
Station/Shift:
School / Institution:
The student will identify the location of items in the Blue Med Bag
Yes No
The student can identify the location of all Medications
The student can identify the location of all IV equipment
The student can identify the location of all Fluids
The student can identify the location of all PPE/BIO bags
Preceptor
Date
Preceptor
Date
Yes No
Preceptor
Date
Yes No
Preceptor
Date
The student will identify the location of items in the Airway Bag
Yes No
The student can identify the Airway Roll and items inside
The student can identify/ knows how to use ALS-BLS Airway equipment
The student can identify the Miscellaneous equipment in Airway bag
The student will identify the location of items in the Trauma Bag
The
The
The
The
student
student
student
student
can
can
can
can
identify
identify
identify
identify
the
the
the
the
location
location
location
location
of
of
of
of
all IV equipment
all Fluids
all PPE
BLS/ALS Trauma equipment
The student will identify the location of items in the Pedi Box
The
The
The
The
The
student
student
student
student
student
can
can
can
can
can
identify
identify
identify
identify
identify
the
the
the
the
the
location
location
location
location
location
of
of
of
of
of
Palm Beach State College – Paramedic Program
all Medications
all IV equipment
all Fluids
all PPE/BIO bags
BLS/ALS equipment
29
FRI
PAYROLL REPORT – CLINICAL
NAME:
DEPARTMENT:
PAYROLL PERIOD: Start Date:
End Date:
Course ID:
DATE
(2664, 2665,
2658, 2659)
Paramedic
Ref#
Shift
ABC
Location
Hosp, FR,
Other
Start-End
Time
DAILY
TOTALS
TOTAL
HOURS
_____
Timesheets are to be submitted to the Clinical Coordinator by noon of due date. If your time sheet is not submitted
on time, the Clinical coordinators signature is required; your hours will not be paid until the following pay date.
Name of Hospital must be stated, not just hosp.
I certify that the information I have recorded above is accurate.
Signature/Date
Approved
Palm Beach State College – Paramedic Program
30
FRI
PALM BEACH STATE COLLEGE
Paramedic Program
PARAMEDIC ASSISTANCE LAB REFERRAL
 DIDACTIC
 LAB
 CLINICAL
(Please fax/scan to Clinical Coordinator @ 868.3419
and keep original)
Class Shift: _____
Clinical Shift: _____
Name of Student: ___________________________________
Date ________________
Initiated by: _________________________ Lead Instructor: ________________________
Problem Identified:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
 Test Scores ________
 Attendance / Tardy
 Policies
Suggested Remediation Plan:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I have participated in the development of my remediation plan and agree to the plan as
stated. I understand I now have the responsibility to see this plan thru with the
assistance of the Occupational Skills Evaluators and my Instructors.
Student’s Signature
Date
Instructor’s Signature
Date
Palm Beach State College – Paramedic Program
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FRI
Assistance Lab Referral
Progress Report
Student______________________ Lead Instructor_______________________________
Date: ________________________
Progress: __________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
 Student has met expectations for remediation.
 Additional remediation is recommended.
Instructor’s Signature: _____________________________
Date: ________________________ Progress: __________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
 Student has met expectations for remediation.
 Additional remediation is recommended.
Instructor’s Signature: _____________________________
Date: ________________________ Progress: __________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
 Student has met expectations for remediation.
 Additional remediation is recommended.
Instructor’s Signature: _____________________________
This page must stay attached to the copy of the Paramedic Student Assistance Lab
Referral, as reference to the “problem identified” as well as the “suggested remediation
plan”. Place report back in box for additional follow-up.
Palm Beach State College – Paramedic Program
32
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PALM BEACH STATE COLLEGE
Paramedic Program
Paramedic Student Assistance Lab Referral
Guidelines
• Once the plan is filled out, it should be placed in the top, middle
slot of the mail boxes in the office. Clinical Instructors will fax.
• Clinical referrals are to be placed in the clinical referral box.
• Any time a student is seen in an Assistance Lab and identifies
themselves as a remediation student, the form is used as
reference for the problem identified.
• When a student participates in the remediation process, the
Progress Report should be filled out as completely as practical
and identified as meeting the expectations for remediation or
additional remediation is recommended, by checking one of the
associated boxes.
• Paperwork should be returned to the slot to be picked up by
either the class Lead, OSE or Clinical coordinator.
• Leads, OSE’s and the Clinical Coordinator originating the
paperwork should routinely check the box to follow up on their
students’ progress throughout the plan.
• When a student has successfully completed any remediation
plan as suggested by our program, the completed paperwork
should be placed in their appropriate student file folder.
• Failure to attend a scheduled assistance lab will count as an
absence.
• Once a clinical deficiency is identified, and the student has
received sufficient remediation in the assistance lab, the
student will have to be re-tested on the skill and successfully
signed off in order to participate in further clinical rotations.
• Any questions an Instructor may have on any student can be
referred to the Lead responsible for that student.
Palm Beach State College – Paramedic Program
33
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Palm Beach State College – Paramedic Program
CLINICAL EVALUATION - PROGRESS REPORT
□ EMS 2664 – CLINICAL 1
□ EMS 2665 – CLINICAL 2
□ EMS 2658 – CLINICAL 3
□ EMS 2659 – Internship
Date
Student Name
Instructor Name
Instructor Signature
Indicate how the student is progressing toward competency by rating the student on a scale of 1-5.
A “1” or “2” rating indicates that immediate remedial work is indicated. A “5” indicates superior performance.
Cognitive Domain (Knowledge Base)
5
4
3
2*
1*
Psychomotor Domain (Clinical Proficiency)
5
4
3
2*
1*
Affective Domain (Behavioral Skills)
5
4
3
2*
1*
Documentation (Typhon)
5
4
3
2*
1*
Comments:
*Grades of 1 or 2 require comments, an Assistance Lab referral form, and Clinical Coordinator notification.
Student Signature:
Palm Beach State College – Paramedic Program
34
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Palm Beach State College – Paramedic Program
CLINICAL EVALUATION - COVER FOR LONG FORM
□ EMS 2664 – CLINICAL 1
□ EMS 2665 – CLINICAL 2
□ EMS 2658 – CLINICAL 3
□ EMS 2659 – Internship
CLASS: _______________
Date
Student Name
Instructor Name
Instructor Signature
Competent
Not Competent
Cognitive Domain (Knowledge Base)
Minimum Score: 24
Psychomotor Domain (Clinical Proficiency)
Minimum Score: 16
Affective Domain (Behavioral Skills)
Minimum Score: 36
Documentation (Typhon)
Minimum Score: 12
Comments:
In any given semester, a Competent score is required in the Psychomotor domain in order to receive a
course satisfactory grade (S). In EMS2664, EMS2665 and EMS2658, other than the above mentioned
requirement, the student may receive only one Not Competent and still receive a course grade of
satisfactory (S). In EMS2659, a Final Evaluation of Competent must be received in ALL categories to
earn a satisfactory grade (S).
CURRENT GRADE:
 Satisfactory
 Unsatisfactory*
*Requires immediate Clinical Coordinator notification
Student Signature:
Palm Beach State College – Paramedic Program
35
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Palm Beach State College – Paramedic Program
CLINICAL EVALUATION - LONG FORM
CLASS: _____________
□ EMS 2664 – CLINICAL 1
□ EMS 2665 – CLINICAL 2
□ EMS 2658 – CLINICAL 3
□ EMS 2659 – Internship
Date
Student Name
Instructor Name
Instructor Signature
Indicate how the student is progressing toward competency by rating the student on a scale of 1-5.
A “1” rating indicates that immediate remedial work is indicated. A “5” indicates superior performance.
Comments are required in all categories.
Cognitive Domain (Knowledge Base)
Has the EMS knowledge necessary to function in a
healthcare setting.
Has the general medical knowledge necessary to
function in his/her given semester.
Is able to collect data from charts and patients.
Is able to interpret patient data.
Is able to recommend appropriate diagnostic and
therapeutic procedures.
Uses sound judgment while functioning in a
healthcare setting.
5
4
3
2
1
5
4
3
2
1
5
5
4
4
3
3
2
2
1
1
5
4
3
2
1
5
4
3
2
1
Minimum 24
SCORE _____ / 30
Comments:
Psychomotor Domain (Clinical Proficiency)
Effectively performs clinical skills for given
semester.
Possesses the skills to perform patient assessment.
Is able to perform approved therapeutic procedures
and modalities.
Is able to perform and interpret diagnostic
procedures.
Minimum 16
Comments:
Palm Beach State College – Paramedic Program
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
SCORE _____ / 20
36
FRI
Affective Domain (Behavioral Skills)
1. INTEGRITY Examples of professional behavior
include, but are not limited to: Consistent honesty; being
able to be trusted with the property of others; can be
trusted with confidential information; complete and
accurate documentation of patient care and/or learning
activities.
2. EMPATHY Examples of professional behavior
include, but are not limited to: Showing compassion for
others; demonstrating respect for others; being
supportive and reassuring to others.
3. SELF – MOTIVATION Examples of professional
behavior include, but are not limited to: Taking initiative
to complete assignments; taking initiative to improve
and/or correct behavior; taking on and following through
on tasks without constant supervision; showing
enthusiasm for learning and improvement; consistently
striving for excellence; accepting constructive feedback
in a positive manner; taking advantage of learning
opportunities.
4. APPEARANCE AND PERSONAL HYGIENE
Examples of professional behavior include, but are not
limited to: Clothing and uniform is appropriate, neat,
clean and well maintained; good personal hygiene and
grooming.
5. SELF – CONFIDENCE Examples of professional
behavior include, but are not limited to: Demonstrating
the ability to trust personal judgment; demonstrating an
awareness of strengths and limitations; exercises good
personal judgment.
6. COMMUNICATIONS Examples of professional
behavior include, but are not limited to: Speaking clearly;
writing legibly; listening actively; adjusting
communication strategies to various situations.
7. TIME MANAGEMENT Examples of professional
behavior include, but are not limited to: Consistent
punctuality; completing tasks and assignments on time.
8. TEAMWORK AND DIPLOMACY Examples of
professional behavior include, but are not limited to:
Placing the success of the team above self interest; not
undermining the team; helping and supporting other
team members; showing respect for all team members;
remaining flexible and open to change; communicating
with others to resolve problems.
9. RESPECT Examples of professional behavior
include, but are not limited to: Being polite to others; not
using derogatory or demeaning terms; behaving in a
manner that brings credit to the profession.
Minimum 36
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
SCORE _____ / 45
Comments:
Palm Beach State College – Paramedic Program
37
FRI
Documentation (Typhon Entries and Narratives)
Typhon reports match paper reports.
5
4
3
Typhon reports are entered within 72 hours of
5
4
3
clinical.
Typhon narratives completed and well written.
5
4
3
Minimum 12
2
1
2
1
2
1
SCORE _____ / 15
Comments:
Student Signature:
Palm Beach State College – Paramedic Program
38
FRI
Team Leadership
This form is intended for use during the paramedic students Field Clinical Ride Time
component of the Palm Beach State Paramedic Program. Please rate each of the following
items as
(S) Satisfactory or (U) Unsatisfactory. Add comments as
Student Name:
Date:
Preceptor Name:
Station:
Establishes and maintains BSI for self and for crew
Communicates roles and responsibilities of each crew member
Determines scene safety and uses necessary precautions
Acts on prompts given by preceptor and crew
Recognizes the need for additional resources
Delegates specific tasks to crew members
Patient care tasks are performed in a timely manner
Is able to multi task
Psychomotor skill sets are performed correctly according to institution and departments SOG’s
Forms a general impression
Determines chief complaint and establishes a rapport with the patient
Establishes and maintains communication with patients family, bystanders, and other EMS personnel
Is empathetic to patients condition and needs
Demonstrates effective and timely critical thinking
Implements acceptable patient care
Directs the EMS team throughout call
Encodes in a succinct and calm manner
Performs a thorough patient turnover to hospital personnel
Documents activities and pertinent information on the PCR
Maintains a high degree of professionalism throughout call
Conducts a critique of the emergency call with crew members
Understands and accepts constructive criticism well
Comments:
Palm Beach State College – Paramedic Program
39
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