<p>Gunnison Valley Hospital-EMS EMT-B & EMT-I </p><p>Trainee Field Evaluation Form</p><p>Purpose: To create more accurate criteria for evaluation and documentation of the Trainee’s progress during the First Phase and Second Phase of Field Training.</p><p>Definition: The Field Evaluation Form is divided into 7 Attending categories and 4 Ambulance Operation categories. The Category evaluation criteria is based on the NHSTA DOT EMT Curriculum, DOT Assessment Based Management outline, and the NREMT’s Assessment skill’s outline. </p><p>Each category will be rated utilizing a scale of one (1) to five (5)</p><p>Evaluation Scale: The following is the criteria for the rating scale used to mark the Trainees performance in each category.</p><p>1 Unacceptable, for independent function does not meet expectations at the ALS or BLS level 2 Needs improvement before independent function, frequently needs prompting and Field Trainer intervention but is competent in aspects of initial BLS care.</p><p>3 Needs improvement before independent function, Trainee occasionally requires prompting and Field Trainer intervention. The trainee performs skills at the Conscious Competence level of comprehension. </p><p>4 Acceptable for independent function: Trainee performs skills at the Automatic level of skill comprehension. Meets expectations to function in their Target Certification Level</p><p>5 Acceptable for independent function: Trainee performs skills beyond the Automatic level of skill comprehension Exceeds expectations to function in their Target Certification Level</p><p>N/A Non-applicable</p><p>Evaluation Criteria: The following are the key criteria for each evaluation category:</p><p>Scene Assessment Disposition Patient ALS Skills Communication Affective Domain Management History& Management Documentation Physical</p><p>Scene Management</p><p> Immediate and constant scene evaluation for safety and appropriate action related to specific safety issues</p><p> Communicates safety issues clearly with on scene first responders and/or partner </p><p> Requests for additional resources in a timely manner</p><p> Displays organized approach when directing first responders assisting with patient care</p><p>Assessment, History & Physical Exam</p><p> Initial assessment completed in a timely manner with rapid intervention for all life threats  General Impression of patient followed by appropriate packaging decision for patient transport  Must demonstrate an organized approach to scene assessment, history taking, physical examination  Completes an organized Trauma or Focused physical assessment with correct interpretation of ALS diagnostics (ECG,BGM, SaO2)  Prioritizes vital signs and ALS diagnostics  Gathers accurate pertinent past medical history, utilizes SAMPLE  Re-evaluates and re-assesses when appropriate</p><p>Field Evaluation form Evaluation Criteria (continued)</p><p>Disposition  Patient is properly dispositioned utilizing assessment based management and differential diagnosis.  Dispositioned properly correctly utilizing medical control, protocols, Policies and procedures specific to Gunnison County’s EMS system.  Transport decisions are made in a timely manner  Evaluates the efficacy and priority of scene and patient care decisions. o INCLUDES: Patient acuity rating, site work-up, evacuation, destination, return code  Properly Dispositions: Refusals, POV, Detox, Police, Air. Ambulance, Aid Not Needed  Demonstrates understanding of EMS medical and scientific principles involved with specific patient cases. o INCLUDES: Academic knowledge, pathophysiology, and treatment protocols Patient Management</p><p> Prioritizes medical care. </p><p> Demonstrates reasonable exercise of medical judgment and ensures the patient receives maximal benefit that could be expected.</p><p> Follows local protocols and standard of care</p><p> Displays functional understanding of pediatric and geriatric considerations </p><p>ALS Skills</p><p> Displays functional understanding of core BLS/ALS skills, ie: airway management primary and secondary airway procedures, IV therapy, medication administration, electrical therapy….etc</p><p> Performs Core BLS/ALS skills correctly and at the appropriate prioritized time during patient care</p><p>Communication & Documentation</p><p> Ability to effectively communicate clinically with Base Hospital personnel and Base Hospital Physician  Accurately Documents all aspects of patient contact, assessment (pertinent + positives and – negatives ) and treatment according to EMS QA/CQI requirements and standard of care</p><p> Documents non-transport patient disposition (AMA Refusal, no aid) according to GVH-EMS medical legal standards of care</p><p>Affective Domain  Ability to effectively communicate and interact with patients, family, bystanders, Ability to acquire pertinent data necessary for development of treatment plan.  Communicates, solicits, and accepts critique from ancillary agency personnel, ED personnel, and co- workers.  Demonstrates professional Interpersonal skills, bio-phone and handoff reports</p><p> Neat and Professional appearance, compliance to uniform policy</p><p> Completes on-duty ambulance pre-check and reports all discrepancies </p><p>Ambulance Operations:</p><p>Driving Vehicle Operation Pre/Post Call Preparation District Knowledge Professionalism</p><p>Driving & Vehicle Operation</p><p>Objective : The Trainee will demonstrate proficient and safe driving operations, with Due Regard for the public, without prompting from the Field Trainer.</p><p> The Trainee will operate the ambulance with Due Regard for crew , patient, and public while in Emergent and non-Emergent modes of operation.</p><p> The Trainee will follow the rules and laws pertaining to emergency vehicle operation. </p><p> The Trainee will follow GVH-EMS policies pertaining to emergency vehicle operation.</p><p> The Trainee will show courtesy and respect towards the public and other drivers. </p><p>Pre and Post Call Preparation</p><p>Objective : The Trainee will demonstrate their ability to prepare and maintain the readiness of all GVH ambulances during their shift.  The Trainee will ensure that all ambulances are well stocked meeting Colorado State minimum requirements for an In-Service ALS transporting vehicle and GVH Pre-Check Requirements.  The Trainee will be proficient at all aspects of ALS equipment operation used within their Target Certification  The Trainee will report all equipment discrepancies and vehicle safety hazards to supervisory personnel prior to vehicle operation </p><p>District Knowledge</p><p>Objective: The Trainee will demonstrate a working knowledge of the Gunnison County road system and County Demographics.  The Trainee will have the ability to navigate major roads and highways within Gunnison County with little reliance on their partner or a map for direction.  The Trainee will demonstrate an ability to read and use Gunnison County District maps.  The Trainee will demonstrate their ability to drive the ambulance to and from a call safely using the most direct routes.</p><p>Professionalism: </p><p>Objective :The Trainee will present themselves to the public in a professional manner when operating a GVH-EMS Vehicle</p><p> The Trainee will ensure the interior and exterior of the emergency vehicle is clean and organized at all times</p><p> The Trainee will follow all rules of the road while always yielding to pedestrians. </p><p> The Trainee will present a professional image while operating the emergency vehicle. This includes no use of cell phones while driving, music radio is off during patient transport, and no eating or drinking while the vehicle is in motion. </p><p> The Trainee will facilitate Vehicle tours and equipment demonstration to members of the public upon request.</p><p>Gunnison Valley Hospital-EMS DATE : ______Phase: _____ Shift _____ Field Training Evaluation Form Trainee : ______Field Trainer:______</p><p>Evaluation Scale: The following is the criteria for the rating scale used to mark the Trainees performance in each category.</p><p>1 Unacceptable, for independent function does not meet expectations at the ALS or BLS level 2 Needs improvement before independent function, frequently needs prompting and Field Trainer intervention but is competent in aspects of initial BLS care. </p><p>3 Needs improvement before independent function, Trainee occasionally requires prompting and Field Trainer intervention. The trainee performs skills at the Conscious Competence level of comprehension. </p><p>4 Acceptable for independent function: Trainee performs skills at the Automatic level of skill comprehension. Meets expectations to function in their Target Certification Level</p><p>5 Acceptable for independent function: Trainee performs skills beyond the Automatic level of skill comprehension Exceeds expectations to function in their Target Certification Level</p><p>N/A Non-applicable</p><p>1 . Contact: ALS BLS Chief Complaint______Age____ Disposition:______</p><p>Scene Assessment Disposition Patient ALS Skills Communication Affective Domain Management History& Management Documentation Physical</p><p>Comments: ______ALS Skills: ______</p><p>2. Contact: ALS BLS Chief Complaint______Age____ Disposition:______</p><p>Scene Assessment Disposition Patient ALS Skills Communication Affective Domain Management History& Management Documentation Physical</p><p>Comments: ______ALS Skills: ______</p><p>Ambulance Operations: Driving Vehicle Operation Pre/Post Call Preparation District Knowledge Professionalism</p><p>Comments: ______</p><p>Shift Summary: ______Trainee Comments: ______</p><p>Field Trainer Signature______Trainee Signature______</p>