Raven EMS Education Program ManualClinical Student Field Internship Team Lead Evaluation Form
During Field Internship, each shift needs a Team Lead Evaluation for every patient contact (this form) AND a Shift Evaluation.
Thank you for being a preceptor for a Raven ALS 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 requires and was provided at least one medication or at least one ALS intervention. Routine cardiac monitoring nor IV access without medication administration are typically NOT considered ALS interventions
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.
Student Name:
Preceptor Name:
Shift’s start date and time:
Patient's Demographics
Male
Female
Other Gender
Patient’s approximate age in years:
Overall
Yes
No
Was this patient in CRITICAL condition?
Critical Conditions are defined as patients requiring at least one of the following interventions and that intervention should be performed by the 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 Critical Diagnosis (STEMI, Stroke, Trauma, or Sepsis), Tourniquet, Vagal maneuver, or IO access.
Was the student SUCCESSFUL in leading this patient encounter?
If you had to take over for patient care, team safety, or other reasons, do NOT mark this as successful. 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 overseen 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.
Evaluation
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
The student provided a good first impression.
The student acted safely and appropriately.
The student interacted well with staff and patients.
The student has applicable knowledge for current level.
The student’s actions were correct and timely according to patient condition and protocols.
The patient appeared informed and comfortable with the student’s care.
As preceptor, I was informed and comfortable with the student’s care.
What went WELL during this call?
What ONE thing should the student work on to improve on the next call?
If you have confidential comments, concerns, or questions, please contact the Deputy Director of EMS:
