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.
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: *
Student's name: *
Clinical shift start date: *
Patient age (years): *
Patient gender: *
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)? *
The student's actions were correct and timely according to patient condition and protocols. *
Strongly disagree
Strongly agree
The patient appeared informed and comfortable with the student's care. *
Strongly disagree
Strongly agree
As preceptor, I was informed and comfortable with the student's care. *
Strongly disagree
Strongly agree
What went well during this call? *
What ONE thing should the student work on to improve on the next call? *
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? *
For more information or comments, please feel free to contact the CMH EMS Education Director.
Theron Becker ( 417-597-6488
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