Practical Evaluation Report

• Site conducted

  Select

• SCORING TOTALS A participant will be marked as unsuccessful for any combination of points totalling a deduction of 8 or more points. The determining factor is the effect on the overall patient outcome.

  Date

• Responder 1

• Responder 2

• Scenario Type

  Select

• Attempt #

  Select

• Scenario #

Scene Assessment

• Environment / MOI / Casualty Count / Chief Complaint / Assistance Required

  Successful

  Minor

  Major

  Critical

• PPE: Gloves / Mask / Eyewear

  Successful

  Minor

  Major

  Critical

• General Impression

  Pass

  Fail

Primary Assessment

• LOR (AVPU)

  Successful

  Minor

  Major

  Critical

• ABCs

  Successful

  Minor

  Major

  Critical

• Pulse Oximetry/Oxygen

  Successful

  Minor

  Major

  Critical

• Rapid Body Survey (Including skin)

  Successful

  Minor

  Major

  Critical

• Transport Decision

  Successful

  Minor

  Major

  Critical

• SMR/Spinal

  Successful

  Minor

  Major

  Critical

• Patient Positioning

  Successful

  Minor

  Major

  Critical

Secondary Assessment

• Signs and Symptoms

  Pass

  Fail

• Allergies

  Pass

  Fail

• Medications

  Pass

  Fail

• Past Pertinent Medical History

  Pass

  Fail

• Last Oral Intake

  Pass

  Fail

• Events Leading Up To

  Pass

  Fail

• Secondary Assessment Score

  Successful

  Minor

  Major

  Critical

Pain Assessment

• Onset

  Pass

  Fail

• Provocation

  Pass

  Fail

• Quality

  Pass

  Fail

• Region / Radiation

  Pass

  Fail

• Severity

  Pass

  Fail

• Time

  Pass

  Fail

• Pain Assessment Score

  Successful

  Minor

  Major

  Critical

Vital Signs

• GCS/LOR

  None

  First Only

  Second Reading Only

  Both

  N/A

• SpO2

  None

  First Only

  Second Reading Only

  Both

  N/A

• Pulse

  None

  First Only

  Second Reading Only

  Both

  N/A

• Respiration

  None

  First Only

  Second Reading Only

  Both

  N/A

• Blood Pressure

  None

  First Only

  Second Reading Only

  Both

  N/A

• Pupils

  None

  First Only

  Second Reading Only

  Both

  N/A

• Skin

  None

  First Only

  Second Reading Only

  Both

  N/A

• Temp

  None

  First Only

  Second Reading Only

  Both

  N/A

• BGL

  None

  First Only

  Second Reading Only

  Both

  N/A

• Vital Signs Score

  Successful

  Minor

  Major

  Critical

Head-to-Toe:

• Head/Face/Neck

  Pass

  Fail

• Chest/Abdomen/Pelvis

  Pass

  Fail

• Back

  Pass

  Fail

• Lower Extremities

  Pass

  Fail

• Upper Extremities

  Pass

  Fail

• Chest Auscultation

  Pass

  Fail

• Neurological

  Pass

  Fail

• Head-to-Toe Score

  Successful

  Minor

  Major

  Critical

Ongoing Assessment

• ABCs

  Successful

  Minor

  Major

  Critical

• Vital Signs

  Successful

  Minor

  Major

  Critical

Patient Care Report (handoff)

• Verbal Report

  Successful

  Minor

  Major

  Critical

• Written Report (submitted)

  Successful

  Minor

  Major

  Critical

Interventions Provided (Please add Intervention details)

• Oxygen

• CPR/AED

• Communication

• Care

Final Outcome (circle one):

• Result

  Pass

  Fail

• Evaluator Comments (mandatory) + A review of this evaluation with feedback has been provided to the participant. Signatures are confirmation of this process

  Successful

  Minor

  Major

  Critical

• Evaluator Name & Signature

  Sign

• Responder Names & Signature

  Sign