EMSP Documentation Project i

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EMSP Documentation Project
A manual to assist EMT candidates to fill out EMSP program
related documentation
i
EMSP
Program
Digitally signed by EMSP Program
DN: CN = EMSP Program, C = US, O
= El Paso Community College, OU =
EMSP
Reason: I am the author of this
document
Date: 2004.06.01 12:10:32 -06'00'
6/1/2004
Forward
I created this manual as part of an honors project in Fall 2003/Winter 2004
semesters. An attempt was made to categorize and modernize all of the
paperwork associated with all of the EMSP courses that are commonly offered.
Another portion of the project was to make available all of the documentation on
CD-Rom and the Web for the candidates. Along with the new distribution
methods a system was developed to ease the tracking of Skills and Hours for
each candidate. This system will allow the candidate and instructor the ability to
track all of the requisite skills and hours. The last portion of the honors project is
the development of a computer problem to allow the instructors to electronically
track all of this information.
Thomas A. King
January 2004
I wish to thank the following people for
their assistance in the preparation and peer review of this manual
T. Baker BEd
G. Williams PhD
C. Kabariti
EMSP Staff at EPCC
"I know you believe you understand what you think I said. But I am not sure you realize that what
you heard is not what I meant."
Patrick Murray
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Table of Contents
FORWARD .................................................................................................................................................. II
INTRODUCTION ......................................................................................................................................... 1
OVERVIEW .................................................................................................................................................. 1
CLINICAL PAPERWORK .......................................................................................................................... 2
PAPERWORK EXAMPLES....................................................................................................................... 2
FORMS FOR THE EMT BASIC CADIDATE
PATIENT CARE RECORD HOSPITAL (PCRH) EMT-BASIC CANDIDATES................................. 6
OVERVIEW ................................................................................................................................................. 6
SEQUENTIAL NUMBER ........................................................................................................................... 8
CLINICAL SITE\UNIT............................................................................................................................... 8
SAMPLE HISTORY AND OPQRST ....................................................................................................... 10
VITAL SIGNS ............................................................................................................................................ 11
SYSTEMS\PHYSICAL EXAMINATION ............................................................................................... 13
TESTS\TREATMENT BACK .................................................................................................................. 15
SKILLS PERFORMED BY CANDIDATE ............................................................................................. 15
TREATMENT PROVIDED BY CANDIDATE....................................................................................... 16
MEDICATIONS GIVEN........................................................................................................................... 16
BOTTOM RIGHT OF FORM .................................................................................................................. 18
PATIENT CARE RECORD AMBULANCE (PCRA) EMT-BASIC..................................................... 19
OVERVIEW ............................................................................................................................................... 19
DETAILED EXPLANATION PCRA....................................................................................................... 19
RUN TIMES ............................................................................................................................................... 22
CHIEF COMPLAINT, CATEGORY, AND AREA OF INJURY ......................................................... 23
NARRATIVE AND VITALS AREA ........................................................................................................ 23
SAMPLE HISTORY .................................................................................................................................. 25
MEDICATIONS GIVEN........................................................................................................................... 28
TREATMENTS .......................................................................................................................................... 28
BACK PAGE .............................................................................................................................................. 29
ONGOING ASSESSMENT....................................................................................................................... 29
GLASGOW COMA SCORE..................................................................................................................... 30
IPS SCORE (TRAUMA SCORE)............................................................................................................. 30
SKILLS PERFORMED............................................................................................................................. 32
BOTTOM OF BACK PAGE ..................................................................................................................... 32
STUDENT PERFORMANCE IMPROVEMENT EVALUATION....................................................... 33
OVERVIEW ............................................................................................................................................... 33
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TOP OF THE FORM ................................................................................................................................. 33
Forms for the EMT Advanced (EMT-I) and Paramedic
PATIENT CARE RECORD HOSPITAL (PCRH) ADVANCED (EMT-I) AND PARAMEDIC
CANDIDATES............................................................................................................................................ 36
OVERVIEW ............................................................................................................................................... 36
DETAILED EXPLANATION PCRH....................................................................................................... 36
TOP OF FORM FRONT ........................................................................................................................... 37
SEQUENTIAL NUMBER ......................................................................................................................... 38
SAMPLE HISTORY AND OPQRST ....................................................................................................... 40
VITAL SIGNS ............................................................................................................................................ 41
GLASGOW................................................................................................................................................. 42
SYSTEMS EXAMINATION..................................................................................................................... 43
ADVANCED PATIENT ASSESSMENT ................................................................................................. 45
TESTS\TREATMENT BACK .................................................................................................................. 46
AIRWAY AND CIRCULATORY MANAGEMENT ............................................................................. 47
SKILLS PERFORMED BY STUDENT................................................................................................... 48
INTRAVENOUS THERAPY RECORD.................................................................................................. 49
ONGOING ASSESSMENT....................................................................................................................... 50
MEDICATIONS GIVEN........................................................................................................................... 51
BOTTOM RIGHT OF FORM .................................................................................................................. 52
PATIENT CARE RECORD AMBULANCE (PCRA) ADVANCED (EMT-I) AND PARAMEDIC
CANDIDATES............................................................................................................................................ 53
OVERVIEW ............................................................................................................................................... 53
DETAILED EXPLANATION PCRA....................................................................................................... 53
TOP OF FORM FRONT ........................................................................................................................... 56
SEQUENTIAL NUMBER ......................................................................................................................... 56
RUN TIMES ............................................................................................................................................... 56
CHIEF COMPLAINT, CATEGORY, AND AREA OF INJURY ......................................................... 57
NARRATIVE AND VITALS AREA ........................................................................................................ 57
SAMPLE HISTORY .................................................................................................................................. 59
VITALS ....................................................................................................................................................... 60
TREATMENTS .......................................................................................................................................... 62
BACK PAGE .............................................................................................................................................. 63
ONGOING ASSESSMENT....................................................................................................................... 63
GLASGOW COMA SCORE..................................................................................................................... 64
IPS SCORE (TRAUMA SCORE)............................................................................................................. 64
SKILLS PERFORMED............................................................................................................................. 66
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BOTTOM OF BACK PAGE ..................................................................................................................... 66
STUDENT PERFORMANCE IMPROVEMENT EVALUATION....................................................... 67
OVERVIEW ............................................................................................................................................... 67
TOP OF THE FORM ................................................................................................................................. 67
CI\PRECEPTOR AND CLINICAL SITE EVALUATION...................................................................... 70
OVERVIEW ................................................................................................................................................ 70
TOP OF THE FORM ................................................................................................................................. 70
EMSP WEEKLY SUMMARY FORM (WSHS)...................................................................................... 72
OVERVIEW ............................................................................................................................................... 72
PATIENT CARE RECORD...................................................................................................................... 72
WEEKLY SKILL AND HOURS SUMMARY (WSHS)......................................................................... 72
SEMESTER SKILLS AND HOURS SUMMARY (SSHS)..................................................................... 73
LEVEL SUMMARY .................................................................................................................................. 73
DETAILED INSTRUCTIONS FOR WEEKLY SKILLS AND HOURS SUMMARY (WSHS) ........ 74
TOP OF FORM .......................................................................................................................................... 75
LEFT HAND BOXES ................................................................................................................................ 75
SEQUENTIAL NUMBER OR S ............................................................................................................... 75
SKILLS ....................................................................................................................................................... 78
TOTALS...................................................................................................................................................... 79
OTHER TOTALS ...................................................................................................................................... 80
Forms for Specialty areas
OVERVIEW ................................................................................................................................................ 82
LABOR AND DELIVERY WORKSHEET (EMSP 1160 & 1161) ....................................................... 82
OVERVIEW ................................................................................................................................................ 82
EKG RECOGNITION \ MANAGEMENT (EMSP 2160 & 2266) ......................................................... 86
OVERVIEW ................................................................................................................................................ 86
TOP OF THE FORM ................................................................................................................................. 86
MIDDLE OF THE FORM .......................................................................................................................... 87
RATIONALE\PATHOPHYSIOLOGY ..................................................................................................... 89
TREATMENT\MEDICATIONS\RATIONALE ........................................................................................ 90
ADVANCED AIRWAY RECORD (EMSP 1161 & 1162) ..................................................................... 91
OVERVIEW ................................................................................................................................................ 91
TOP OF THE FORM ................................................................................................................................. 91
DETAILED INSTRUCTIONS ................................................................................................................... 92
MIDDLE OF FORM STUDENT EVALUATION .................................................................................... 92
BOTTOM OF FORM ................................................................................................................................. 93
LABORATORY RECORD (EMSP 1161)............................................................................................... 94
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Instructor Forms
EMSP SEMESTER SUMMARY .............................................................................................................. 97
OVERVIEW ............................................................................................................................................... 97
DETAILED INSTRUCTIONS FOR SEMESTER SKILLS AND HOURS SUMMARY (SSHS) ...... 98
SSHS TOP OF THE FORM ...................................................................................................................... 98
TOP LEFT OF FORM............................................................................................................................... 99
TOP RIGHT OF FORM.......................................................................................................................... 100
BOTTOM LEFT OF FORM ................................................................................................................... 101
BOTTOM RIGHT OF FORM ................................................................................................................ 102
Appendixes
APPENDIX I COMMON MEDICAL ABBREVIATION........................................................................ 105
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Introduction
Welcome to El Paso Community College’s Emergency Medical Services
Program (EMSP). The profession of Emergency Medical Technician (EMT) is a
relatively new one that came into being in the 1970’s. Currently EPCC offers five
different levels of training for the EMT. The entry level is the EMT-Basic course
also known as EMSP 1160. This course introduces you to the profession of the
EMT and teaches many different skills and procedures. The next level of training
is the Advanced level which comprises two different courses EMSP 1161 and
EMSP 1162. These courses prepare you to write the NREMT test and an EMTIntermediate.
Lastly there is the EMT-Paramedic course which is comprised of two more
courses, EMSP 2160 and EMSP 2266. There are a number of ancillary support
courses required in order to graduate, so please check with an EPCC counselor.
In order to graduate as an EMT at any level you need to fill out all of your course
paperwork correctly.
To this end this manual has been written as part of a general overhaul of all five
of the courses that are at the core of the EMSP program. The manual is divided
into the following sections;
• EMT Basic\EMSP 1160
• EMT Advanced & Paramedic\EMSP 1161, 1162, 2160, and 2266
• Common forms for all levels of EMT candidate
• Specialty area forms
• Instructor forms
This manual will cover most of the forms that are in use today by the EMSP
faculty and attempt to help the EMT candidate, of any level; to fill out these forms
as completely as possible.
Overview
This manual has been written with the new EMT candidate in mind; however, it
applies to all levels of EMT candidates. Initially it will discuss which forms are to
be used on a weekly basis during your clinical rotations through the Ambulance,
Hospital, and other specialty settings.
A list of the typical forms to be submitted to your primary instructor on a weekly
basis during clinical rotations will be detailed. This manual is also divided into
forms for the EMT-Basic Candidate and forms for the Advanced (EMT-I) and
Paramedic (EMT-P) candidates. Each form type will be discussed in detail as to
what information should be charted. Charting is the act of writing down your
actions in the clinical setting and it is an art which will take time to learn and
master. When you chart your observations and treatments you need to use good
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- grammar along with proper medical terminology and abbreviations. At the end
of this document is a list of some of the more common medical abbreviations.
It is always a good idea for an EMT candidate to keep photocopies of any
materials that are turned into the Primary Instructor. The importance of this
cannot be overstated as accidents do happen! The information that is contained
in your paperwork will follow you throughout your training at EPCC and is used to
help ensure that you are fully prepared and qualified to write the National
Registry Examination.
Clinical Paperwork
During each of the EMSP courses there is a period of time where the EMT
candidate is expected to perform clinical rotations. These rotations can occur on
ambulances, in hospitals, or other specialty areas and each requires some type
of paperwork be turned in for documentation purposes.
Each time you go to a clinical rotation you will be expected to fill out your
paperwork and have the Clinical Instructor or Preceptor review the forms and
then sign off on them. At the end of each shift your CI\Preceptor will fill out an
evaluation form about your performance and provide comments about how you
might improve or how well you did. In return, you are expected to fill out a
CI\Preceptor and Site evaluation form which you need not sign.
Each week you will be expected to turn in your paperwork to your Primary
Instructor. It is in your best interest to make sure all the paperwork is complete
and turned in as a package. Failure to do so can result in problems with you
completing the course.
Paperwork Examples
For example, if you completed a six hour shift at the emergency department in
the first week of clinical rotations and assessed 3 patients you would be expected
to turn in the following forms at your next classroom session:
•
•
•
•
3 Patient Care Records Hospital (PCRH) front and back
1 Student Performance Improvement Evaluation (SPIE)
1 CI\Preceptor and Clinical Site Evaluation (CCSE)
1 Weekly Skills and Hours Summary (WSHS)
The PCRH’s, SPIE, and CCSE are filled out during your clinical rotation. The
WSHS is to be filled out prior to handing in your paperwork. Information required
to fill out the WSHS will be obtained from the PCRH’s. It is recommended that
the WSHS be placed on top to allow your Primary Instructor a ready reference to
your clinical experience. Below are samples of this paperwork. For brevity, only
the front page of one of the PCRH’s has been included. Each of the PCR’s
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(ambulance and hospital) has a back page that needs to be filled out completely.
The examples below are for an Advanced candidate (EMT-I).
Figure 1 Clinical Paperwork Week 1 Example
Another example. In your second week of clinical rotations you are scheduled to
work a 12 hour shift on the ambulance. During your shift you assess and treat 6
patients. You would need to turn in the following:
• 6 Patient Care Records Ambulance (PCRA) front and back
• 1 Student Performance Improvement Evaluation (SPIE)
• 1 CI\Preceptor and Clinical Site Evaluation (CCSE)
• 1 Weekly Skills and Hours Summary (WSHS)
The examples below are for an Advanced candidate (EMT-I).
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Figure 2 Clinical Paperwork Week 2 Example
Each clinical specialty area may have additional paperwork to fill out and your
Primary Instructor will inform you of these requirements as your class
progresses. These specialty area forms are located later in this manual. Each
clinical form has a detailed outline and procedure in order to complete it fully;
however some parts can only be filled out after you have covered specific
instructions in the classroom.
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Forms specific to
EMSP 1160
Emergency Medical
Technician
Basic
Course
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Patient Care Record Hospital (PCRH) EMT-Basic Candidates
Overview
This is the primary form with which you track your encounters with patients while in the
hospital and associated specialty areas. The Patient Care Record Hospital, hereinafter
referred to as PCRH, documents the patient’s chief complaint, physical examination,
vital signs, SAMPLE history, and your treatments. This is a two sided form on which you
will record all of the pertinent information. When it is complete, have your preceptor
review it and then sign it, along with your preceptor. Once a week you will compile all of
your PCRH’s and your PCRA’s and enter the required data in the Weekly Skills and
Hours Summary (WSHS) form and submit all of the PCR’s and the WSHS form to your
Primary Instructor.
While initially these forms can appear daunting to the new EMT candidate they will
become less so with practice and familiarity. A detailed explanation of the form appears
below and there are several samples of the filled out form appended to this document.
Detailed Explanation PCRH
Below is a completed version of the PCRH for the EMSP 1160 course. Each area of the
form will be explained in detail later on.
Figure 3 PCRH Basic Completed Front Example
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Figure 4 PCRH Basic Completed Rear Example
Top of Form Front
In this area of the PCRH you need to enter the following information:
• Primary Instructors name
• If you are documenting skills check the Skills Only box
• Sequential Number
• Your name
• Clinical Site\Unit
• Date
• Age and Sex of your patient
• Mechanism of Injury or Nature of Illness
• Time in and out of facility
• Total hours of shift
• Chief complaint of patient
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Sequential Number
The Sequential Number is a unique identifier that is assigned to each and every Patient
Care Record you complete. When you start as an EMT-B and you have your very first
patient encounter and do a physical assessment, the Sequential Number on that Patient
Care Record will be 1 . The next patient you encounter and assess will have a Sequential
Number of 2 on their Patient Care Record. If on your first day of clinical you are at the
hospital and do three patient assessments your first PCRH will have the Sequential
Number 1, the second the Sequential Number 2, and the third PCRH will be numbered 3.
If your next clinical day happens to be on the ambulance and you assess 2 patients, the
Sequential Numbers for these two PCRA’s will be 4 and 5. This process of assigning
each Patient Care Record you complete with a unique Sequential Number as an identifier
will continue unbroken throughout your progression from EMT-B to EMT-P. The reason
for the Sequential Number is to allow both the student and the instructor greater ease in
tracking hours and skills.
Clinical Site\Unit
In this area, enter the hospital or clinical site and the particular unit. Some clinical sites
only have one area thus you would only enter the clinical site name. Below is the table of
Clinical Sites\Units.
Table 1 PCRH Basic Facility\Unit
Facility
Thomason Hospital
Las Palmas
William Beaumont Army
Medical Center
Del Sol Medical Center
El Paso FMS
Life Ambulance
Sunwest Ambulance
Rio Grand Ambulance
El Paso Morgue
Immunization Team
Abbreviation
RET
LAS
WBH
Nursing Home
GER
SOL
FMS
LIF
SUN
RGA
MOR
IMM
Date
The date should be in the format MM/DD/YY
8
Unit
Emergency Dept
Intensive Care
Labor and
Delivery
Operating Room
PICU
NICU
Nursery
Cardiac Care
Wound Care
Hyperbaric
Chamber
Abbreviation
ED
ICU
L&D
OR
PIC
NIC
NUR
CCU
WND
HYB
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Age
This should be in the form of numbers and if the patient is less than 1 year add the
abbreviation mo after the numbers in order to indicate Months. If no mo occurs after the
numbers it indicates the age in years.
Sex
Always use an F for female or an M for male.
MOI\ NOI
MOI stands for Mechanism of Injury, which indicates how the injuries occurred and
usually pertains to trauma patients. NOI stands for Nature of Illness, which indicates
what type of illness you are dealing with and generally applies to medical patients.
Simply chart a few words in this area.
Time in\out
In this area, chart the times you officially started and finished your shift. Please use the
2400 hour system when entering this data.
Total Hours
In this area, chart the total number of hours you spent on shift.
Chief Complaint\History
In this area, chart the reason why the patient came to the hospital\specialty area. This can
sometimes be a very challenging area for the EMT candidate. The Chief Complaint
should always be in the patient’s own words if possible. If a patient comes into the ER
unconscious then it is acceptable to use the ambulance’s classification.
Figure 5 PCRH Basic Upper Front Example
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SAMPLE History and OPQRST
Signs\Symptoms
In this area, chart what you see and what the patient complains about.
Allergies
In this area, chart any allergies the patient has.
Medications
In this area, chart what medications the patient is currently on. Include prescription
medications, herbal preparations, and over the counter medications. It is also wise to ask
about any medication the patient may get from Juarez. If medication comes from Mexico
and you do not recognize it you can call the El Paso Poison Control Center for further
information. EPPCC is one of the few centers that have a Mexican formulary. Note: you
can also reach the poison control center directly over the FMS radio.
Previous Medical History
In this area, chart the patient’s pertinent past medical history.
Last Oral Intake and LMP (if applicable)
In this area, chart when the patient ate last and how large the meal was. If the patient is of
child bearing years you will need to chart the Last Menstrual Period if pertinent.
Events
In this area, chart a brief description of the events that lead up to the hospital visit.
OPQRST
In this area, chart the OPQRST pneumonic. This pneumonic generally applies to the
description of pain but does have some other uses. Your instructor will explain them to
you during your course of study. Below is an overview of each letter of the pneumonic:
O
The “O” stands for Onset of the pain. This describes the speed with which the condition
occurred. For example: Was the Onset rapid or did it take a few days?
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P
The “P” stands for Provocation. This means is there action which makes the pain worse
or better.
Q
The “Q” stands for Quality. This is used to describe how the pain feels and should be in
the patient’s own words. Some examples are: “Sharp”, “Stabbing”, and “Dull”. In some
instances the patient does not have the words so you will have to ask some leading
questions such as, “Is the Pain sharp or dull?”
R
The “R” stands for Radiation. This whether or not the pain moves from the original site
to another area of the body. For example when a patient has chest pain initially and it
goes to the left arm.
S
The “S” stands for the Severity of the pain. There are a number of scales used to indicate
pain however the easiest one is 1 to 10 where the number 1 stands for not too bad and 10
stands for the worst pain you ever had.
T
The “T” stands for the Time the pain started and how long it has lasted.
Figure 6 PCRH Basic SAMPLE - OPQRST Example
Vital Signs
Time
In this area, chart the time you took the patients vitals. Please use the 24 hour system
when entering the time. For a stable patient, chart vitals every 15 minutes. For unstable
patients you need to chart vital signs every 5 minutes.
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Glasgow
This is where you would enter the Glasgow coma scale for all patients. The scale goes
from 3 – 15. Below is a sample of the scale for your information.
Table 2 PCRH Basic Glasgow Coma Scale
Description
Motor Response
None
Decerebrate
Decorticate
Localizes Pain
Obeys Commands
Eye Opening
None/Swollen
To Pain
To Voice
Spontaneous
Verbal Response
None Intubated
Incomprehensible
Inappropriate
Confused
Oriented
Value
1
2
3
4
5
1
2
3
4
1
2
4
4
5
B/P
In this area, chart the patient’s blood pressure. Currently there are two commonly
accepted methods for charting blood pressure; BP by auscultation and BP by palpation.
BP by auscultation is charted as Systolic over Diastolic: i.e., 110\90, and the palpation
method is charted Systolic over P: i.e., 110\P
Pulse
In this area, chart the pulse rate in BPM or Beats per Minute. It should be charted with an
R for regular and I for irregular: e.g., 120R or 134I
Respirations
In this area, chart the patient’s respiratory rate. It is charted in Respirations per Minute.
You also need to chart whether the rate is regular or irregular. Use R or I and chart it as
22R or 14I.
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Pupils
IN this area, chart whether the pupils are equal and reacting to light. You can use the
acronym of PERL which stands for Pupils Equal and Reacting to Light. Also chart if they
are -unresponsive, dilated, or constricted. It is also a good idea to chart the size of the
pupil if you have a pupil gauge handy. e.g., PERL 3.0 mm.
Skin
In this area, chart the color of the skin and whether it is wet or dry.--e.g. Clammy\moist
SAO2\Pulse Oximetery
If the patient is hooked up to pulse oximeter, chart the reading and note if the patient is
on room air or supplemental O2. For example, 98%\RA means the patient is saturating at
98% on Room Air.
Figure 7 PCRH Basic Vital Signs Example
Systems\Physical Examination
The human body is divided up into systems which are interrelated. This next segment of
the form allows you to chart your physical examination.
General Impression
In this area, chart what your general impression of the patient is. You may use No,
Minimal, Moderate, or Severe distress in this area.
Integumentary
This area is used to chart the condition of the skin. Examples include poor skin turgor or
decubitus ulcers present.
Head/Neck
In this area, chart the condition of the head and neck and any trauma or other
abnormalities.
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Neuro
In this area, chart information about the level of consciousness and any weakness or
paralysis in the extremities.
Thorax
In this area, describe your examination of the chest. Note any trauma or other
abnormalities. You also chart lung and heart sounds in this area.
Abdomen
In this area, chart your examination of the abdominal area. Note any trauma,
abnormalities, or ascites here. You should also chart if the abdomen is Soft or Rigid,
Tender or Non Tender, and Distended or Non Distended. It is also a good thing to chart
whether you heard any bowel sounds or not.
Pelvis
In this area, chart whether the pelvis is stable or unstable. It is also a good area to chart
any incontinence if it is found.
Extremities
In this area, chart any trauma or other abnormalities. Capillary refill for all extremities
and CMS for all extremities need to be charted here.
Back\Other
Note any trauma or other abnormalities here.
Figure 8 PCRH Basic Physical Exam Example
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Tests\Treatment Back
In this area, chart all of the tests and treatments that were performed on the patient by the
hospital. In the example below the treatments are charted in point format in order to give
a rapid clinical picture. You may also chart in a detailed fashion if the case is sufficiently
complex. Charting in this area can be somewhat complex for the EMT candidate;
however with a sufficient amount of practice it can be mastered.
Figure 9 PCRH Basic Tests\Treatment Back Example
Skills Performed By Candidate
This area is a simple check box table that contains all of the skills you are likely to do in
the hospital. If you do a skill that is not contained in this table, simply chart it in the
treatment area. These skills are broken down into common skills that all levels of EMT
perform. Please do not exceed your skill level when checking the appropriate boxes. This
information is to be transferred to your Weekly Skills and Hours Summary form
(WSHS) which is detailed elsewhere in this manual.
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Figure 10 PCRH Basic EMT Skills Example
Treatment Provided by Candidate
In this area, chart any treatments or assessments you, the EMT Candidate, performed.
Below is an example of a filled out ongoing assessment.
Figure 11 PCRH Basic Treatment by Candidate Example
Medications Given
In this area, chart all medications given to your patient. All levels of EMT give
medications. However, it is up to the EMT candidate to not exceed their scope of
practice. Only administer the medications that are permitted to your level of training.
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Time
In this area, chart the time you gave the patient medication. Please use the 2400 hour
system when charting time.
Drug\Solution
In this area chart, what drug or solution you are giving. For example; Morphine Sulphate.
Dose\Rate
In this area, chart the concentration of the drug and how fast it was administered. For
example;
• 2.0 mg \ slow iv push
• 1 gm\250 cc D5W \ 16ml\min
Needle\Route
In this area, chart what needle you used by gauge and length and the type of
administrative route. For example;
• 24 ga x 5\8” \ IM
• Needles into Y port \ Slow IV push
Initials
In this area, get your Preceptor or the RN who told you to give that particular medication
to put their initials.
Figure 12 PCRH Basic Medications Given Example
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Bottom Right of Form
In this area, you need to place your signature and you need to have your CI\Preceptor
sign it also. There is also a space for any comments your preceptor may have.
Figure 13 PCRH Basic Signature\Comment Example
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Patient Care Record Ambulance (PCRA) EMT-Basic
Overview
This is the primary form with which you track your encounters with patients while on the
ambulance. The Patient Care Record Ambulance, hereinafter referred to as PCRA,
documents the patient’s chief complaint, physical examination, vital signs, SAMPLE
history, and your treatments. This is a two sided form on which you will record all of the
pertinent information. When it is complete, have your preceptor review it and then sign it,
along with your preceptor. Once a week you will compile all of your PCRA’s and your
PRCH’s and enter the required data in the Weekly Skills and Hours Summary (WSHS)
form and submit all of the PCR’s and the WSHS form to your primary instructor.
While initially these forms can appear daunting to the new EMT candidate they will
become less so with practice and familiarity. A detailed explanation of the form appears
below and there are several samples of the form filled out appended to this document.
Detailed Explanation PCRA
Below is a completed version of the PCRA for the EMSP 1160 course. Each area of the
form will be explained in detail later on.
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Figure 14 PCRA Basic Front Example
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Figure 15 PCRA Basic Rear Example
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Top of Form Front
In this area of the PCRH you need to enter the following information:
•
•
•
•
•
Primary instructors name
Sequential Number
Your name
Time In and Out
Total Hours spent
Sequential Number
The Sequential Number is a unique identifier that is assigned to each and every Patient
Care Record you complete. When you start as an EMT-B and you have your very first
patient encounter and do a physical assessment, the Sequential Number on that Patient
Care Record will be 1 .The next patient you encounter and assess will have a Sequential
Number of 2 on their Patient Care Record. If on your first day of clinical you are at the
hospital and do three patient assessments your first PCRH will have the Sequential
Number 1, the second the Sequential Number 2 and the third PCRH will be numbered 3.
If your next clinical day happens to be on the ambulance and you assess 2 patients, the
Sequential Numbers for these two PCRA’s will be 4 and 5. This process of assigning
each Patient Care Record you complete with a unique Sequential Number as an identifier
will continue unbroken throughout your progression from EMT-B to EMT-P. The reason
for the Sequential Number is to allow both the student and the instructor greater ease in
tracking hours and skills.
Figure 16 PCRA Basic Top Example
Run Times
This segment of the form documents the general details of your ambulance trip and
includes all times, Medic unit number, Age of the patient, and Sex of the patient.
• Unit - this is the unit number of the ambulance you are working on
• Date - in the format MM/DD/YY
• Dispatched - the time the ambulance was dispatched to the call. NOTE you must
use the 24 hour system of time charting
• Arrived - Time the ambulance arrived at the scene
• Contact - Time of your first contact with the patient
• Departed - Time you left the scene of the call
• Hospital - Time you arrived at the hospital
• In Service - Time your ambulance returned to service from the hospital
• Age - Age of the patient
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•
Sex - Sex of the patient
Figure 17 PCRA Basic Run Times Example
Chief Complaint, Category, and Area of Injury
In this area, chart what the patient tells you about why the ambulance was called. It
should always be in the patients own words if possible. There is also a check box list
where you categorize the Chief Complaint. The patient can have more than one Chief
Complaint Category so please check all that apply. You should also check what severity
level this patient is: Minor, Moderate, or Severe. At the right is the Area of Injury, which
is a drawing front and back of a person. In this area circle all of the areas of the body that
seem to be affected.
Figure 18 PCRA Basic Chief Complaint, Category Example
Narrative and Vitals Area
In this area, document your physical exam, vital signs, and SAMPLE history. The ability
to chart a clear and simple physical exam and SAMPLE history can be somewhat
difficult when you are just starting out, however with practice and the liberal use of
medical abbreviations it will become easier.
Narrative and SAMPLE History
AVPU
Select the patients overall level of responsiveness A=Alert, V=Verbal stimuli, P=Painful
stimuli, U=Unresponsive.
General Impression
In this area, chart what your general impression of the patient is. You may use No,
Minimal, Moderate, or Severe distress in this area.
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Integumentary
In this area, chart the condition of the skin. Examples include poor skin turgor, or
decubitus ulcers present.
Head/Neck
In this area, chart the condition of the head and neck and any trauma or other
abnormalities.
Neuro
In this area, chart information about the level of consciousness and any weakness or
paralysis in the extremities.
Thorax
In this area, chart your examination of the chest. Note any trauma or other abnormalities.
You would also chart lung and heart sounds in this area.
Abdomen
In this area, chart your examination of the abdominal area. Note any trauma,
abnormalities, or ascites here. Chart whether the abdomen is Soft or Rigid, Tender or
Non Tender, and Distended or Non Distended. It is also a good thing to chart whether
you heard any bowel sounds or not.
Pelvis
In this area, chart whether the pelvis is stable or unstable. It is also a good area to chart
any incontinence if it is found.
Extremities
In this area, chart any trauma or other abnormalities. Capillary refill for all extremities
and CMS for all extremities need to be charted here.
Back\Other
Note any trauma or other abnormalities here.
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SAMPLE History
Signs\Symptoms
IN this area, chart what you see and what the patient complains about.
Allergies
In this area, chart any allergies the patient has.
Medications
In this area, chart what medications the patient is currently on. Include prescription
medications, herbal preparations, and over the counter medications. It is also wise to ask
about any medication the patient may get from Juarez. If medication comes from Mexico
and you do not recognize it you can call the El Paso Poison Control Center for further
information. EPPCC is one of the few centers that have a Mexican formulary. Note you
can also reach the poison control center directly over the FMS radio.
Previous Medical History
In this area, chart the patient’s pertinent past medical history.
Last Oral Intake and LMP (if applicable)
In this area, chart when the patient ate last and how large the meal was. If the patient is of
child bearing years you will need to chart the Last Menstrual Period if pertinent.
Events
In this area, provide a brief description of the events that lead up to the ambulance being
called.
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Figure 19 PCRA Basic Narrative Example
Vitals
Time
In this area, chart the time you took the patient’s vitals. Please use the 24 hour system
when entering the time. For a stable patient, chart vitals every 15 minutes. For unstable
patients you need to chart vital signs every 5 minutes.
Glasgow
This is where you enter the Glasgow coma scale for all patients. The scale goes from 3 –
15 and there is a chart on the back of PCRA to assist you in calculating it.
B/P
In this area, chart the patient’s blood pressure. Currently there are two commonly
accepted methods for charting blood pressure; BP by auscultation and BP by palpation.
BP by auscultation is charted as Systolic over Diastolic i.e., 110\90, and the palpation
method is charted Systolic over P i.e., 110\P
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Pulse
In this area, chart the patient’s pulse rate in BPM or Beats per Minute. It should be
charted with an R for regular and I for irregular e.g. 120R or 134I
Respirations
In this area, chart information about the patient’s respiratory rate. It is charted in
Respirations per Minute. You also need to chart if the rate is regular or irregular. Use R
or I and chart it as 22R or 14I.
Pupils
In this area, chart whether the pupils are equal and reacting to light. You can use the
acronym of PERL which stands for Pupils Equal and Reacting to Light. Also chart if they
are unresponsive, dilated, or constricted. It is also a good idea to chart the size of the
pupil if you have a pupil gauge handy e.g. PERL 3.0 mm.
Skin
In this area, chart the color of the skin and whether it is wet or dry. e.g. Clammy\moist.
Temperature
In this area, chart the temperature of the skin e.g. warm or cool.
Pulse Oximetery
If the patient is hooked up to pulse oximeter, chart the reading and note if the patient is
on room air or supplemental O2. For example 98%\RA means the patient is saturating
at 98% on Room Air.
Glucometer
In this area, chart the result of any Glucometer test you do. It is ok to just chart the
number as most read on mg/dl which stands for milligrams per deciliter.
EKG Rhythm
If you are a Paramedic student please chart the EKG rhythm observed. EMT B & I
candidates do not have to chart this area.
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Oxygen
Chart here if you started the patient on Oxygen. You need to chart the rate and method of
delivery. For example 15\MNR means you administered Oxygen @ 15 liters per
minute by Mask Non Rebreather.
Medications Given
In this area, chart any medications you gave the patient. Each EMT candidate is
responsible for working within the limits of their training. Do not supersede your scope
of practice. Only administer drugs you are approved to. These drugs are generally
outlined on the letter of authorization from EPCC’s medical director.
Figure 20 PCRA Basic Vital Signs Example
Treatments
In this area, chart in a narrative format all treatments. This includes treatment prior to
arrival (PTA), On Scene, During Transport, and what treatment the EMT candidate
performed. It can be continued onto the back page at the top so try not to write too small.
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Figure 21 PCRA Basic Treatments Example
Back Page
Figure 22 PCRA Basic Treatments Back Example
Notice that the space that is not used is “stroked out”. It is always a good idea to do this
to properly finish your PCRA. “Stroking-out” prevents comments from being added later.
Ongoing Assessment
In this area, chart your ongoing assessment of the patient after your initial stabilization
and treatment of the patient. This should be in narrative format and should use medical
abbreviations where appropriate. Notice that the excess part of the form has been
“stroked out”.
Figure 23 PCRA Basic Ongoing Assessment Example
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Glasgow Coma Score
This area is used to calculate the Glasgow coma score. This score runs from 3 to 15 and
your instructor will teach you how to assess a patient using this method. Once you have
calculated the score enter it at the top, where it says Glasgow Score = . This score is
also used in the next column where you calculate the IPS (Trauma) Score.
Figure 24 PCRA Basic Glasgow Coma Scale Example
IPS Score (trauma score)
This is the area where the trauma score is calculated. This is used to help categorize the
severity of a trauma patient. It consists of 5 assessments which are added together in
order to come up with the trauma score.
GCS Conversion (Box A)
First take the GCS number that you calculated above. Then look in Box A. Find the
appropriate converted score and enter it in the appropriate area of the TRAUMA SCORE.
Respiratory Rate (Box B)
Look up the respiratory rate in Box B. Enter the number in the appropriate area of the
TRAUMA SCORE.
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Respiratory Expanse (Box C)
Look at the patient’s chest and determine his depth of respiration. Look up the
description in Box C. Enter the number in the appropriate area of the TRAUMA SCORE.
Systolic Blood Pressure (Box D)
Take the patient’s systolic blood pressure reading and look up the value in Box D. Enter
the number in the appropriate area of the TRAUMA SCORE.
Capillary Refill (Box E)
Take the patient’s capillary refill time and look up the value in Box E. Enter the number
in the appropriate area of the TRAUMA SCORE.
Trauma Score
Now simply add up all of the boxes and you have your Trauma Score. Be sure to chart
the Time at which the score was calculated.
Figure 25 PCRA Basic IPS Score Example
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Skills Performed
This area is a simple check box table that contains all of the skills you are likely to do on
an ambulance. If you do, however perform a skill that is not contained in this table simply
chart it in the treatment area. These skills are broken down into common skills all levels
of EMT perform. Please do not exceed your skill level when checking the appropriate
boxes. This information is to be transferred to your Weekly Skills and Hours Summary
form (WSHS) which is detailed elsewhere in this form.
Figure 26 PCRA Basic EMT Skills Performed Example
Bottom of Back Page
This area must have your signature and your Preceptor’s signature in order to be
complete. The preceptor also has a brief area to write comments about this call and your
performance on it.
Figure 27 PCRA Basic Signature Example
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Student Performance Improvement Evaluation
Overview
The backbone of any EMSP program is the Student Evaluation. This evaluation
provides feedback to the EMT candidate on their performance in the clinical
setting. It is a subjective yardstick telling the candidate how they are progressing
through the practical skills required by EMSP program. It also assists the Primary
Instructor in helping the student to pass the course.
Top of the form
In this area you need to enter the following:
•
•
•
•
•
•
•
Check the EMSP number of the course you are in
Enter the name of your Primary Instructor
Place the date of the clinical experience in the format MM\DD\YY
Enter your name
Enter the CI\Preceptor’s name and title
Enter the clinical site. Please use the abbreviations in the table below
Enter the unit name. Please use the abbreviations in the table below
Table 3 SPIE Basic Facility\Unit
Facility
Thomason Hospital
Las Palmas
William Beaumont Army
Medical Center
Del Sol Medical Center
El Paso FMS
Life Ambulance
Sunwest Ambulance
Rio Grand Ambulance
El Paso Morgue
Immunization Team
Abbreviation
RET
LAS
WBH
Nursing Home
GER
SOL
FMS
LIF
SUN
RGA
MOR
IMM
33
Unit
Emergency Dept
Intensive Care
Labor and
Delivery
Operating Room
PICU
NICU
Nursery
Cardiac Care
Wound Care
Hyperbaric
Chamber
Abbreviation
ED
ICU
L&D
OR
PIC
NIC
NUR
CCU
WND
HYB
6/1/2004
Figure 28 SPIE Basic Top of Form Example
The rest of the form is filled in by your CI\Preceptor at the end of your shift in
the clinical area. Once the CI\Preceptor has finished filling out the form,
please read it over before signing it. There is also an area to enter your
comments about the CI\Preceptors evaluation of you.
Figure 29 SPIE Basic Example
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Forms specific to
EMSP 1161, 1162, 2260,
2266
Emergency Medical
Technician
Advanced and Paramedic
Courses
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Patient Care Record Hospital (PCRH) Advanced (EMT-I) and
Paramedic Candidates
Overview
This is the primary form with which you track your encounters with patients while in the
hospital and associated specialty areas. The Patient Care Record Hospital, hereinafter
referred to as PCRH, documents the patient’s chief complaint, physical examination,
vital signs, SAMPLE history, and your treatments. This is a two sided form on which you
will record all of the pertinent information. When it is complete, have your Preceptor
review it and then sign it, along with your preceptor. Once a week you will compile all of
your PCRH’s and your PCRA’s and enter the required data in the Weekly Skills and
Hours Summary (WSHS) form and submit all of the PCR’s and the WSHS form to your
Primary Instructor.
While initially these forms can appear daunting to the new EMT candidate they will
become less so with practice and familiarity. A detailed explanation of the form appears
below and there are several samples of the form filled out appended to this document.
Detailed Explanation PCRH
Below is a completed version of the PCRH for the 1161, 1162, or 2160 levels. Each area
of the form will be explained in detail later on.
Figure 30 PCRH Advanced Front Example
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Figure 31 PCRH Advanced Rear Example
Top of Form Front
In this area of the PCRH you need to enter the following information:
• Primary Instructors name
• EMSP number (Courses 1161, 1162, 2160)
• If you are documenting skills check the Skills Only box
• Sequential Number
• Your name
• Clinical Site\Unit
• Date
• Age and sex of your patient
• Mechanism of Injury or Nature of Illness
• Time in and out of facility
• Total hours of shift
• Chief complaint of patient
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Sequential Number
The Sequential Number is a unique identifier that is assigned to each and every Patient
Care Record you complete. When you start as an EMT-B and you have your very first
patient encounter and do a physical assessment, the Sequential Number on that Patient
Care Record will be 1 .The next patient you encounter and assess will have a Sequential
Number of 2 on their Patient Care Record. If on your first day of clinical you are at the
hospital and do three patient assessments your first PCRH will have the Sequential
Number 1, the second the Sequential Number 2 and the third PCRH will be numbered 3.
If your next clinical day happens to be on the ambulance and you assess 2 patients, the
Sequential Numbers for these two PCRA’s will be 4 and 5. This process of assigning
each Patient Care Record you complete with a unique Sequential Number as an identifier
will continue unbroken throughout your progression from EMT-B to EMT-P. The reason
for the Sequential Number is to allow both the student and the instructor greater ease in
tracking hours and skills.
Clinical Site\Unit
In this area, enter the hospital or clinical site and the particular unit. Some clinical sites
only have one area thus you would only enter the clinical site name. Below is the Table
of Clinical Sites\Units.
Table 4 PCRH Advanced Facility\Unit
Facility
Thomason Hospital
Las Palmas
William Beaumont Army
Medical Center
Del Sol Medical Center
El Paso FMS
Life Ambulance
Sunwest Ambulance
Rio Grand Ambulance
El Paso Morgue
Immunization Team
Abbreviation
RET
LAS
WBH
Nursing Home
GER
SOL
FMS
LIF
SUN
RGA
MOR
IMM
Date
The date should be in the format MM/DD/YY
38
Unit
Emergency Dept
Intensive Care
Labor and
Delivery
Operating Room
PICU
NICU
Nursery
Cardiac Care
Wound Care
Hyperbaric
Chamber
Abbreviation
ED
ICU
L&D
OR
PIC
NIC
NUR
CCU
WND
HYB
6/1/2004
Age
This should be in the form of numbers. If the patient is less than 1 year add the
abbreviation mo after the numbers in order to indicate Months. If no mo occurs after the
numbers that it indicates the age in years.
Sex
Always use an F for female or an M for male.
MOI\ NOI
MOI stands for Mechanism of Injury which indicates how the injuries occurred and
usually pertains to trauma patients. NOI stands for Nature of Illness which indicates what
type of illness you are dealing with and generally applies to medical patients. Simply
chart a few words in this area.
Time in\out
In this area, chart the time you officially started and finished. Please use the 2400 hour
system when entering this data.
Total Hours
In this area, chart the total number of hours you spent on your shift.
Chief Complaint\History
This area can sometimes be a very challenging area for the EMT candidate. The Chief
Complaint is why the patient came to the hospital\specialty area. It should always be in
their own words if possible. If a patient comes into the ER unconscious then it is
acceptable to use the ambulance’s classification.
Figure 32 PCRH Advanced Top of Form Example
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SAMPLE History and OPQRST
Signs\Symptoms
In this area, chart what you see and what the patient complains about.
Allergies
In this area, chart any allergies the patient has.
Medications
In this area, chart what medications the patient is currently on. Include prescription
medications, herbal preparations, and over the counter medications. It is also wise to ask
about any medication the patient may get from Juarez. If medication comes from Mexico
and you do not recognize it you can call the El Paso Poison Control Center for further
information. EPPCC is one of the few centers that have a Mexican formulary. Note: you
can also reach the poison control center directly over the FMS radio.
Previous Medical History
In this area, chart the patient’s pertinent past medical history.
Last Oral Intake and LMP (if applicable)
In this area, chart when the patient ate last and how large the meal was. If the patient is of
child bearing years you will need to chart the Last Menstrual Period if pertinent.
Events
In this area, chart a brief description of the events that lead up to the hospital visit.
OPQRST
In this area, chart the OPQRST pneumonic. This pneumonic generally applies to the
description of pain but does have some other uses. Your instructor will explain them to
you as you proceed in your course of study. Below is an overview of each letter of the
pneumonic:
O
The “O” stands for Onset of the pain. It describes the speed with which the condition
occurred. For example: Was the Onset rapid or did it take a few days?
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P
The “P” stands for Provocation. This means is there action which makes the pain worse
or better.
Q
The “Q” stands for Quality. It is used to describe how the pain feels and should be in the
patient’s own words. Some examples are: “Sharp”, “Stabbing”, and “Dull”. In some
instances the patient does not have the words so you will have to ask some leading
questions such as, “Is the Pain sharp or dull?”
R
The “R” stands for Radiation. This means does the pain move from the original site to
another area of the body. For example when a patient has chest pain initially and it goes
to the left arm.
S
The “S” stands for the Severity of the pain. There are a number of scales used to indicate
pain. The easiest one is 1 to 10 where the number 1 stands for not too bad and 10 stands
for the worst pain you ever had.
T
The “T” stands for the Time the pain started and how long it has lasted.
Figure 33 PCRH Advanced SAMPLE - OPQRST Example
Vital Signs
Time
In this area, chart the time you took the patients vitals. Please use the 24 hour systems
when entering the time. For a stable patient, chart vitals every 15.minutes. For unstable
patients you need to chart vital signs every 5 minutes.
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Glasgow
This is where you would enter the Glasgow coma scale for all patients. The scale goes
from 3 – 15. Below is a sample of the scale for your information.
Table 5 PCRH Advanced Glasgow Coma Scale
Description
Motor Response
None
Decerebrate
Decorticate
Localizes Pain
Obeys Commands
Eye Opening
None/Swollen
To Pain
To Voice
Spontaneous
Verbal Response
None Intubated
Incomprehensible
Confused
Oriented
Value
1
2
3
4
5
1
2
3
4
1
2
3
4
B/P
In this area, chart the patient’s blood pressure. Currently there are two commonly
accepted methods for charting blood pressure; BP by auscultation and BP by palpation.
BP by auscultation is charted as Systolic over Diastolic i.e., 110\90, and the palpation
method is charted Systolic over P i.e., 110\P
Pulse
In this area, chart the pulse rate in BPM or Beats per Minute. It should be charted with an
R for regular and I for irregular e.g. 120R or 134I
Respirations
In this area, chart information about the patient’s Respiratory Rate. it is charted as
Respirations per Minute. You also need to chart if the rate is regular or irregular. Use R
or I and chart it as 22R or 14I.
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Pupils
In this area, chart whether the pupils are equal and reacting to light. You can use the
acronym of PERL which stands for Pupils Equal and Reacting to Light. Also chart if they
are -unresponsive, dilated, or constricted. It is also a good idea to chart the size of the
pupil if you have a pupil gauge handy e.g. PERL 3.0 mm.
Skin
In this area, chart the color of the skin and whether it is wet or dry. e.g. Clammy\moist
SAO2\Pulse Oximetery
If the patient is hooked up to a pulse oximeter, chart the reading and note if the patient is
on room air or supplemental O2. For example 98%\RA means the patient is saturating at
98% on Room Air.
Figure 34 PCRH Advanced Vital Signs Example
Systems Examination
The human body is divided up into systems which are interrelated. This next segment of
the form allows you to chart your physical examination.
General Impression
In this area, chart what your general impression of the patient is. You may use No,
Minimal, Moderate, or Severe distress in this area.
Integumentary
In this area, chart the condition of the skin. For example, poor skin turgor or decubitus
ulcers present.
Head/Neck
In this area, chart the condition of the head and neck and any trauma or other
abnormalities.
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Neuro
In this area, chart information about the level of consciousness and any weakness or
paralysis in the extremities.
Thorax
In this area, describe you examination of the chest. Note any trauma or other
abnormalities. Also chart lung and heart sounds in this area.
Abdomen
In this area, chart your examination of the abdominal area. Note any trauma,
abnormalities, or ascites here. Chart whether the abdomen is Soft or Rigid, Tender or
Non Tender, and Distended or Non Distended. It is also a good thing to chart whether
you heard any bowel sounds or not.
Pelvis
In this area, chart whether the pelvis is stable or unstable. It is also a good area to chart
any incontinence if it is found.
Extremities
In this area, chart any trauma or other abnormalities. Capillary refill for all extremities
and CMS for all extremities need to be charted here.
Back\Other
Note any trauma or other abnormalities here.
Figure 35 PCRH Advanced Physical\Systems Exam Example
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Advanced Patient Assessment
Please note that that this area is for use by EMT Intermediate and EMT Paramedic
candidates only. EMT Basic candidates do not have to fill out this portion of the form
and, indeed, there is a special version of this form which does not have this portion.
However it is recommended that all candidates familiarize themselves with this format.
Cardiac
In this area, chart extra information about your assessment of the patient’s cardiac
system. Include cardiac rhythm, MAP, pulse pressures, etc.
Endocrine
In this area, chart your assessment of any endocrine disorders that the patient may have.
For example a history of diabetes or thyroid deficiency or other related area.
Psychiatric
In this area, chart your assessment of the patient’s mentation and state of mind. You can
also chart in this area any psychological tests the hospital performed or any comments
that the patient made to you.
Immunological
In this area, chart information related to the patient’s immunizations and any active
infections the patient knows about. For example: How long ago was the patient’s last
tetanus shot? Does the patient have active TB?
Skeletal
In this area, chart information about the patient’s musculoskeletal system, being sure to
include any abnormalities, range of motion, or sensory deficits.
Neurological
In this area, chart a detailed neurological examination or other pertinent observations that
were not charted in the NEURO: section on the other side of this page. An example
would be the results of a dermatome mapping test.
Respiratory
In this area, chart any advanced assessment of the patient’s respiratory system or tests
that were performed. Some examples are inspiratory volume, laryngoscopic examination,
or ventilator settings.
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Genitourinary
In this area, chart any abnormal findings in the GUI systems. For example, you can chart
if the patient has a burning sensation when voiding. You can also place here any
abnormalities with the patient’s bladder and bowel habits.
Gastrointestinal
In this area, chart a detailed examination and assessment of the patient GI system. For
example, you could chart the patients bowel sounds and whether the patient is vomiting
blood.
Figure 36 PCRH Advanced Advanced Systems Example
Tests\Treatment Back
In this area, chart all of the tests and treatments that were performed on the patient by the
hospital and the EMT candidate. You can also chart the results of the various tests
performed here. In the example below, the treatments are charted in point format in order
to give a rapid clinical picture. You may also chart in a detailed fashion if the case is
sufficiently complex. Charting in this area can be somewhat complex for the EMT
candidate; however with a sufficient amount of practice it can be mastered.
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Figure 37 PCRH Advanced Tests\Treatment Back Example
Airway and Circulatory Management
In these two areas the EMT candidate will chart a variety of treatments and observations.
Generally this area is reserved for what the EMT candidate directly observed or any
treatments that were performed by the candidate.
Airway Management
In this area, please chart any interventions you performed related to patient’s respiratory
system. Some examples are:
• Oxygen administration – Chart the liter flow and the administration device type.
E.g. O2 @ 15 l\min via MNR.
• Airway insertion - Inserted #3 OPA into patient – tolerated well.
• BVM -- Assisted patient’s respirations with BVM (bag valve mask).
• Suction – Suctioned mouth x2 – 10 ml of blood collected – pt tolerated well.
• Nebulizer – Administered Ventolin 2.5mg/3ml NS via Nebulizer – patient’s
respiratory effort decreased.
Circulatory Management
In this area, please chart any interventions you performed related to the patient’s
cardiovascular system. Some examples are:
• Controlled bleeding – Applied direct pressure to stab wound on arm to control
bleeding – Bleeding controlled after 3 minutes.
• Blood draw – Performed venipuncture and drew red and purple top vacutainers –
sent tubes to lab.
• CPR – Assisted with CPR in full arrest patient.
• EKG – Attached EKG electrodes – noticed RSR at a rate of 80 bpm with no
aberrancies noted.
• Dressing – Changed dressing on patient’s leg using sterile technique – noted small
amount of muco-purulent discharge. Pt experienced minor discomfort during
dressing change.
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•
Glucometer – Obtained blood sample and checked with Glucometer – reading
obtained was 86 mg\dl – bleeding from site controlled with direct pressure and
band aid applied – patient tolerated well.
Figure 38 PCRH Advanced Airway and Circulatory Management Example
Skills Performed By Student
This area is a simple check box table that contains all of the skills you are likely to do in
the hospital. If, however, you do a skill that is not contained in this table simply chart it
in the treatment area. These skill are broken down into
•
•
•
Common skills all levels of EMT
Skills performed by EMT I and P
Skills performed by EMT-P’s only
Please do not exceed your skill level when checking the appropriate boxes. This
information is to be transferred to your Weekly Skills and Hours Summary form
(WSHS) which is detailed elsewhere in this form.
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Figure 39 PCRH Advanced EMT Skills Performed Example
Intravenous Therapy Record
In this area, chart when intravenous therapy is initiated by the EMT Candidate. This
section applies to EMT I and P candidates only and EMT B candidates should not chart
in this area.
Order
This is the doctor’s order as written in the doctor’s orders portion of the patient’s chart.
Simply transcribe the entry to the PCRH.
Reason
Chart the reason this IV is being established. Some examples are:
• Patient is dehydrated
• Patient is in shock
• Route to deliver medications
Solution
Chart the type of solution that is being administered to the patient. Some examples are:
• D5W
• NS
• Ringers
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Location
Chart the location where you started the IV. Some examples are:
• Right A\C
• Back of right hand
• Left external jugular
Gauge
Chart the type, size, and length of the catheter you used. Some examples are:
• 18 Ga x 1 ½” over the needle catheter
• 22 Ga x ¾” butterfly
Rate
Chart the rate of flow of the IV. Some examples are:
• 30 cc\hr
• TKO
Attempts
Chart the total number of attempts it took to gain IV access to the patient. Note: EMT
candidates are limited to 2 attempts on any patient.
CI\Preceptor initials
Have you preceptor or one of the MD’s\RN’s place their initials in this area.
Figure 40 PCRH Advanced IV Therapy Record Example
Ongoing Assessment
In this area, chart the ongoing care and assessment of the patient. The EMT needs to do a
baseline assessment of all patients and an ongoing reassessment of patients in their care.
Chart the status of the patient on an ongoing basis as well as how they responded to the
treatment provided. For example, if the patient got worse despite your interventions this
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would be the area to chart these observations. Below is an example of a filled out
ongoing assessment.
Figure 41 PCRH Advanced Ongoing Assessment Advanced Example
Medications Given
In this area, chart any medications given to your patients. All levels of EMT give
medications, however it is up to the EMT candidate to not exceed their scope of practice.
Only administer the medications that are permitted to your level of training.
Time
In this area, chart the time you gave the medication. Please use the 2400 hour system
when charting time.
Drug\Solution
In this area, chart what drug or solution you are giving. For example; Morphine Sulphate
Dose\Rate
In this area, chart the concentration of the drug and how fast it was administered. For
example;
• 2.0 mg \ slow iv push
• 1 gm\250 cc D5W \ 16ml\min
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Needle\Route
In this area, chart what needle you used by gauge and length, and the administrative
route. For example;
• 24 ga x 5\8” \ IM
• Needles into Y port \ Slow IV push
Initials
In this area, get your Preceptor or the RN who told you to give that particular medication
to put their initials.
Figure 42 PCRH Advanced Medications Given Advanced Example
Bottom Right of Form
In this area, place your signature and have your CI\Preceptor sign it also. There is also a
space for any comments your preceptor may have.
Figure 43 PCRH Advanced Signatures Example
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Patient Care Record Ambulance (PCRA) Advanced (EMT-I) and
Paramedic Candidates
Overview
This is the primary form with which you track your encounters with patients while on the
ambulance. The Patient Care Record Ambulance, hereinafter referred to as PCRA,
documents the patient’s chief complaint, physical examination, vital signs, SAMPLE
history, and your treatments. This is a two sided form on which you will record all
pertinent patient information. When it is complete, have your preceptor review it and then
sign it, along with your preceptor. Once a week you will compile all of your PCRA’s and
your PCRH’s and enter the required data in the Weekly Skills and Hours Summary
(WSHS) form and submit all of the PCR’s and the WSHS form to your primary
instructor.
While initially these forms can appear daunting to the new EMT candidate they will
become less so with practice and familiarity. A detailed explanation of the form appears
below and there are several samples of the form filled out appended to this document.
Detailed Explanation PCRA
Below is a completed version of the PCRA for the 1161, 1162, or 2266 courses. Each
area of the form will be explained in detail later on.
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Figure 44 PCRA Advanced Front Example
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Figure 45 PCRA Advanced Rear Example
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Top of Form Front
In this area of the PCRH you need to enter the following information:
•
•
•
•
•
•
Primary instructors name
Sequential Number
Your name
EMSP course (check)
Time In and Out
Total Time spent
Sequential Number
The Sequential Number is a unique identifier that is assigned to each and every Patient
Care Record you complete. When you start as an EMT-B and you have your very first
patient encounter and do a physical assessment, the Sequential Number on that Patient
Care Record will be 1 . The next patient you encounter and assess will have a
Sequential Number of 2 on their Patient Care Record. If on your first day of clinical
you are at the hospital and do three patient assessments your first PCRH will have the
Sequential Number 1, the second the Sequential Number 2, and the third PCRH will be
numbered 3. If your next clinical day happens to be on the ambulance and you assess 2
patients, the Sequential Numbers for these two PCRA’s will be 4 and 5. This process of
assigning each Patient Care Record you complete with a unique Sequential Number as an
identifier will continue unbroken throughout your progression from EMT-B to EMT-P.
The reason for the Sequential Number is to allow both the student and the instructor
greater ease in tracking hours and skills.
Figure 46 PCRA Advanced Top of Form Example
Run Times
This segment of the form documents the general details of your ambulance trip and
includes all times, Medic unit number, Age of the patient, and Sex of the patient.
• Unit -- this is the unit number of the ambulance you are working on
• Date -- in the format MM/DD/YY
• Dispatched -- the time the ambulance was dispatched to the call. NOTE you must
use the 24 hour system of time charting
• Arrived -- Time the ambulance arrived at the scene
• Contact -- Time of your first contact with the patient
• Departed -- Time you left the scene of the call
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•
•
•
•
Hospital -- Time you arrived at the hospital
In Service -- Time your ambulance returned to service from the hospital
Age -- Age of the patient
Sex -- Sex of the patient Male or Female
Figure 47 PCRA Advanced Run Times Example
Chief Complaint, Category, and Area of Injury
In this area, chart what the patient tells you about why the ambulance was called. It
should always be in the patients own words if possible. There is also a check box list to
categorize the Chief Complaint or Complaints. The patient can have more than one Chief
Complaint category so please check all that apply. You should also check what severity
level this patient is: Minor, Moderate, or Severe. On the right is the Area of Injury, which
is a drawing front and back of a person. In this area, circle all areas of the body that seem
to be affected.
Figure 48 PCRA Advanced Chief Complaint and Category Example
Narrative and Vitals Area
In this area, chart your physical exam, vital signs, and SAMPLE history. The ability to
chart a clear and simple physical exam and SAMPLE history can be somewhat difficult
when you are just starting out, however with practice and the liberal use of medical
abbreviations it will become easier.
Narrative and SAMPLE History
AVPU
Select the patients overall level of responsiveness A=Alert, V=Verbal stimuli, P=Painful
stimuli, U=Unresponsive.
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General Impression
In this area, chart what your general impression of the patient is. You may use No,
Minimal, Moderate, or Severe distress in this area.
Integumentary
In this area, chart the condition of the skin. Examples include poor skin turgor, or
decubitus ulcers present.
Head/Neck
In this area, chart the condition of the head and neck and any trauma or other
abnormalities.
Neuro
In this area, chart information about the level of consciousness and any weakness or
paralysis in the extremities.
Thorax
In this area, describe your examination of the chest. Note any trauma or other
abnormalities. You would also chart lung and heart sounds in this area.
Abdomen
In this area, chart your examination of the abdominal area. Note any trauma,
abnormalities, or ascites here. Also, chart if the abdomen is Soft or Rigid, Tender or Non
Tender, and Distended or Non Distended. It is also a good thing to chart whether you
heard any bowel sounds or not.
Pelvis
In this area, chart whether the pelvis is stable or unstable. It is also a good area to chart
any incontinence if it is found.
Extremities
In this area, chart any trauma or other abnormalities. Capillary refill for all extremities
and CMS for all extremities need to be charted here.
Back\Other
IN this area, chart any trauma or other abnormalities.
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SAMPLE History
Signs\Symptoms
In this area, chart what you see and what the patient complains about.
Allergies
In this area, chart any allergies the patient has.
Medications
In this area, chart what medications the patient is currently on. Include prescription
medications, herbal preparations, and over the counter medications. It is also wise to ask
about any medication the patient may get from Juarez. If medication comes from Mexico
and you do not recognize it you can call the El Paso Poison Control Center for further
information. EPPCC is one of the few centers that have a Mexican formulary. Note you
can also reach the poison control center directly over the FMS radio.
Previous Medical History
In this area, chart the patient’s pertinent past medical history.
Last Oral Intake and LMP (if applicable)
In this area, chart when the patient ate last and how large the meal was. If the patient is of
child bearing years you will need to chart the Last Menstrual Period if pertinent.
Events
In this area, provide a brief description of the events that lead up to the ambulance being
called.
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Figure 49 PCRA Advanced Narrative Example
Vitals
Time
In this area, chart the time you took the patient’s vitals. Please use the 24 hour system
when entering the time. For a stable patient, chart vitals every 15 minutes. For an
unstable patient you need to chart vital signs every 5 minutes.
Glasgow
In this area, chart the Glasgow coma scale for the patient. The scale goes from 3 – 15 and
there is a chart on the back of PCRA to assist you in calculating it.
B/P
In this area, chart the patient’s Blood Pressure. Currently there are two commonly
accepted methods for charting blood pressure; BP by auscultation and BP by palpation.
BP by auscultation is charted as Systolic over Diastolic, i.e. 110\90, and the palpation
method is charted Systolic over P i.e., 110\P
Pulse
In this area, chart the Pulse Rate in BPM or Beats per Minute. It should be charted with
an R for regular and I for irregular e.g. 120R or 134I.
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Respirations
In this area, chart information about the patient’s Respiratory Rate. Chart this as
Respirations per Minute. Also chart whether the rate is regular or irregular. Use R or I
and chart it as 22R or 14I.
Pupils
In this area, chart whether the pupils are equal and reacting to light. You can use the
acronym of PERL which stands for Pupils Equal and Reacting to Light. Also chart if they
are unresponsive, dilated, or constricted. It is also a good idea to chart the size of the
pupil if you have a pupil gauge handy e.g. PERL 3.0 mm.
Skin
In this area, chart the color of the skin and whether it is wet or dry, e.g. clammy\moist
Temperature
In this area, chart the temperature of the skin, e.g., warm or cool
Pulse Oximetery
If the patient is hooked up to a pulse oximeter, chart the reading and note if the patient is
on room air or supplemental O2. For example, 98%\RA means the patient is saturating
at 98% on Room Air.
Glucometer
In this area, chart the result of any Glucometer test you do. It is ok to just chart the
number as most read on mg/dl which stands for milligrams per deciliter.
EKG Rhythm
Paramedic Candidates ONLY.
In this area, chart the EKG rhythm observed. EMT B & I candidates do not have to
chart this area.
Oxygen
Chart here if you started the patient on Oxygen. Chart the rate and method of delivery.
For example, 15\MNR means you administered Oxygen @ 15 liters per minute by Mask
Non Rebreather.
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Medications Given
In this area, chart any medications you gave the patient. Each EMT candidate is
responsible for working within the limits of their training. Do not supersede your scope
of practice. Only administer drugs you are approved to. These drugs are generally
outlined on the letter of authorization from EPCC’s medical director.
Figure 50 PCRA Advanced Vital Signs Example
Treatments
In this area, chart all treatments using a narrative format. This includes treatment prior to
arrival (PTA), On Scene, During Transport, and any treatment you, the EMT candidate,
performed. It can be continued onto the back page at the top so try not to write too small.
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Figure 51 PCRA Advanced Treatments Front Example
Back Page
Figure 52 PCRA Advanced Treatments Back Example
Notice that the space that is not used is “stroked out”. It is always a good idea to “stroke
out” unused areas in order to properly finish your PCRA. This prevents comments from
being added later.
Ongoing Assessment
In this area, chart your ongoing assessment of the patient after your initial stabilization
and treatment of the patient. Use the narrative format and make use of medical
abbreviations where appropriate. Notice that the excess part of the form has been
“stroked out”.
Figure 53 PCRA Advanced Ongoing Assessment Example
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Glasgow Coma Score
This area is used to calculate the Glasgow Coma Score. This score runs from 3 to 15 and
your instructor will teach you how to assess a patient using this method. Once you have
calculated the score enter it at the top where it says Glasgow Score =. This score is also
used in the next column where you calculate the IPS (Trauma) Score.
Figure 54 PCRA Advanced Glasgow Example
IPS Score (trauma score)
This is the area where the Trauma Score is calculated. This is used to help categorize the
severity of a trauma patient. The Trauma Score consists of 5 assessments which are
added together to indicate the severity of the patient’s condition.
GCS Conversion (Box A)
First take the GCS number that you calculated above and then look in Box A. Find the
appropriate converted score and enter it in the appropriate area of the TRAUMA SCORE.
Respiratory Rate (Box B)
Look up the respiratory rate in Box B. Enter the number in the appropriate area of the
TRAUMA SCORE.
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Respiratory Expanse (Box C)
Look at the patient’s chest and determine his depth of respiration. Look up the
description in Box C. Enter the number in the appropriate area of the TRAUMA SCORE.
Systolic Blood Pressure (Box D)
Take the patient’s systolic blood pressure reading. Look up the value in Box D. Enter the
number in the appropriate area of the TRAUMA SCORE.
Capillary Refill (Box E)
Take the patient’s capillary refill time. Look up the value in Box E. Enter the number in
the appropriate area of the TRAUMA SCORE.
Trauma Score
Now simply add up all of the boxes and you have your Trauma Score. Chart this Score
and the Time at which the assessment was calculated. Remember to use the 24 hour
system when recording times.
Figure 55 PCRA Advanced IPS Score Example
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Skills Performed
This area is a simple check box table that contains all of the skills you are likely to do on
an ambulance. However, if you do a skill that is not contained in this table, simply chart it
in the Treatment area. These skills are broken down into
•
•
•
Common skills all levels of EMT
Skills performed by EMT I and P
Skills performed by EMT-P’s only
Please do not exceed your skill level when checking the appropriate boxes. This
information is to be transferred to your Weekly Skills and Hours Summary form
(WSHS) which is detailed elsewhere in this form.
Figure 56 PCRA Advanced EMT Skills All Example
Bottom of Back Page
This area must have your signature and your preceptor’s signature in order to be
complete. The preceptor also has an area to write brief comments about this call and your
performance on it.
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Figure 57 PCRA Advanced Signature Example
Student Performance Improvement Evaluation
Overview
The backbone of any EMSP program is the student evaluation. This evaluation
provides feedback to the EMT candidate on their performance in the clinical
setting. It provides a subjective yardstick to the candidate as to how they are
progressing practically through the EMSP program and assists the Primary
Instructor in helping the student to pass the course.
Top of the form
In this area, enter the following:
•
•
•
•
•
•
•
Check the EMSP number of the course you are in
Enter the name of your Primary Instructor
Place the date of the clinical experience in the format MM\DD\YY
Enter your name
Enter the CI\Preceptor’s name and title
Enter the Clinical Site. Please use the abbreviations in the table below
Enter the Unit Name. Please use the abbreviations in the table below
Table 6 SPIE Advanced Facility\unit
Facility
Thomason Hospital
Las Palmas
William Beaumont Army
Medical Center
Del Sol Medical Center
El Paso FMS
Life Ambulance
Sunwest Ambulance
Rio Grand Ambulance
El Paso Morgue
Immunization Team
Abbreviation
RET
LAS
WBH
SOL
FMS
LIF
SUN
RGA
MOR
IMM
Nursing Home
GER
Figure 58 SPIE Advanced Top of Form Example
67
Unit
Emergency Dept
Intensive Care
Labor and
Delivery
Operating Room
PICU
NICU
Nursery
Cardiac Care
Wound Care
Hyperbaric
Chamber
Abbreviation
ED
ICU
L&D
OR
PIC
NIC
NUR
CCU
WND
HYB
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The rest of the form is filled in by your CI\Preceptor at the end of your shift in
the clinical area. Once the CI\Preceptor has finished filling out the form please
read it over before signing it. There is also an area to enter your comments
about the CI\Preceptors evaluation of you.
Figure 59 SPIE Advanced Example
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Forms common to all
EMSP courses 1160, 1161,
1162, 2260, 2266
Emergency Medical
Technician Basic,
Advanced and Paramedic
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CI\Preceptor and Clinical Site Evaluation
Overview
This form allows the EMSP faculty to assess the CI\Preceptors on an ongoing
basis. It is very important that the EMT candidate fill out one of these forms for
each clinical rotation. You do not need to place your name on this form. All
information is confidential. This form is used by all five of the EMSP classes.
Top of the Form
In this area you need to enter the following:
•
•
•
•
•
Check the EMSP number of the course you are in
Enter the CI\Preceptors name
Enter the date of the clinical experience in the format MM\DD\YY
Enter the Clinical Site. Please use the abbreviations in the table below
Enter the Unit Name. Please use the abbreviations in the table below
Table 7 CCSE Facility\unit
Facility
Thomason Hospital
Las Palmas
William Beaumont Army
Medical Center
Del Sol Medical Center
El Paso FMS
Life Ambulance
Sunwest Ambulance
Rio Grand Ambulance
El Paso Morgue
Immunization Team
Abbreviation
RET
LAS
WBH
Nursing Home
GER
SOL
FMS
LIF
SUN
RGA
MOR
IMM
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Unit
Emergency Dept
Intensive Care
Labor and
Delivery
Operating Room
PICU
NICU
Nursery
Cardiac Care
Wound Care
Hyperbaric
Chamber
Abbreviation
ED
ICU
L&D
OR
PIC
NIC
NUR
CCU
WND
HYB
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Figure 60 CCSE Top of Form Example
The rest of the form is self explanatory; however there are detailed
instructions at the top of the form.
Figure 61 CCSE Example
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EMSP Weekly Summary Form (WSHS)
Overview
The process of becoming an Emergency Medical Technician can be a long and trying
one. One of the major obstacles that exist is the ability to keep track of the requisite
hours, skills, and patient types in an orderly fashion. The following pages describe a
simple system to keep track these items. While you, as a student, may think this is the
instructor’s problem it really is yours and detailed records must be turned in to your
school. It is always wise to keep a paper copy of anything you turn in. Sometimes
paperwork gets lost and your copy may be the only way to document that a skill was
performed or clinical hours were met.
The statistics that need to be tracked as an EMT student fall into three broad areas;
1. Number of hours spent in a hospital or ambulance
2. Number of practical skills performed
3. Type of patients cared for
The tracking of this information is essential for EPCC graduation and the ability to write
the National Registry of EMT’s certifying exams. EPCC and NREMT track slightly
different hours and competencies. The paperwork you fill out will help to track all areas
relevant to you while a student. This information is also cumulative and can be used from
EMT-B through EMT-P, thus the reason to keep detailed records. Wherever possible,
check boxes have been used to assist you and your instructors to complete these forms.
Patient Care Record
The first portion of this documentation is the Patient Care Record (PCR). On this form
you will document all aspects of your patient care along with relevant information such
as hours, patient type, patient category, and age class. Each of these areas will be
explained in detail as we proceed. Information on filling out the PCR Ambulance and
Hospital are covered elsewhere. Patient Care Records are generally turned in on a
weekly basis to your Primary Instructor. Please keep a paper copy of these forms for your
records.
Weekly Skill and Hours Summary (WSHS)
This form is to be turned in along with the PCR’s for each week in your schedule. This
form should be on top of the PCR’s and will reflect a summary of skills and hours. It is
your responsibility as a student to have this completed prior to handing in your PCR’s. It
is recommend that you fill out this form after each clinical experience and not leave it to
the last moment. Please keep a paper copy of these forms for your records.
This form contains a lot of places for data and the proper completion of it will be
discussed below. This form only tracks your clinical hours/skills/patient types and not
your didactic marks.
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Semester Skills and Hours Summary (SSHS)
This form is filled out by your Primary Instructor on an ongoing basis and uses the
Weekly Summaries as its data source. This form will provide you and your instructor a
picture of you clinical progress on a weekly basis. You should be able to go to your
instructor during the semester and ask where you are in regards to skills/hours/patient
types. This form only tracks your clinical hours/skills/patient types and not your didactic
marks.
Level Summary
This form is filled out by your Primary Instructor at the completion of each level of
EMT. You should have a total of three forms if you complete the paramedic program.
This form will allow the Program Coordinator to fill out your certificate of completion
with a minimum of problems. This form only tracks your clinical hours/skills/patient
types and not your didactic marks.
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Detailed Instructions for Weekly Skills and Hours Summary (WSHS)
This is a detailed explanation for the completion of the Weekly Skills and Hours
Summary (WSHS) form. Each data point will have a brief explanation and there is a
sample of a completed sheet below. Please use it while reviewing this material. There is
also a copy of a blank form at the end of this document.
Figure 62 Completed WSHS Example
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Top of Form
Please fill out your Name and check your course number, e.g. 1161. Also you need to fill
out the start and end dates of this form. You may use more than one form per week as
needed to document all of your skills and hours.
Figure 63 WSHS Top of Form Example
Left hand boxes
Sequential Number or S
In these boxes record the Sequential Numbers off of the PCR’s you have completed
during the week OR the letter S. The Sequential Number is a unique identifier that is
assigned to each and every Patient Care Record you complete. The first patient you
document in the EMT-B class has a PCR Sequential Number of 1. Your second
documented patient has the PCR Sequential Number 2, and so on. This process of
assigning each Patient Care Record you complete with a unique Sequential Number as an
identifier will continue unbroken throughout your progression from EMT-B to EMT-P.
The reason for the Sequential Number is to allow both the student and the instructor
greater ease in tracking hours and skills.
The exception to this rule is if in the clinical setting you are asked to do an isolated skill
on a patient and you do not do a Patient Assessment. In this instance you would not
assign a Sequential Number. Simply put a capital S and then document the Skills on a
PCR and attach.
Date
In this field, record the month and day. The year is based on the end date at the top of the
page. You will notice in the example that Sequential Numbers 15 and 17 bear the date
03/03 which indicates that the PCR’s were generated on March 03 to March 03. Notice a
line is drawn between the 03/03 and the 03/03. This line says, “These patients were all
done on the same date.”
Facility\Unit
In this box, indicate what facility you did your rotation at and what unit. Please use the
codes indicated in the table below. As with the Date, the line indicates that these patients
were all seen at the same facility and unit.
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Table 8 WSHS Facility\unit
Facility
Thomason Hospital
Las Palmas
William Beaumont Army
Medical Center
Del Sol Medical Center
El Paso FMS
Life Ambulance
Sunwest Ambulance
Rio Grand Ambulance
El Paso Morgue
Immunization Team
Abbreviation
RET
LAS
WBH
Nursing Home
GER
SOL
FMS
LIF
SUN
RGA
MOR
IMM
Unit
Emergency Dept
Intensive Care
Labor and
Delivery
Operating Room
PICU
NICU
Nursery
Cardiac Care
Wound Care
Hyperbaric
Chamber
Abbreviation
ED
ICU
L&D
OR
PIC
NIC
NUR
CCU
WND
HYB
You will notice in the example that the first shift was done at El Paso FMS, abbreviated
as FMS. The second shift was done at Thomason hospital, abbreviated RET and the Unit
is ER which is between the 2 RET. Thus if you were to do an OR rotation at Las Palmas
it would be abbreviated LAS – OR.
Hours
In this box, indicate your Start time and End time. You will need a minimum of 2
columns per shift in order to show your start time and end time. Should it happen that you
see One or Zero patients on your shift, record the End time in the adjacent box and draw
a vertical line through the remainder of the column, above and below the End Time to
prevent it accidentally being used for your next PCR Sequential Number. Note in the
example that on March 03 the start time was 1500 and the end time was 2400. Please do
not use AM/PM, instead use the 2400 system also known as military time.
Patient Type
In this box, indicate the type of patient you treated. There are 5 distinct types as shown in
the table below.
Table 9 WSHS Patient Type
Type
Trauma
Medical
OBYGYN
Psychiatric
Other
Abbreviation
T
M
G
P
O
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You will notice in PCR 15 that the patient is classified as T thus they are a trauma
patient.
Patient Category
In this box, indicate what your Patient Category is. It is related to National Registry
tracking requirements. They are outlined in the table below.
Table 10 WSHS Patient Category
Category
Abdominal
Chest Pain
Respiratory Distress
Altered Level of
Consciousness
Syncope (fainting)
Other
Type
ABD
CP
DY
LOC
SYN
OTH
You will notice in PCR #15 that the patient is classified as Other.
Age Class
In this box, record the patient’s age as a Class. There are only a total of three classes.
These classes are outlined below.
Table 11 WSHS Patient Age Class
Description
Pediatric
Adult
Geriatric
Abbreviation
P
A
G
All patients fall into one of the three classes. Simply enter the abbreviation for your
patient. In PCR 15 the patient is classified as an ADULT. Pediatric age is 0 to < 18 years
old, Adults are 18 to 65 years old, and Geriatric patients are > 65 years old.
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Figure 64 WSHS Category Data Example
SKILLS
EMT Basic Candidate
This is the largest portion of the page and relates to the common skills practiced by all
levels of EMT from the Basic to the Paramedic. To complete this section refer to the back
of the PCR you are transcribing where there is a similar check box table. To complete the
WSHS simply check the box if you did the skill. If you are an EMT Basic Candidate
you do not have to fill out anything below the EMT Intermediate and Paramedic
Common Skills. Please note that prior to handing in this form you must total up all the
skills of a particular type and enter the total in the rightmost column. Also there is one
blank area at the bottom for any skills not listed.
Figure 65 WSHS EMT Basic Skills Example
EMT Advanced (EMT-I) Candidate
If you are an EMT Advanced (EMT-I) Candidate you must fill out the Common Skills
EMT Basic, Intermediate, and Paramedic and the Common Skills EMT Intermediate
and Paramedic. You do not have to fill out any of the skills below the Common Skills
EMT Intermediate and Paramedic
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Figure 66 WSHS EMT Advanced (EMT-I) Skills Example
EMT Paramedic Candidate
If you are an EMT Paramedic Candidate you must fill in all the skills you performed at
all levels. Thus you are responsible for Common Skills EMT Basic, Intermediate, and
Paramedic, Common Skills EMT Intermediate and Paramedic, and the EMT
Paramedic Skills portion.
Figure 67 WSHS EMT Paramedic Skills Example
TOTALS
National Registry Tracking Patient Type, Age, and Category Totals
In this area, located at the bottom of the form, you simply count up and record the
number of patients according to Type, Age, and Category. This must be done before
submitting the form to your Primary Instructor.
Figure 68 WSHS Totals Example
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Other Totals
Down the right side of the form are Skills and Hour totals. To complete this area, simply
count across to tally the total number of a particular Skill and enter it in the rightmost
column. Your instructor uses this information to ensure you are getting enough
experience with the medical procedures you are learning.
Figure 69 WSHS Skills Totals Example
Skill
Totals
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Forms for Specialty Areas
Emergency Medical
Technician Basic,
Advanced and Paramedic
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Specialty Area Forms
Overview
Some forms are not used in all courses. They target specific skill sets that are
required as you progress through your education as an EMT. Your Primary
Instructor will tell you if you need these forms and when to use them.
Labor and Delivery Worksheet (EMSP 1160 & 1161)
Overview
During you rotations in the Labor and Delivery area (L&D) you will find it
useful to copy information contained on the L&D Status Board onto this form.
Some instructors also mandate that this form be evaluated at the end of each
L&D rotation. You will also be responsible for completing several PCRH’s
while in the L&D area in order to gain credit for your time spent there.
While completing this form please ensure you do not use any of the patient’s
personally identifiable data. Items such as the patient’s name or hospital ID
must NOT be copied onto this form in order to comply with HIPPA
requirements. The only piece of identifiable personal information that needs to
be charted is the patient’s age.
Below is a brief explanation of some of the nomenclature you may see on the
L&D status board. While this list is comprehensive each L&D area may have
other abbreviations which are not contained in the list. When in doubt ask one
of the staff what a particular abbreviation means.
Room Number
This is the room where the patient is laboring and where you will introduce
yourself to the patient and ask permission to witness the birth. You must
obtain permission from the patient in order to view the birth.
Nurse
This is where you chart the name of the patient’s nurse. This is the primary
nurse assigned to the patient during labor.
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Clinic
In this area of the form you will chart where the patient has received her prenatal
care. In some cases the patient may have a zero (0) in this space. This indicates that
the mother has had no prenatal care and is in a high risk category.
Age
Chart the age in years of the patient in this area of the form.
Gravida\Para (G\P)
Gravida means how many pregnancies that the woman has had. Para
means how many live births or children she has delivered. You will see this
information written on the board as 1\0, 3\2, or possibly 6\5. The first number is
the gravida and the second is the para. This says that the woman has been
pregnant x number of times and that she has x number of children.
Occasionally you will see three numbers such as 3\1\1. This means that the
woman has been pregnant three (3) times, has lost one child either from a
miscarriage (often called a spontaneous abortion) or an induced abortion,
and has one living child. Women who have had other children tend to
progress faster through the labor process that those experiencing their first
births.
Gestational Age (Ges. Age)
This is the gestational age of the baby. It is measured in weeks and days.
You may see it written as 38 4\7. This means that the baby is 38 weeks and
4 days old. Normal gestational age for human babies is 38 to 42 weeks. Any
gestational age less than 38 weeks or greater than 42 weeks is considered
abnormal. Less than 38 weeks is called pre-term and greater than 42 weeks
is called post-term. Either condition can mean possible problems for mother
and baby. Pre-term babies are often not fully developed. Post-term babies
can be at risk for other problems.
**NOTE
Cervix refers to the thick muscular ring at the mouth of the uterus. The status
of the cervix is measured in three different parameters.
Cervical Dilation (DIL)
Cervical dilation is measured in centimeters and it refers to how large the
opening to the uterus has become. A "C" written in this column means that
cervical dilation has been completed. A "Cl" in this space means closed. The
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cervix must be dilated about 9 to 10 centimeters for delivery to be
accomplished vaginally.
Cervical Station (STA)
This refers to how far down the birth canal the baby has descended. The stations are
noted as -4, -3, -2, -1, 0, +1, +2, +3, +4, or on the perineum. Zero (0) station is the
point where the baby's head is even with the ischial spines in the pelvic girdle. At this
point the baby is considered to be "engaged" in the birth canal.
At this point, with cervix completely dilated, the woman should start to push. If you
see a zero (0) or a positive number (i.e. +1) in this space, stay on your toes for this
may be the next delivery. Another indicator of imminent delivery is if you hear the
nurses in a room with a patient start to count to ten (10) intermittently while having
the patient push, please go into this room and ask if delivery on this patient is close..
Cervical Effacement (EFF)
Cervical effacement is the thinning of the cervix in order for dilation to take
place. This is measured in percentages (%). If you see ninety percent (90%)
on the board, look at the rest of the numbers. For example a woman who has
had multiple deliveries (two or more), at nine (9cms) dilation and is (90%)
effaced will probably be delivering very quickly.
Presentation (Pres)
The presentation refers to how the baby is facing. For humans the normal presentation
is head first or vertex which is abbreviated "vtx". Other presentations are frank breech
- buttocks first, footling breech - one or both feet first, shoulder or transverse
presentation - baby is crosswise to the birth canal (usually a c-section for these last
two).
Bag of Waters (BOW)
The bag of waters is the amniotic sac, which is a membrane that surrounds the fetus
and contains amniotic fluid. You may see the following abbreviations:
•
•
•
•
“I” this letter indicates that the BOW is intact or not broken.
“SROM” this means spontaneous rupture of membranes; "her water broke".
“AROM” this means artificial rupture of membranes and the BOW was
intentionally ruptured by the doctor.
“MEC” or “Meconium Stain” this means that the baby has had a bowel
movement in utero. Usually this happens when the baby has experienced some
form of stress. Since babies in the uterus swallow and breathe amniotic fluid,
extra care is taken with them upon delivery to remove as much fluid from
their lungs as possible. You will most likely see the baby's lungs suctioned
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with an ET (endotracheal) tube. This baby may be transferred to the Neonatal
Intensive Care Unit (NICU) for observation in order to prevent respiratory
distress from developing.
Time
This is the time the BOW ruptured.
Exam
This is the time of the last exam of the patient by the physician.
Information (INFORM)
In this space other information about the patient is charted. For example you
may see a note that the patient is pre-eclamptic, that she has been put on a
pitocin drip (to induce or strengthen her contractions), or other pertinent data.
Figure 70 Labor and Delivery Worksheet Example
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EKG Recognition \ Management (EMSP 2160 & 2266)
Overview
This form is used to chart the results when an EMT-Paramedic candidate
takes an EKG from a patient. This form is generally only used in EMSP 2160
and 2266 and after the candidate has taken EMSP 2444.
Top of the Form
In this area you will chart the following:
•
•
•
•
•
•
Check the EMSP number of the course you are in
Enter the name of your Primary Instructor
Place the date of the clinical experience in the format MM\DD\YY
Enter your name
Enter the CI\Preceptor’s name and title
Enter the Clinical Site and Unit Name. Please use the abbreviations in the
table below
Table 12 EKG Facility\unit
Facility
Thomason Hospital
Las Palmas
William Beaumont Army
Medical Center
Del Sol Medical Center
El Paso FMS
Life Ambulance
Sunwest Ambulance
Rio Grand Ambulance
El Paso Morgue
Immunization Team
Abbreviation
RET
LAS
WBH
Nursing Home
GER
SOL
FMS
LIF
SUN
RGA
MOR
IMM
Figure 71 EKG Top of Form Example
86
Unit
Emergency Dept
Intensive Care
Labor and
Delivery
Operating Room
PICU
NICU
Nursery
Cardiac Care
Wound Care
Hyperbaric
Chamber
Abbreviation
ED
ICU
L&D
OR
PIC
NIC
NUR
CCU
WND
HYB
6/1/2004
Middle of the Form
This area is used to attach a copy of the EKG to be read. If the EKG strip is
too long then please staple it to the back.
EKG Rhythm Analysis
In this area, chart the measurements of the EKG strip. A detailed explanation
of each entry is below.
Rhythm
Is the EKG rhythm regular or irregular? Circle the answer.
Rate
Is the rate Normal, Brady, or Tachy? Normal rate is between 60 to 100 bpm,
Brady is less than 60 bpm, and Tachy is greater than 100 bpm. Circle the
answer.
Atrial Rate
Measure the P to P interval and calculate the atrial rate in beats per minute,
bpm.
Ventricular Rate
Measure the R to R interval and calculate the ventricular rate in beats per
minute, bpm.
P before each QRS?
Is there a P wave before every QRS complex and is there a QRS complex for
every P wave? Circle the answer.
More P’s than QRS’s?
Are there more P waves than QRS complexes? Circle the answer. If so it may
indicate a block.
Mono or Polymorphic P waves
Are the P waves from the same focus or are there P waves that do not
originate in the SA node? Circle the answer.
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PR Interval
Record the PR interval. Normal 0.12 to 0.20 seconds.
QRS Mono or Polymorphic
Are the QRS complexes from the focus or are the QRS complexes different
from each other? (Polymorphic) Circle the answer.
QRS Duration
Record the QRS duration. Normal range is 0.04 to 0.08 seconds.
Axis Deviation
Is there any axis deviation if you are reading a 12 lead EKG. If you are
reading a standard 3 lead EKG then leave this response blank.
QT Interval
Record the QT Interval. Measure from the start of the Q wave to where the T
wave goes back to isoelectric. Normal range is 0.32 to 0.44 seconds.
Comments
Add any comments you may have about the EKG in this area.
Infarction, Q waves, Inverted T’s, ST Segment elevation\depression
Circle the word if you see any indications of these problems in the EKG.
Atrial Rhythm
Chart whether the Atrial Rhythm is regular or irregular.
Ventricular Rhythm
Chart whether the Ventricular Rhythm is regular of irregular.
Interpretation
In this area chart what your interpretation of the EKG is.
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Figure 72 EKG Rhythm Analysis Example
Rationale\Pathophysiology
In this area, chart the rationale for your interpretation of the EKG. Try to use
point format while charting in this area.
Figure 73 EKG Rationale\Pathophysiology Example
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Treatment\Medications\Rationale
In this area, chart any treatments given and why they were performed. Be as
detailed as possible here.
Figure 74 EKG Treatment\Medications\Rationale Example
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Advanced Airway Record (EMSP 1161 & 1162)
Overview
The Advanced EMT Candidate (EMT-I) must go through several rotations in
the Operating Room (OR) in order to gain the required experience with
intubations. During the OR rotations you will use a variety of advanced airway
techniques and devices. The purpose of this form is to chart your intubations
for National Registry purposes. If, as an Advanced EMT candidate, you
perform an intubation while on ambulance rotation this form should also be
used.
Top of the Form
In this area you will chart the following:
•
•
•
•
•
•
Check the EMSP number of the course you are in
Enter the name of your Primary Instructor
Place the date of the clinical experience in the format MM\DD\YY
Enter your name
Enter the CI\Preceptor’s name and title
Enter the Clinical Site and Unit Name. Please use the abbreviations in the
table below
Table 13 AAR Facility\unit
Facility
Thomason Hospital
Las Palmas
William Beaumont
Army Medical Center
Del Sol Medical Center
El Paso FMS
Life Ambulance
Sunwest Ambulance
Rio Grand Ambulance
El Paso Morgue
Immunization Team
Abbreviation
RET
LAS
WBH
Nursing Home
GER
SOL
FMS
LIF
SUN
RGA
MOR
IMM
91
Unit
Emergency Dept
Intensive Care
Labor and
Delivery
Operating Room
PICU
NICU
Nursery
Cardiac Care
Wound Care
Hyperbaric
Chamber
Abbreviation
ED
ICU
L&D
OR
PIC
NIC
NUR
CCU
WND
HYB
6/1/2004
Figure 75 AAR Top of Form Example
Detailed Instructions
In this area there are detailed instructions to your CI\Preceptor in case they
have not seen this form before. The EMT candidate should familiarize
themselves with these instructions prior to their first OR rotation.
Figure 76 AAR Detailed Instructions Example
Middle of Form Student Evaluation
In this area the CI\Preceptor will mark your performance performing advanced
airway skills. You will be marked on the following areas:
• Universal precautions – Were universal precautions followed?
• Equipment Check – Was the intubation equipment checked prior to
use?
• Ventilation – Did the candidate appropriately ventilate the patient?
• Airway type – Which advanced airway was used?
• Confirmation – Did the candidate confirm placement of the airway
appropriately?
• Extubation – Did the candidate perform an extubation properly?
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Figure 77 AAR Middle of Form Example
Bottom of Form
Sign the form and provide any comments you may have regarding how you
think the intubation went. Your CI\Preceptor must also sign in this area and
provide any comments they had. Note if your CI\Preceptor does not sign
this form then it will not count.
Figure 78 AAR Signature Example
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Laboratory Record (EMSP 1161)
Overview
Part of the EMT candidate’s job is the procurement of blood for routine
laboratory analysis. In order to sharpen the candidate’s skill at peripheral
venipuncture time must be spent in the laboratory drawing blood for various
tests. This form is used to track your patient encounters.
Top of Form
In this area you must enter the following:
•
•
•
Your name
Your primary instructor
The date in the format MM\DD\YY
Figure 79 LR Top of Form Example
Middle of Form
In this area of the form you will chart the details of your patient encounter.
You may chart up to 34 patients on this form. It is recommended when you go
to the lab you take an extra copy of this form.
Number
This is simply the number of patients you saw during your lab rotation. If you
did not get the required amount of blood draws during your shift you will need
to reschedule another lab rotation with your primary instructor.
Age\Sex
Please enter the patients age in years followed by a slash and then the
patients sex, either “M” or “F”.
Method
In this area chart the type of blood draw you performed. The primary methods
are; Vacutainer, Butterfly, Syringe.
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Area
Please chart in this area where on the patient you performed the
venipuncture. For example R A\C means Right Antecubital.
Analysis
Chart the relevant tests that the blood is being drawn for or the colors of the
tubes used.
1st attempt\2nd attempt
In this area simply check if you got the blood on the first or second attempt.
Students are limited to two (2) venipuncture attempts on any given patient.
Figure 80 LR Middle of Form Example
Comments
Please have your preceptor chart any comments in this area.
Figure 81 LR Comments Example
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Forms for the Instructor of
EMSP classes
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EMSP Semester Summary
Overview
The ability to track an EMT student’s Hours, Skills, and Patient Information in a timely
fashion is of great importance. The Semester Skills and Hours Summary form has been
designed to meet this challenge. An executive summary format has been used and this
form should be filled out in conjunction with the Weekly Summary form which the EMT
candidate fills out weekly during the clinical phase of their training. This form should be
used by the Primary Instructor of a particular course.
This form does not track the didactic portion of a course. It attempts to present the
psychomotor skills and hours of a course in an easily read tabular format, which will
simplify record keeping and allow the instructor and student to know where the student is
at any time during the clinical phase of the course. Using this form will also aid data
entry of the skills and hours into the SkillTrac© program.
SkillTrac© is being co-developed at the same time as the EMSP forms are being revised.
The SkillTrac© program will allow the EMSP instructor to track the Didactic,
Psychomotor, and Hours required for an EMT to complete any particular course. Plus it
will have the ability to compare a student’s progress through the EMSP program against
the National Registry requirements. This system will provide both quantitative and
qualitative tracking to help ensure the highest caliber of EMT when they graduate.
The statistics that need to be tracked at the semester level are as follows:
1. Number of hours spent in a hospital or specialty clinical area
2. Number of ambulance hours
3. Number and type of practical skills performed
4. Age grouping of patients cared for: e.g. Pediatric, Adult, and Geriatric
5. Type of patient cared for: e.g. Trauma, Medical, Obygyn, Psychiatric, and
Other.
6. Patient categorization e.g: Abdominal, Chest Pain, Dyspnea, Altered LOC,
and Syncope.
The tracking of this information is essential for EPCC graduation and the ability to write
the National Registry of EMT’s certifying exams. EPCC and NREMT track slightly
different hours and competencies. The paperwork you fill out will help to track all areas
relevant to the student and the course level. This information is also cumulative and can
be used from EMT-B through EMT-P, thus the reason to keep detailed records.
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Detailed Instructions for Semester Skills and Hours Summary (SSHS)
This is a detailed explanation for the completion of the Semester Skills and Hours
Summary form (SSHS), each data point will have a brief explanation and there is a
sample of a completed sheet below. Please use it while reviewing this material. There is
also a copy of a blank form at the end of this document.
Figure 82 SSHS Form Example
SSHS Top of the Form
Please fill out the students name and check your course number e.g. 1161. Also you need
to fill out the start and end dates of the semester. You should not need more than one of
these forms per semester however it is acceptable to add another if the space is required.
Figure 83 SSHS Top of Form Example
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Top left of Form
In this area the hours per facility are tracked. Generally you take the information that is
on lines 3 and 4 for the WSHS and enter the total hours per facility for that week. At the
end of the semester you tally up all of the hours spent in each area and enter it into the
total box at the bottom. When a facility or unit is not visited during a particular course
simply put an N/A in the total box.
Figure 84 WSHS Top Left Example
Figure 85 SSHS Top Left Example
The candidates fill out the WSHS using a code system that stands for a particular
specialty area or ambulance. On the next page is the table used on the WSHS. Simply
look up the code in the table below and enter the hours in the appropriate area on the
form. This form is appropriate for all levels of EMT.
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Table 14 SSHS Facility\unit
Facility
Thomason Hospital
Las Palmas
William Beaumont Army
Medical Center
Del Sol Medical Center
El Paso FMS
Life Ambulance
Sunwest Ambulance
Rio Grand Ambulance
El Paso Morgue
Immunization Team
Abbreviation
RET
LAS
WBH
Nursing Home
GER
SOL
FMS
LIF
SUN
RGA
MOR
IMM
Unit
Emergency Dept
Intensive Care
Labor and
Delivery
Operating Room
PICU
NICU
Nursery
Cardiac Care
Wound Care
Hyperbaric
Chamber
Abbreviation
ED
ICU
L&D
OR
PIC
NIC
NUR
CCU
WND
HYB
Top right of form
In this area the Type of patient that student attended is tracked. This area is for National
Registry and EPCC purposes. This information is transferred from the WSHS as
indicated below
Figure 86 WSHS Patient Type Example
At the end of the semester you tally up all of the Patient Types and enter it into the Total
box at the bottom.
Figure 87 SSHS Patient Type Example
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Bottom Left of Form
In this area, track the skills performed by the EMT candidate on a semester basis. The
information for this area comes from the WSHS in the middle portions of that form.
Depending on the level of the EMT candidate they may fill out from only EMT BIP
common skills fill out only the EMT BIP Common Skills and EMT IP Common Skills,
or all of the skill areas if the candidate is an EMT-P candidate. Below is a sample of the
appropriate area of the WSHS form.
Figure 88 WSHS Skills Example
As you can see the student has filled out all of the skills they performed in a particular
week. As skills are charted in all areas we can deduce that this is a Paramedic student.
Notice that down the right hand column is the skill totals for that week. It is
recommended that the instructor insist that the students place a zero in the totals column
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Bottom Left of Form continued
if that skill was not performed that week. This will help insure accuracy when
transferring the totals over to the SSHS form. While the skills tracked on the WSHS are
very detailed the skills required by EPCC and the National Registry are much less
detailed.
Figure 89 SSHS Skills Example
Bottom Right of Form
This area is comprised of the two areas requiring tracking by the National Registry,
Patient Category and Patient Age. This area of the form is filled out from the WSHS form
as shown in the example below. Simply enter the totals in the appropriate areas.
Figure 90 WSHS Patient Age and Category Example
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Figure 91 SSHS Patient Category and Age Example
Once all the data points have been entered on the SSHS form you can use the information
to ascertain if the student meets the criteria for graduation from that particular semester.
If the candidate has completed a particular level in their EMT training then a Level
Summary form should be completed using the Semester Skills and Hours Summary
(SSHS) form. This form is still under development.
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Appendices
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Appendix I Common Medical Abbreviations
Abbreviation / Symbol / Description
female
left
male
negative
positive
right
1°
primary
2°
secondary
<
less than
>
greater than
@
at
change
decrease(d)
increase(d)
~
approximately
before
A.Fib
atrial fibrillation
AAL
anterior axillary line
abd
abdomen
A/O
alert and orientated
AKA
above the knee amputation
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AM
before noon; time should be expressed in 24 h format
AMA
against medical advice
approx
approximately
ASA
acetylsalicylic acid, aspirin
ASAP
as soon as possible
ausc
auscultation
auto
automobile
BBB
bundle branch block
BG
blood glucose
BHMD
Base Hospital Medical Director
BHP
Base Hospital Physician
BKA
below the knee amputation
BM
bowel movement
BP
blood pressure
bpm
beats per minute
BS
breath sounds
BS=BL
breath sounds equal bilaterally
BVM
bag valve mask
with
C/A
conscious/alert
C/A/O
conscious/alert/orientated
c/o
complaint of
C/P
chest pain
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CA
cancer
CAD
coronary artery disease
CCU
coronary care unit
CHF
congestive heart failure
CNS
central nervous system
con't
continued
COPD
chronic obstructive pulmonary disease
CPR
cardiopulmonary resuscitation
CRIC
needle cricothyroidotomy
CT
critical, may not divert from hospital destination due to a patient's condition;
for critical trauma requires transport to a designated trauma center
CVA
cerebral vascular accident
DBP
diastolic blood pressure
dc
discontinue
DCF
disaster control facility
DKA
diabetic ketoacidosis
DOE
dyspnea on exertion
drsg
dressing
DX
diagnosis
ECG
electrocardiogram
ED
Emergency Department
EKG
electrocardiogram
EMT-B
Provider of Basic Life Support
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EMT-I
provider of Intermediate Life Support
EMT-P
EMT-Paramedic, provider of BLS and ALS level of services; also MICP,
Mobile Intensive Care Paramedic
epi
epinephrine
ET
endotracheal
ETA
estimated time of arrival
ETI
endotracheal intubation
ETOH
alcohol
ETT
endotracheal tube
exam
examination
f/u
follow-up
fl
fluid
fx
fracture
GB
gall bladder
GCS
Glasgow Coma Scale
GI
gastrointestinal
gm
gram
grav
gravida
GSW
gunshot wound
gtt
drop
GU
genitourinary
h
hour
H&P
history and physical
H2O
water
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HA
headache
hosp
hospital
HR
heart rate
HTN
hypertension
Hx
history
ICU
intensive care unit
IM
intramuscular
IO
intraosseous
IV
intravenous
IVP
intravenous push
JVD
jugular venous distension
Kg
kilogram
L
liter
lac
laceration
lg
large
lido
lidocaine
LLQ
left lower quadrant
LMH
Lodi Memorial Hospital
LMP
last menstrual period
LOC
loss of consciousness
LR
Lacated Ringers
LS
lung sounds
LUQ
left upper quadrant
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m
min
m/o
month old
mA
milliamp
MAL
mid-axillary line
MCA
motorcycle accident
mcg
microgram
MCL
mid-clavicular line
mEq
milliequivalent
mg
milligram
mgtt
micro-drop
MI
myocardial infarction
MICN
Mobile Intensive Care Nurse; also ARN, Authorized Registered Nurse
MICU
Mobile Intensive Care Unit
ml
milliliter
MNR
Mask Non Rebreather
MS
morphine sulfate
MVA
motor vehicle accident
N/V
nausea and vomiting
NC
nasal cannula
NCT
non-critical, may divert from hospital destination
neuro
neurological
NKDA
no known drug allergies
NPA
nasopharyngeal airway
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NS
normal saline
NSR
normal sinus rhythm
NTG
nitroglycerine
NTI
nasotracheal intubation
O2
oxygen
OB
obstetrics
OD
overdose
O\E
On Examination
OPA
oropharyngeal airway
OTI
orotracheal intubation
P
pulse
after
PAC
premature atrial contraction
para
parity, e.g. gravida 2 para 1 means the patient has been pregnant twice and
given birth once, also written G2P1
PAT
paroxysmal atrial tachycardia
PCN
penicillin
PE
physical examination
PEA
pulseless electrical activity
ped
pedestrian
pedi
pediatric
PEARL
pupils equal and reactive to light
PJC
premature junctional contraction
PM
afternoon, time should be expressed in 24 h format
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PND
paroxysmal nocturnal dyspnea, difficulty breathing that awakens the patient
from sleep or prevents sleep
PO
by mouth
post-op
post operative
PR
per rectum
PRN
as needed
pt
patient
P\T
Prior To
PTA
prior to arrival
PVC
premature ventricular contraction
q
every
R
respiration
RAS
released at scene
resp
respiratory
RLQ
right lower quadrant
ROM
range of motion
RUQ
right upper quadrant
Rx
prescription
without
S-brady
sinus bradycardia
s/p
status post
s/s
signs and symptoms
SBP
systolic blood pressure
SC
subcutaneous
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SL
sublingual
sm
small
SOB
shortness of breath, equivalent to dyspnea
ST
sinus tachycardia
stat
immediately
SVT
supraventricular tachycardia
SX
symptom
T
temperature
TB
tuberculosis
TCN
tetracycline
TIA
transient ischemia attack
TKO
to keep open
torr
mm Hg, unit of blood pressure measurement
trans
transport
Tx
treatment
V-tach
ventricular tachycardia
vag
vaginal
VS
vital signs
w/c
wheelchair
WNL
within normal limits
w/o
wide open
wt
weight
y/o
year old
113
6/1/2004
°F
degrees Fahrenheit
114
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