SMS Inc, Preceptor Evaluation EMT Basic Student
Each clinical student must have an evaluration completed per clinical shift.
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Email
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Student Name:
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Date
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MM
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YYYY
Time in
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Time
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AM
PM
Time Out
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Time
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AM
PM
Preceptor Name and Title
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Your answer
Total Shift Hours
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Your answer
Part A Affecitve Domain/ Professional Appearance:
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4) Uniform clean and neat . Student well groomed
2) Uniform acceptabl could improve.
1) Uniform is dirty, wrinkled or has holes in it. poor judgement in jewelry & or Makeup or facial hair grooming
0) Not in uniform and or poor hygeine
Part A: Affective Domain /Preparedness : The student arrived ontime with appropriate eqiuptment.. pen, tablet of paper stethescope, eye protection,pen light,
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4) On Time, not rushed has appropriate equiptment and in uniform with badge
3) Arrives at the last minute , missing 0-1 item listed above
2) 5-10 minutes late &/or missing 1-2 items above
1) 10-15 min late & or missing 2-3 items above
0) More than 15 min late &/or no equiptment
Initiative; Student demonstate interest in EMS through actions and interactions with Preceptor
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4) Asks questions , curious, takes initiative and follows through
3) Asks questions , studies in down time, active in participation
2) Asks questions, or studies, good participation if asked, but little initiative
1) Asks few questions, minimal participatation & initiative
0) No questions asked , minimal participation when requested
Conduct: Student interacts with patients, families & EMS Staff in a respectful and empathetic manner. Demonstrates respectabilty and professional ethics
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4) Initiates therapeutic communication. Puts patients need above own self interest, Demonstates an attitude of professionalism
3) Overall conduct adeequate. Needs self - confidence and assertivness
2) Interacts with pateints & crew but lacks in empathy & or professionalism
1) Shows Little interest or ability in interacting with patients or crew
0) Violates the rights of others : can not be trusted with the property of others. Violates privacy and confidentiality . Is rude , disrespectful , uses vulgar language
NOTICE IF Student is given a 0 the preceptor is asks to report as soon as possible to SMS Education Coordinator via email Amy Herek - aherek@smca.org
Part B Psycomotor Domain/Careful Delivery of Service: Student follows plicies , procedures & Protocols. Uses appropriate safeguards in teh performance of duties.
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4) Know Skills. Organizes the task efficiently, performs accurately and without hesitation
3) Knows skills, performs correctly , but need to increase speed.
2) Knows what skill is indicated , but performs poorly witihout instrucution
1) May know what skill is indicated , but cannot perform it.
0) Does not know what skill is indicated & if prompted cannot perform it.
Part C: Cognative Domain/ Kowledge: the student can recall common terms, facts, principles and basic concepts in EMS
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4) Outstanding recall of principles and theories
3) Good recall of most facts & concepts give the current point in the course.
1) Somewhat limited recall fo facts and principles
0) Significant deficits in knowledge; e.g. cannot use basic medial terminology
Problem Solving: the student uses knowledge to solve a previously unencountered situation
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4) Identifies problems and can independently devise a plan to solve the problem
3) Identifies the problem adn takes some steps toward solving it, but needs guidance
1) Recognizes the problem, cannot solve it
0) Unable to recognize Problems.
Evaluation : the student can judge the appropriatness of actions and can defend his / her decisions.
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4) Student provides a sound and rationale for decisions and actions
2) Attempts to defend his or her decisions or actions, but does not provide a defensible argument
0) Student cannot give a rationale or explanation for actions or decisions
Please use the space below to write any additonal comments and suggestions for further development of the students potential.
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