STUDENT
CLINICAL
BOOK
10/29/2013
Table of Contents
STUDENT CLINICAL BOOK REQUIREMENTS: ...................................... 1
BOOK ATTESTATION PAGE............................................................... 3
STUDENT CLINICAL MANUAL ........................................................... 4
CLINICAL SIGN IN SHEET ................................................................. 5
CLINICAL EVALUATION – PROGRESS REPORT .................................. 6
CLINICAL EVALUATION - COVER FOR LONG FORM ............................ 7
MANDATORY PARAMEDIC DRUGS .................................................... 8
REPORT WRITING NARRATIVE REQUIREMENTS ................................. 9
MANDATORY DRUGS ..................................................................... 10
PATIENT CARE REPORT................................................................. 11
SKILLS SIGN OFF .......................................................................... 14
STUDENT EQUIPMENT COMPETENCY CHECK LIST - LP .................... 15
STUDENT EQUIPMENT COMPETENCY CHECK LIST – MED BAG ........ 16
STUDENT EQUIPMENT COMPETENCY CHECK LIST - STRETCHER ....... 17
SKILLS PERFORMED WORKSHEET.................................................. 18
Palm Beach State College – Paramedic Program
Student Clinical Book
Palm Beach State College
Paramedic Program
STUDENT CLINICAL BOOK REQUIREMENTS:
To be assembled with tabs
If clinical rotation has not happened yet – keep blank forms out of book.
** Outside Cover is the Attestation Page**
1.
Front Page – Name Page
2.
Clinical Sign In Sheet
3.
Drug Card Check Off Sheet (EMS 2664 ONLY)
4.
Medical Director Rotation
5.
Medical Director Patient Contact Sheet
6.
Pediatric Partners
7.
Pedi Grand Rounds
8.
Trauma Surgeon Documentation Forms
9.
Healey Rehab
10.
Cottages
11.
Humane Society Form
12.
O.R. Intubation rotation
13.
Midterm and Final Evaluation, Cover Sheet for Long Form
14.
Preceptor Objective Worksheet
15.
Preceptor Feedback Tool
16.
Patient Care Reports One Tab for Hospital Reports.
17.
PCR’s from Fire Rescue
**Binder clipped when turned in with labeled tabs.
Palm Beach State College – Paramedic Program
1
Student Clinical Book
Palm Beach State College – Paramedic Program
2
Student Clinical Book
Paramedic Clinical
BOOK ATTESTATION PAGE
CLASS SHIFT: ____________
I hereby attest that the reports and documentation contained
within this Student Clinical Book for:
Are complete, accurate, have been reviewed by the student and
myself, verified with our signatures, and reflect the student’s
TYPHON entries.
Clinical Instructor Printed Name:
_______________________________________________
Clinical Instructor Signature:
_______________________________________________
Date of Submission:
_______________________________________________
□ EMS 2664 – CLINICAL 1
□ EMS 2658 – CLINICAL 3
□ EMS 2665 – CLINICAL 2
□ EMS 2659 – Internship
Palm Beach State College – Paramedic Program
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Student Clinical Book
Palm Beach State College
PARAMEDIC PROGRAM
STUDENT CLINICAL MANUAL
EMS 2664, 2665, 2658, 2659
STUDENT NAME________________________________
CLINICAL INSTRUCTOR__________________________
FIRE RESCUE INSTRUCTOR______________________
CLASSROOM INSTRUCTOR______________________
Palm Beach State College – Paramedic Program
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Student Clinical Book
CLINICAL INSTRUCTOR_______________________________
FIRE RESCUE INSTRUCTOR____________________________
INSTRUCTOR PHONE # ________________________________
Clinical Shift ___________
Class Shift _____________
PALM BEACH STATE COLLEGE
PARAMEDIC STUDENT
CLINICAL SIGN IN SHEET
STUDENT: Fill out this sheet every time you attend a clinical function. Fill out the dates you are absent.
Keep this sheet in your Clinical Book.
Student Name
Date
Time In
Time Out
Palm Beach State College – Paramedic Program
Site
5
Instructor Printed Name
Instructor Signature
Student Clinical Book
Calls
Reports
Palm Beach State College – Paramedic Program
CLINICAL EVALUATION – PROGRESS REPORT
□ EMS 2664 – CLINICAL 1
□ EMS 2665 – CLINICAL 2
□ EMS 2658 – CLINICAL 3
□ EMS 2659 – Internship
Class:
Date
Student Name
Instructor Name
Instructor Signature
Indicate how the student is progressing toward competency by rating the student on a scale of 1-5.
A “1” or “2” rating indicates that immediate remedial work is indicated. A “5” indicates superior performance.
Cognitive Domain (Knowledge Base)
5
4
3
2*
1*
Psychomotor Domain (Clinical Proficiency)
5
4
3
2*
1*
Affective Domain (Behavioral Skills)
5
4
3
2*
1*
Documentation (FISDAP/Typhon)
5
4
3
2*
1*
Comments:
*Grades of 1 or 2 require comments, an Assistance Lab referral form, and Clinical Coordinator notification.
Student Signature:
Palm Beach State College – Paramedic Program
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Student Clinical Book
Palm Beach State College – Paramedic Program
CLINICAL EVALUATION - COVER FOR LONG FORM
□ EMS 2664 – CLINICAL 1
□ EMS 2665 – CLINICAL 2
□ EMS 2658 – CLINICAL 3
□ EMS 2659 – Internship
CLASS: _______________
Date
Student Name
Instructor Name
Instructor Signature
Competent
Not Competent
Cognitive Domain (Knowledge Base)
Minimum Score: 24
Psychomotor Domain (Clinical Proficiency)
Minimum Score: 16
Affective Domain (Behavioral Skills)
Minimum Score: 36
Documentation (Typhon)
Minimum Score: 12
Comments:
In any given semester, a Competent score is required in the Psychomotor domain in order to receive a
course satisfactory grade (S). In EMS2664, EMS2665 and EMS2658, other than the above mentioned
requirement, the student may receive only one Not Competent and still receive a course grade of
satisfactory (S). In EMS2659, a Final Evaluation of Competent must be received in ALL categories to
earn a satisfactory grade (S).
CURRENT GRADE:
 Satisfactory
 Unsatisfactory*
*Requires immediate Clinical Coordinator notification
Student Signature:
Palm Beach State College – Paramedic Program
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Student Clinical Book
MANDATORY PARAMEDIC DRUGS
1) Adenocard
26) Magnesium Sulfate
2) Albuterol
27) Mannitol
3) Amiodarone
28) Methylprednisone
4) Amyl Nitrite
29) Midazolam
5) Aspirin
30) Morphine
6) Atropine
31) Naloxone
7) Calcium Chloride
32) Nitroglycerine
8) Dexamethasone
33) Nitrous Oxide
9) Dextrose 50%
34) Oxygen
10) Diazepam
35) Oxytocin
11) Digoxin
36) Pralidoxime
12) Diltiazem
37) Procainamide
13) Diphenhydramine
38) Prochlorperazine
14) Dopamine
39) Promethazine
15) Epinephrine 1:1,000
40) Proventil
16) Epinephrine 1:10,000
41) Salbutamol
17) Etomidate
42) Sodium Bicarbonate
18) Flumazenil
43) Sodium Nitrite
19) Furosemide
44) Sodium Thiosulfate
20) Glucagon
45) Succinylcholine
21) Ipratropium
46) Terbutaline
22) Labetalol
47) Tetracaine
23) Levalbuterol
48) Thiamine
24) Lidocaine
49) Vasopressin
25) Lorazepam
50) Verapamil
Palm Beach State College – Paramedic Program
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Student Clinical Book
PALM BEACH STATE COLLEGE
EMS Academy
DATE:
- Paramedic Program
August 2010
PATH:
REPORT WRITING NARRATIVE REQUIREMENTS
Excellent report writing and documentation skills are paramount for
paramedic students to master. These skills require much diligence and
patience in order to achieve excellence.
Therefore, all paramedic students are required to use the following
narrative styles in each subsequent semester. Templates and examples for
each can be found on Typhon.
Semester 1: Students will write narratives in the CHARTE format.
Semester 2: Students will write narratives in the SOAP format.
Semester 3 and Internship: Students will write narratives in the
Descriptive Narrative format
Palm Beach State College – Paramedic Program
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Student Clinical Book
MANDATORY DRUGS
1. These are mandatory for student drug cards. Instructors may also add additional drugs as they see
fit.
2. All drug cards are to be hand written and turned into the Clinical Lead Instructor by the end of
EMS 2664.
3. The Clinical Lead Instructor will check each box once they see and approve each drug card.
□ 1) Adenocard
□ 2) Albuterol
□ 3) Amiodarone
□ 4) Amyl Nitrite
□ 5) Aspirin
□ 6) Atropine
□ 7) Calcium Chloride
□ 8) Dexamethasone
□ 9) Dextrose 50%
□ 10) Diazepam
□ 11) Digoxin
□ 12) Diltiazem
□ 13) Diphenhydramine
□ 14) Dopamine
□ 15) Epinephrine 1:1,000
□ 16) Epinephrine 1:10,000
□ 17) Etomidate
□ 18) Flumazenil
□ 19) Furosemide
□ 20) Glucagon
□ 21) Ipratropium
□ 22) Labetalol
□ 23) Levalbuterol
□ 24) Lidocaine
□ 25) Lorazepam
□ 26) Magnesium Sulfate
□ 27) Mannitol
□ 28) Methylprednisone
□ 29) Midazolam
□ 30) Morphine
□ 31) Naloxone
□ 32) Nitroglycerine
□ 33) Nitrous Oxide
□ 34) Oxygen
□ 35) Oxytocin
□ 36) Pralidoxime
□ 37) Procainamide
□ 38) Prochlorperazine
□ 39) Promethazine
□ 40) Proventil
□ 41) Salbutamol
□ 42) Sodium Bicarbonate
□ 43) Sodium Nitrite
□ 44) Sodium Thiosulfate
□ 45) Succinylcholine
□ 46) Terbutaline
□ 47) Tetracaine
□ 48) Thiamine
□ 49) Vasopressin
□ 50) Verapamil
Student Printed Name: _____________________________________
Student Signature: _________________________________________
Clinical Instructor Signature: _________________________________
Date Completed: ___________________________________________
Palm Beach State College – Paramedic Program
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Student Clinical Book
PALM BEACH STATE COLLEGE
EMT/Paramedic Program
PATIENT CARE REPORT
Student:
_________________________
EMT
Paramedic
Date:
____/____/_____
Time of Call: _______________
Hospital/Agency: ____________
Unit: ____________
Age:____
□ I accompanied this patient to the hospital during transport.
Instructor/Preceptor Name:
Instructor/Preceptor Signature:
______________________
______________________
ETHNICITY
M
F
African American
American Indian
Asian
Caucasian
Hispanic
Abdominal
Cardiac
CVA
Diabetic
OB/GYN
Other:
___________________
None
Motorcycle
Airbag
Rollover
Chief TRAUMA COMPLAINT
Chief MEDICAL COMPLAINT
OD-Poison
Psychiatric
Respiratory
Seizure
Sepsis
Abdomen
Chest
Extrem.
Muscular
Other ___________________
Other ___________________
MECHANISM OF INJURY
Driver MVA
Passenger MVA
Fall/Jump
Seatbelt
Entrapment
Blunt
Penetrating Injury – Type: _____________________
Neck/Back
Pelvic
Head/Face
Multisystem
Auto-Pedestrian
Ejection
Other: ______________________________________
ALLERGIES:
MEDICATIONS:
PAST MEDICAL HX:
Time
BP
Eyes Open→
Pulse
Resp
Spontaneous 4
AVPU
Pupils
To Voice 3
Lungs
To Pain 2
Drug/Tx
None 1
Dose
Route
Glasgow Score =
_________
Verbal→
Orient 5
Confused 4
Inappropriate 3
Garbled 2
None
1
Motor→
Obey Com. 6
Pain/Local 5
Pain/Withdraw 4
Pain/Flexion 3
None 1
Palm Beach State College – Paramedic Program
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Student Clinical Book
Pain/Ext 2
BLS AIRWAY
NC
BVM
@ ______L/Min
ALS AIRWAY
___
NRB
Surgical
Nasal ET
Pulse Ox on room air ⇒ ________
IV / IO Attempts X:
_____
ELECTRICAL
THERAPY
Y
OBS.
Site: ________
PERF.
MANUAL DEFIBRILLATION
Oral airway
Oral ET Attempts X: ____
% After O2 ⇒ ________
Success:
N
ENERGY
LEVELS
Nasal airway
Success Y N ET size:
% Glucometer ⇒ __________
Gauge: ______
Solution: ______
EKG INTERPRETATION
OBS PERF
Rhythm 1:
SYNCHRONIZED
CARDIOVERSION
TRANSCUTANEOUS
PACING
Rhythm 2:
Rhythm 3:
PHTLS CARE
BLS CARE
OBS
PERF
OBS PERF
PATIENT INTERVIEW
WITNESSED ARREST
VITAL SIGNS
SUCTION
02 ADMINISTRATION
CHEST COMPRESSIONS
BANDAGING
VENTILATIONS
TRACTION SPLINT
BLS airway adjunct
C-SPINE
AIRWAY ADJUNCT TYPE:
IMMOBILIZATION
ALS CARE – OTHER
LONG BACKBOARD
DESCRIBE
LONG BONE
# PERFORMED
IMOBILIZATION
STUDENT PHYSICALLY
INVOLVED IN LIFTING
PATIENT
YES
NO
CHEST DECOMPRESSION
CRICOTHYROIDOTOMY
12 LEAD ECG
PULSE OXIMETRY
BLOOD GLUCOSE
Palm Beach State College – Paramedic Program
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Student Clinical Book
Obs Per
SOAP NARRATIVE
Subjective:_____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Objective:______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Assessment:____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Procedures/Response to
Procedures:_____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Palm Beach State College – Paramedic Program
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Student Clinical Book
SKILLS SIGN OFF
Name:
Date:
Instructor:
Clinical Location:
Patient Age:
Patient Gender:
Skill Performed
Successful:
Initials:
Student Signature:
Date:
Instructor Signature:
Date:
Palm Beach State College – Paramedic Program
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Student Clinical Book
STUDENT EQUIPMENT COMPETENCY CHECK LIST - LP
Student Name:
Station/Shift:
School / Institution:
The student will locate and show knowledge of the CPAP
Yes No
Preceptor
Date
Preceptor
Date
Preceptor
Date
Preceptor
Date
The student can identify the location of the CPAP
The student can identify the location of all accessories for equipment
The student can show and apply the proper procedure for the CPAP
The student will locate and show knowledge of the Carevent
Yes No
The student can identify the location of the CAREVENT
The student can identify the location of all accessories for equipment
The student can show and apply the proper procedure for the C AREVENT
The student will locate and show knowledge of the Suction Unit
Yes No
The student can identify the location of the Suction Unit
The student can identify the location of all accessories for equipment
The student can show and apply the proper procedure for the Suction Unit
The student will identify the location of items in the LifePack 15
Yes No
The student can identify the location of the LifePack 15
The student can identify the location of all accessories for equipment
The student can show and apply the proper procedures for the LifePack 15
Palm Beach State College – Paramedic Program
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Student Clinical Book
STUDENT EQUIPMENT COMPETENCY CHECK LIST – MED BAG
Student Name:
Station/Shift:
School / Institution:
The student will identify the location of items in the Blue Med Bag
Yes No
The student can identify the location of all Medications
The student can identify the location of all IV equipment
The student can identify the location of all Fluids
The student can identify the location of all PPE/BIO bags
Preceptor
Date
Preceptor
Date
Yes No
Preceptor
Date
Yes No
Preceptor
Date
The student will identify the location of items in the Airway Bag
Yes No
The student can identify the Airway Roll and items inside
The student can identify/ knows how to use ALS-BLS Airway equipment
The student can identify the Miscellaneous equipment in Airway bag
The student will identify the location of items in the Trauma Bag
The
The
The
The
student
student
student
student
can
can
can
can
identify
identify
identify
identify
the
the
the
the
location
location
location
location
of
of
of
of
all IV equipment
all Fluids
all PPE
BLS/ALS Trauma equipment
The student will identify the location of items in the Pedi Box
The
The
The
The
The
student
student
student
student
student
can
can
can
can
can
identify
identify
identify
identify
identify
the
the
the
the
the
location
location
location
location
location
of
of
of
of
of
all Medications
all IV equipment
all Fluids
all PPE/BIO bags
BLS/ALS equipment
Palm Beach State College – Paramedic Program
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Student Clinical Book
STUDENT EQUIPMENT COMPETENCY CHECK LIST - STRETCHER
Student Name:
Station/Shift:
School / Institution:
The student will display knowledge & demonstrate how to operate the stair chair
The
The
The
The
The
student
student
student
student
student
can identify the location of all handles
can identify the location of all levers
can identify the location of all straps
can demonstrate how to fold and unfold chair
will demonstrate correct way to move patient
Yes No
Preceptor
Date
The student will display knowledge & demonstrate the operation of the either PBCFR stretchers
The
The
The
The
student
student
student
student
can identify the location of all handles
can identify the location of all levers
can identify the location of all straps
will demonstrate raising and lowering feet/head
Yes No
Preceptor
Date
The student will identify the location and use of the Pedi, Miller, BackBoards & Scoop stretcher
The
The
The
The
The
student
student
student
student
student
can
can
can
can
can
identify the location of all Boards
identify the location of extra straps
identify the location of the decon spray
demonstrate how to correctly use straps
correctly use above equipment
Palm Beach State College – Paramedic Program
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Yes No
Preceptor
Date
Student Clinical Book
Skills Performed Worksheet
STUDENT NAME: ____________________________
DATE: ______________________
INSTRUCTOR: _______________________________
CLINICAL LOCATION: ______________________
PATIENT
AGE
PATIENT
GENDER
SKILL
PERFORMED
SUCCESSFUL
INITIALS
PRINT NAME: _______________________________________________________
STUDENT SIGNATURE: ______________________________________________
DATE: ____________
PRINT NAME: _______________________________________________________
INSTRUCTOR SIGNATURE: ___________________________________________
Palm Beach State College – Paramedic Program
18
DATE: ____________
Student Clinical Book