Team Leader Evaluation Form - FISDAP



IHCC Optional Run Evaluation Form

Student: ______________________ Preceptor: ________________________ Date: _______________

|#Run |Patient: (LOC, Age, Gender, onset, Field Impression, Event/Circumstances) |□ ALS □ BLS |

| | |FISDAP ID# |

| |Differential Dx: | |

Students: Complete this form Preceptors: Review and discuss ratings. Sign only if you agree to this evaluation’s accuracy and fairness. If there is a difference in opinion, please discuss it. This difference must be reconciled or each party should complete their own form. Complete this box before you respond to THIS call:

Before this call: List one of the numbered items on this form that you have previously had difficulty with or simply would like to improve during this lead attempt:

Post-Run Self Evaluation:

|Task: 4 = Strongly Agree; 3 = Agree; 2 = Disagree; 1 = Strongly Disagree; 0|4 |

|= Not Attempted but could have been possible lead. NA = Not applicable or not| |

|permitted by preceptor or situation | |

|A. | |

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|B. | |

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List any information that you need to research before treating another similar patient or another patient in general.

Additional Comments from Preceptor or Instructor Reviewing the form. (use additional sheets if necessary):

□ Accepts feedback

□ A Patient Evaluation was completed on this call

We both agree that this evaluation is accurate and fair (use separate evaluation if you disagree)

Preceptor Signature: Student Signature:

Patient Contact Narrative

(Write narrative before leaving clinical site, check spelling/meds)

Subjective - History of Present Illness/Injury (Hx) – Begin with intro statement (25%)

Past Medical Hx (5%):

Medications (5%) (list what they are used for):

Allergies (5%):

Objective – Head to toe Physical Exam – Objective (30%)

HEENT:

CHEST: LS:

ABD/PELVIS:

EXTREM:

Vitals: Time: ______ BP ____/____ P _____ R _______ SpO2 _______%

Vitals: Time: ______ BP ____/____ P _____ R _______ SpO2 _______%

Assessment - List Rule Out (R/O:) or Possible/Differential Dx (Example: ?CVA, ?TIA) (10%)

Plan ABC’s, Hx, Vs. and PE; listing of all procedures and treatments, List changes. (20%)

| | |Critical Criteria |

| |( | More than 3 Grammatical Errors |

| |( | More than 5 Spelling Mistakes |

| |( | PE Not in the right format or Illegible |

| |( | Run report not in pen in black/blue ink |

| |( | Run report not completed during the shift |

| |( | Please visit the writing center for tutoring on the problem areas above. |

| | |Document Writing Center Name of tutor or instructor that assisted you: ______________________ |

| | |Total % points________; Letter Grade _____ ; ( Excellent (; ( Good (; |

Patient Feedback

Student Name: Date: ID#

Check one: I was the □ Patient □ Family Member

Thank you for your assistance is providing feedback to the Paramedic Intern who just took care of you.

Please take a moment to complete this form and return it to the paramedic preceptor, nurse, or simply mail it back. The address and postage are already provided on the card. Thank you.

5 = Strongly Agree; 4 = Agree; 3 = Disagree; 2 = Strongly Disagree; 1 = Not attempted

|Interest in Patient as a Person; The paramedic student: |5 |4 |3 |2 |1 | |1 |Attended to my physical comfort during interview, exam and treatment | | | | | | |2 |Communicated caring, including learning my name, and addressing me with respect | | | | | | |3 |Listened carefully | | | | | | |4 |Made me feel like I could tell him/her anything, even something personal | | | | | | |5 |Created a positive rapport including identifying him/herself, and making eye contact | | | | | | | |Participation in Care; The paramedic student: | | | | | | |6 |Asked me if I had any questions | | | | | | |7 |Clearly explained things (both assessments and treatments) in a language I could understand | | | | | | |8 |When possible encouraged me to make decisions about my treatment (including hospital destination, etc..) | | | | | | | |History, Physical and Treatment; The paramedic student: | | | | | | |9 |Warned me about what he/she was going to examine next | | | | | | |10 |Performed a respectful physical exam | | | | | | |11 |Seemed to know appropriate treatment(s) | | | | | | |12 |Overall, successfully led the EMS team to take good care of me | | | | | | |

Additional Comments

Adapted from Rochester Communication Rating Scale 2002; Epstein RM; Comprehensive Assessment of Professional Competence: The Rochester Experiment; Teaching and Learning in Medicine; April 1, 2004, V16, N2, P186-196

Definitions:

• Successful Team Lead: The student has team led if he or she has conducted (not necessary performed the entire interview or physical exam, but rather been in charge-of) a comprehensive assessment, 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 disposition and packaging and moving the patient. Minimal to no prompting was needed by the preceptor. No action was initiated, performed or withheld that endangered the physical or psychological safety of the patient, bystanders, first responders or crew.

• BLS Encounter: Patient care does not require advanced assessment techniques or invasive interventions

• Professional Behaviors:

- Self motivated: Behavior includes taking initiative to complete assignments, improve/correct problems. Strive for excellence.

- Efficient: Keeps scene times to a minimum, releases first responders when not needed, organizes team to work faster/better.

- Flexible: Makes adjustments to communication style, or direction of team; Changes field impression based on findings;

- Careful: Pays attention to details of skills, documentation, patient comfort, set-up and clean up; Completes tasks thoroughly.

- Communicates well with patient: Listens actively, makes eye contact, clarifies complaint, respectfully addresses patients. Demonstrates compassionate and/or firm “bedside” manner depending on the needs of the situation.

- Confident: Makes decisions, Trusts and exercises good personal judgment, is aware of limitations and strengths;

- Accepts feedback: Listens to mentor and accepts constructive feedback. Adjusts behavior/performance based on feedback.

• ALS Encounter: Any call where an

a) IV has been attempted AND an EKG has been monitored, OR

b) A medication other than oxygen has been administered OR

c) Advanced judgment/assessment (as determined by the preceptor) has been performed.

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