<p> IHCC Emergency Health Services Degree Program Field Clinical Evaluation Form Student Name: Mentor Name: Date: Shift: Ambulance Service: Arrived at: Student Instructions: Complete all shaded areas and checkboxes, front and back, prior to submission to preceptor. Preceptor Instructions: Expect your student to team lead all BLS calls and complete a run report on every call. Initial each run only if you agree with the student’s assessment. Definitions are listed on the back of this form. N = Not Attempted; U = Unsuccessful; S = Successful (no prompting); P = Prompting;</p><p>1 Patient: (LOC, Age, Gender, onset, CC, Event/Circumstances) □ ALS □ BLS FISDAP ID# Field Impressions: N U S P Mentor Initials Completed comprehensive interview Completed an appropriate head-to-toe and/or focused physical exam Formulated a field impression and implemented treatment plan Student successfully led the EMS team during this patient encounter. Professional: □ Self Motivated; □ Efficient; □ Flexible; □ Careful; □ Confident; □ Comm. well with patient; Comments: □ Accepts feedback;</p><p>2 Patient: (LOC, Age, Gender, onset, CC, Event/Circumstances) □ ALS □ BLS FISDAP ID# Field Impressions: N U S P Mentor Initials Completed comprehensive interview Completed an appropriate head-to-toe and/or focused physical exam Formulated a field impression and implemented treatment plan Student successfully led the EMS team during this patient encounter. Professional: □ Self Motivated; □ Efficient; □ Flexible; □ Careful; □ Confident; □ Comm. well with patient; Comments: □ Accepts feedback;</p><p>3 Patient: (LOC, Age, Gender, onset, CC, Event/Circumstances) □ ALS □ BLS FISDAP ID# Field Impressions: N U S P Mentor Initials Completed comprehensive interview Completed an appropriate head-to-toe and/or focused physical exam Formulated a field impression and implemented treatment plan Student successfully led the EMS team during this patient encounter. Professional: □ Self Motivated; □ Efficient; □ Flexible; □ Careful; □ Confident; □ Comm. well with patient; Comments: □ Accepts feedback;</p><p>This form may be returned to the student or mailed directly to: David Page, EHS Department, 2500 E. 80thSt., Inver Grove Heights, MN 55076; Office: (651)450-8576; Fax: (651)450-8679; E-mail: [email protected] 4 Patient: (LOC, Age, Gender, onset, CC, Event/Circumstances) □ ALS □ BLS FISDAP ID# Field Impressions: N U S P Mentor Initials Completed comprehensive interview Completed an appropriate head-to-toe and/or focused physical exam Formulated a field impression and implemented treatment plan Student successfully led the EMS team during this patient encounter. Professional: □ Self Motivated; □ Efficient; □ Flexible; □ Careful; □ Confident; □ Comm. well with patient; Comments: □ Accepts feedback;</p><p>5 Patient: (LOC, Age, Gender, onset, CC, Event/Circumstances) □ ALS □ BLS FISDAP ID# Field Impressions: N U S P Mentor Initials Completed comprehensive interview Completed an appropriate head-to-toe and/or focused physical exam Formulated a field impression and implemented treatment plan Student successfully led the EMS team during this patient encounter. Professional: □ Self Motivated; □ Efficient; □ Flexible; □ Careful; □ Confident; □ Comm. well with patient; Comments: □ Accepts feedback;</p><p>6 Patient: (LOC, Age, Gender, onset, CC, Event/Circumstances) □ ALS □ BLS FISDAP ID# Field Impressions: N U S P Mentor Initials Completed comprehensive interview Completed an appropriate head-to-toe and/or focused physical exam Formulated a field impression and implemented treatment plan Student successfully led the EMS team during this patient encounter. Professional: □ Self motivated; □ Efficient; □ Flexible; □ Careful; □ Confident; □ Comm. well with patient; Comments: □ Accepts feedback;</p><p>Definitions:  Successful Team Lead: The student has team led if he or she has conducted (not necessary performed the entire interview or physical exam, but rather been in charge-of) a comprehensive assessment, formulated and implemented a treatment plan for the patient. This means that most (if not all) of the decisions have been made by the student, especially formulating a field impression, directing the treatment, determining patient disposition and packaging and moving the patient. Minimal to no prompting was needed by the preceptor. No action was initiated, performed or withheld that endangered the physical or psychological safety of the patient, bystanders, first responders or crew.  BLS Encounter: Patient care does not require advanced assessment techniques or invasive interventions  Professional Behaviors: - Self motivated: Behavior includes taking initiative to complete assignments, improve/correct problems. Strive for excellence. - Efficient: Keeps scene times to a minimum, releases first responders when not needed, organizes team to work faster/better. - Flexible: Makes adjustments to communication style, or direction of team; Changes field impression based on findings; - Careful: Pays attention to details of skills, documentation, patient comfort, set-up and clean up; Completes tasks thoroughly. - Communicates well with patient: Listens actively, makes eye contact, clarifies complaint, respectfully addresses patients. Demonstrates compassionate and/or firm “bedside” manner depending on the needs of the situation. - Confident: Makes decisions, Trusts and exercises good personal judgment, is aware of limitations and strengths; - Accepts feedback: Listens to mentor and accepts constructive feedback. Adjusts behavior/performance based on feedback.</p><p> ALS Encounter: Any call where an a) IV has been attempted AND an EKG has been monitored, OR b) A medication other than oxygen has been administered OR c) Advanced judgment/assessment (as determined by the preceptor) has been performed.</p>