Paramedic Student Field Internship Team Lead Evaluation
Thank you for being a preceptor for a CMH EMS paramedic field internship student. Please conduct an evaluation after each ALS patient encounter. In order for the student to get credit for this call, an evaluation must be completed.
Please rate the student according to the statements below. WHILE SCORING, PLEASE KEEP IN MIND THE STUDENT'S WORST PERFORMANCE, not the average or best performance. Score only the outcome, not the attempt.
* Required
This form is to be completed on all ALS patient encounters.
ALS patient definition: An ALS Patient is one that required and was provided at least one medication or at least one ALS intervention. In order for an interfacility transfer to be an ALS Team Lead patient, the patient must be transferred to a higher level of care requiring ALS assessment and treatment(s). For example, an intubated patient with multiple drips running that were all started in the ER of a smaller hospital being transferred to a trauma center would NOT be an ALS Team Lead if the student is just maintaining interventions. However, if during a transfer, the patient's condition deteriorates to where the student needs to assess, formulate a treatment plan, and provide care, this WOULD be an ALS Team Lead.
Preceptor's name:
*
Choose
Aldridge, Owen
Alharbi, Abdulaziz
Amorose, Mark
Aumiller, Matthew
Baker, Austin
Barnett , Bill
Barrett, Brandon
Bayer, Jim
Beasley, Jeffrey
Becker, Theron
Bernier, David
Berscheid, Robby
Boaz, Rick
Buckner, Allen
Burton, Nathan
Cannon, Wayne
Cardwell, Aaron
Carfield, Robert
Carnes, Victoria
Choate, Benjamin
Claxton, Jared
Coats, James
Collins, Sean
Cook, Candace
Cook, Logan
Cramer, Travis
Cummings, Jim
Davis, Jack
Davis, Kevin
Dempsey, Olivia
DeWitt, Claire
Dickover, Amanda
Divine, Lloyd
Doherty, James
Dole, Kelly
Downs, Bill
Dungan, Joel
Estes, Jessica
Evans, Jonathan
Evans, Lora
Faxon, Kyler
Ferguson, Tyler
Fisher, Robin
Flynn, Brice
Foster, Brandon
Frost, Ambyr
Gilfedder, Paul
Gohl, Rebecca
Gonder, Jason
Greer, Bradley
Gregory, Sue
Griffin, Richard
Guynn, Dan
Hammer, Florian
Harrison, Brad
Hawkins, Renee
Higgins, Scott
Hill, Travis
Hilton, Jason
Holden, Nathan
Holstein, Zach
Hughes , Mike
Jackson, Josh
Jenkins, David
Johnson, Aubrey
Jones, Comorgan
Keller, Steven
Kenall, Brandon
Keys, Kerry
Kluhsman, Raymond
Knierim, Jacob
Kroger, Scott
Lawler, Richard
Lewis, Tariq
Liberty, Tom
Long, Joseph
Luck, Frank
Lunsford, David
Malen, Chase
Matchett, Tyler
McCaslin, Andy
McDonald, Ryan
McKinnon, Matt
Meadows, Kyle
Merritt, Jesse
Mesey, Austin
Meuschke, Robert
Moore, Greg
Morton, Sarah
Murphy, Rebecca
Muse, Stephanie
Naugle, Bruce
OConnor, Brian
Ohrenberg, Matthew
Penick, Robyn
Perkins, Nic
Phillippe, Robert
Price, Jeremy
Privett, Adam
Pulley, Donal
Rice, Wes
Roberts, Alice
Robinson, Eric
Rogers, Nathan
Rossiter, Jim
Rugen, Jeremy
Rupert, Joel
Ryan, Thomas
Sampson, Solonia
Sanchez, Karol
Scanlin, Russ
Schoester, Kristen
Schrader, Earl
Schulz, Kenny
Semans, Daryl
Semans, Kellee
Shoemaker, Sarah
Single, Joshua
Smith, Molly
Spooner, Trey
Staab, Bert
Stockstill, Colby
Storer, Luke
Swickard, Brent
Swihart, Fred
Test, Robert
Tracy, Michael
Trimble, Grant
Triplett, Sally
Tudor, Johnathan
Ulm, Steven
VanBecelaere, Adam
Walker, Luke
Weaver, Aaron
Whalen, Arnet
Wilson, Adam
Wood, Megan
Woodall, Sam
Young, Morgan
Student's name:
*
Choose
Carroll, James
Colston, Anna
Columbus, Edward
Cone, Kristin
Cordon, LaTara
Cutler, Chloe
Daily, Jerry
Gore, Zane
Grant, Kelsey
Hackbart, Matthew
Holman, Kayla
Jones, Brandi
Lingbeck, Monica
McCormick, Lacey
Sebastian, Krystin
Sukovaty, Megan
Taylor, Blake
Thomas, Logan
Yielding, Wesley
Clinical shift start date:
*
MM
/
DD
/
YYYY
Patient age (years):
*
Your answer
Patient gender:
*
Female
Male
Definitions of patient contact classifications used in the next question:
Pediatric Patient: Pediatric patients are defined as less than 18 years old and must meet the requirements of ALS Team Lead above.
Unconscious Patient: Unconscious patients are defined as GCS less than eight, severely altered level of consciousness, or other criteria deemed appropriate by the preceptor and must meet the requirements of the ALS Team Lead above. The patient should be unconscious at the time of assessment or during treatment.
With Mentor: Each student selects a mentor and is approved by the mentor and the lead instructor. The first several and last several ALS Team Lead Patients should be with this assigned mentor.
Critical Patient: Critical patients are defined as requiring at least one of the following interventions and that intervention should be performed by the paramedic student.
- Administration of Adenosine, TXA, any vasopressor, or any medication requiring medical control,
- Advanced or supraglottic airway insertion or Rapid Sequence Intubation,
- Assistance of ventilation,
- Chest decompression,
- Childbirth,
- CPR,
- Cricothyrotomy,
- Electrical Therapy,
- Gastric tube,
- Restraints,
- Traction splint,
- Time Cricital Diagnosis (STEMI, Stroke, Trauma, or Sepsis),
- Tourniquet,
- Vagal maneuver,
- IO access
Which classifications does this patient contact fit into (you may select more than one)?
*
Critical Patient
Pediatric Patient
Unconscious Patient
With Mentor
None of the above
Required
The student's actions were correct and timely according to patient condition and protocols.
*
Strongly disagree
1
2
3
4
5
Strongly agree
The patient appeared informed and comfortable with the student's care.
*
Strongly disagree
1
2
3
4
5
Strongly agree
As preceptor, I was informed and comfortable with the student's care.
*
Strongly disagree
1
2
3
4
5
Strongly agree
What went well during this call?
*
Your answer
What ONE thing should the student work on to improve on the next call?
*
Your answer
Definition of successful team lead:
The student has successfully led the team if he or she has conducted a comprehensive assessment (not necessarily performed the entire interview or physical exam, but rather been in charge of the assessment), as well as formulated and implemented a treatment plan for the patient. This means that most (if not all) of the decisions have been made by the student., especially formulating a field impression, directing the treatment, determining patient acuity, disposition and packaging/moving the patient (if applicable). Minimal to no prompting was needed by the preceptor. No action was initiated or performed that endangered the physical or psychological safety of the patient(s), bystanders, other responders, or crew.
If the above was met, mark "Yes" below. If not, or if you had to take over for patient care, team safety, or other reason, mark "No" below.
Was the student successful in leading this patient encounter?
*
Yes
No
For more information or comments, please feel free to contact the CMH EMS Education Director.
Theron Becker (
theron.becker@citizensmemorial.com
) 417-597-6488
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