Advanced EMT Daily Clinical Experience Report
Student Name
*
Course ID
*
Example: A2024-D6
Email
*
Preceptor Name
*
Clinical Date
*
-
Month
-
Day
Year
Date
Clinical Location
*
Please Select
Amerimed Columbus
Amerimed Macon
Ameripro Lamar County
Ameripro Upson County
AMR Medic 1
AMR Medic 2
AMR Medic 3
AMR Medic 4
AMR Medic 5
CARE - Phenix City
CFEMS Medic 1
CFEMS Medic 5
CFEMS Medic 8
CFEMS Medic 9
CFEMS Medic 10
CFEMS Medic 11
CFEMS Medic 12
Community Medic 2
Community Medic 3
Community Medic 7
Community Macon Bibb County
Macon County Medic 1
Macon County Medic 2
Meriwether County Medic 1
Meriwether County Medic 12
Montgomery MGM 1
Montgomery MGM 2
Montgomery MGM 3
Montgomery MGM 4
Montgomery MGM 5
Montgomery MGM 6
Montgomery MGM 7
Montgomery MGM 8
Montgomery MGM 9
Montgomery MGM 10
Start Time / End Time
*
Hour Minutes
Until
until
Hour Minutes
Total 0.0
Clinical/Field Hours Category
*
Please Select
Field: Ambulance
Field: MFR
Clinical (In an approved facility)
Capstone Field Internship
A minimum of 96 hours total, including 48 hours on the Ambulance and 24 hours for the Capstone Field Internship. Capstone may only be started after all other clinical minimums have been met.
Patient Number 1 For This Clinical Date
Run Number
A minimum of 20 GEMSIS Elite ePCRs must be completed.
Age Category
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
A minimum of 30 patient contacts must be achieved, including 5 Pediatrics, 10 Adults, and 5 Geriatrics.
Patient DOB
Age
Patient Complaint Type (Choose all that apply)
Cardiac Arrest
Cardiac - Minimum of 4
Distressed Neonate
Neuro - Minimum of 4
OB
Medical - Minimum of 2
Psychiatric - Minimum of 2
Respiratory - Minimum of 4
Trauma - Minimum of 4
Skills Completed On This Patient (Choose all that apply)
None of these
Defibrillation
BVM
Chest Compressions
Endotracheal Suctioning
Medication IM
Medication Intranasal
Medication IO
Medication IV Bolus
Medication PO/SL/TD
Establishing IV Access
Establishing IO Access
Inserting Supraglottic Airway
Drawing Labs
Waveform Capnography
IV Attempts - Minimum of 10 Successful
IO Attempts
Medication Administration - Minimum of 1 / Not Oxygen or Crystalloid Solution / Must Be In AEMT Scope of Practice
Comments
Patient Number 2 For This Clinical Date
Run Number
Age Catagory
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
Patient DOB
Age
Patient Complaint Type (Choose all that apply)
Cardiac Arrest
Cardiac
Distressed Neonate
Neuro
OB
Medical
Psychiatric
Respiratory
Trauma
Skills Completed On This Patient (Choose all that apply)
None of these
Defibrillation
BVM
Chest Compressions
Endotracheal Suctioning
Medication IM
Medication Intranasal
Medication IO
Medication IV Bolus
Medication PO/SL/TD
Establishing IV Access
Establishing IO Access
Inserting Supraglottic Airway
Drawing Labs
Waveform Capnography
IV Attempts
IO Attempts
Medication Administration
Comments
Patient Number 3 For This Clinical Date
Run Number
Age Catagory
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
Patient DOB
Age
Patient Complaint Type (Choose all that apply)
Cardiac Arrest
Cardiac
Distressed Neonate
Neuro
OB
Medical
Psychiatric
Respiratory
Trauma
Skills Completed On This Patient (Choose all that apply)
None of these
Defibrillation
BVM
Chest Compressions
Endotracheal Suctioning
Medication IM
Medication Intranasal
Medication IO
Medication IV Bolus
Medication PO/SL/TD
Establishing IV Access
Establishing IO Access
Inserting Supraglottic Airway
Drawing Labs
Waveform Capnography
IV Attempts
IO Attempts
Medication Administration
Comments
Patient Number 4 For This Clinical Date
Run Number
Age Catagory
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
Patient DOB
Age
Patient Complaint Type (Choose all that apply)
Cardiac Arrest
Cardiac
Distressed Neonate
Neuro
OB
Medical
Psychiatric
Respiratory
Trauma
Skills Completed On This Patient (Choose all that apply)
None of these
Defibrillation
BVM
Chest Compressions
Endotracheal Suctioning
Medication IM
Medication Intranasal
Medication IO
Medication IV Bolus
Medication PO/SL/TD
Establishing IV Access
Establishing IO Access
Inserting Supraglottic Airway
Drawing Labs
Waveform Capnography
IV Attempts
IO Attempts
Medication Administration
Comments
Patient Number 5 For This Clinical Date
Run Number
Age Catagory
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
Patient DOB
Age
Patient Complaint Type (Choose all that apply)
Cardiac Arrest
Cardiac
Distressed Neonate
Neuro
OB
Medical
Psychiatric
Respiratory
Trauma
Skills Completed On This Patient (Choose all that apply)
None of these
Defibrillation
BVM
Chest Compressions
Endotracheal Suctioning
Medication IM
Medication Intranasal
Medication IO
Medication IV Bolus
Medication PO/SL/TD
Establishing IV Access
Establishing IO Access
Inserting Supraglottic Airway
Drawing Labs
Waveform Capnography
IV Attempts
IO Attempts
Medication Administration
Comments
Patient Number 6 For This Clinical Date
Run Number
Age Catagory
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
Patient DOB
Age
Patient Complaint Type (Choose all that apply)
Cardiac Arrest
Cardiac
Distressed Neonate
Neuro
OB
Medical
Psychiatric
Respiratory
Trauma
Skills Completed On This Patient (Choose all that apply)
None of these
Defibrillation
BVM
Chest Compressions
Endotracheal Suctioning
Medication IM
Medication Intranasal
Medication IO
Medication IV Bolus
Medication PO/SL/TD
Establishing IV Access
Establishing IO Access
Inserting Supraglottic Airway
Drawing Labs
Waveform Capnography
IV Attempts
IO Attempts
Medication Administration
Comments
Patient Number 7 For This Clinical Date
Run Number
Age Catagory
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
Patient DOB
Age
Patient Complaint Type (Choose all that apply)
Cardiac Arrest
Cardiac
Distressed Neonate
Neuro
OB
Medical
Psychiatric
Respiratory
Trauma
Skills Completed On This Patient (Choose all that apply)
None of these
Defibrillation
BVM
Chest Compressions
Endotracheal Suctioning
Medication IM
Medication Intranasal
Medication IO
Medication IV Bolus
Medication PO/SL/TD
Establishing IV Access
Establishing IO Access
Inserting Supraglottic Airway
Drawing Labs
Waveform Capnography
IV Attempts
IO Attempts
Medication Administration
Comments
Patient Number 8 For This Clinical Date
Run Number
Age Catagory
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
Patient DOB
Age
Patient Complaint Type (Choose all that apply)
Cardiac Arrest
Cardiac
Distressed Neonate
Neuro
OB
Medical
Psychiatric
Respiratory
Trauma
Skills Completed On This Patient (Choose all that apply)
None of these
Defibrillation
BVM
Chest Compressions
Endotracheal Suctioning
Medication IM
Medication Intranasal
Medication IO
Medication IV Bolus
Medication PO/SL/TD
Establishing IV Access
Establishing IO Access
Inserting Supraglottic Airway
Drawing Labs
Waveform Capnography
IV Attempts
IO Attempts
Medication Administration
Comments
Patient Number 9 For This Clinical Date
Run Number
Age Catagory
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
Patient DOB
Age
Patient Complaint Type (Choose all that apply)
Cardiac Arrest
Cardiac
Distressed Neonate
Neuro
OB
Medical
Psychiatric
Respiratory
Trauma
Skills Completed On This Patient (Choose all that apply)
None of these
Defibrillation
BVM
Chest Compressions
Endotracheal Suctioning
Medication IM
Medication Intranasal
Medication IO
Medication IV Bolus
Medication PO/SL/TD
Establishing IV Access
Establishing IO Access
Inserting Supraglottic Airway
Drawing Labs
Waveform Capnography
IV Attempts
IO Attempts
Medication Administration
Comments
Patient Number 10 For This Clinical Date
Run Number
Age Catagory
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
Patient DOB
Age
Patient Complaint Type (Choose all that apply)
Cardiac Arrest
Cardiac
Distressed Neonate
Neuro
OB
Medical
Psychiatric
Respiratory
Trauma
Skills Completed On This Patient (Choose all that apply)
None of these
Defibrillation
BVM
Chest Compressions
Endotracheal Suctioning
Medication IM
Medication Intranasal
Medication IO
Medication IV Bolus
Medication PO/SL/TD
Establishing IV Access
Establishing IO Access
Inserting Supraglottic Airway
Drawing Labs
Waveform Capnography
IV Attempts
IO Attempts
Medication Administration
Comments
Student and Preceptor Signatures
Student's Signature (By signing below, I agree the information entered above is true and factual to the best of my knowledge.)
*
Preceptor's Signature (By signing below, I agree the information entered above is true and factual to the best of my knowledge.)
*
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