Emergency Medical Technician Daily Clinical Experience Report
Student Name
*
Course ID
*
Example: E2024-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 1
CARE Phenix City 2
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)
A minimum of 48 hours total, including a minimum of 24 hours on the Ambulance. Up to 24 hours may be performed on a MFR/Clinical Site.
Patient Number 1 For This Clinical Date
Run Number
A minimum of 10 GEMSIS Elite ePCRs must be completed.
Age Category
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
A minimum of 20 patient contacts must be achieved, including 2 Pediatrics, 5 Adults, and 5 Geriatrics.
Patient DOB
Please use the patient's real date of birth.
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
Vital Signs - Minimum of 20
Transported Patient - Minimum of 10
Defibrillation
BVM
Chest Compressions
Suctioning
Medication Intranasal
Medication PO/SL
Inserting OPA/NPA
Other
Medication Administration
Comments
Patient Number 2 For This Clinical Date
Run Number
A minimum of 10 GEMSIS Elite ePCRs must be completed.
Age Category
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
A minimum of 20 patient contacts must be achieved, including 2 Pediatrics, 5 Adults, and 5 Geriatrics.
Patient DOB
Please use the patient's real date of birth.
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
Vital Signs - Minimum of 20
Transported Patient - Minimum of 10
Defibrillation
BVM
Chest Compressions
Suctioning
Medication Intranasal
Medication PO/SL
Inserting OPA/NPA
Other
Medication Administration
Comments
Patient Number 3 For This Clinical Date
Run Number
A minimum of 10 GEMSIS Elite ePCRs must be completed.
Age Category
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
A minimum of 20 patient contacts must be achieved, including 2 Pediatrics, 5 Adults, and 5 Geriatrics.
Patient DOB
Please use the patient's real date of birth.
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
Vital Signs - Minimum of 20
Transported Patient - Minimum of 10
Defibrillation
BVM
Chest Compressions
Suctioning
Medication Intranasal
Medication PO/SL
Inserting OPA/NPA
Other
Medication Administration
Comments
Patient Number 4 For This Clinical Date
Run Number
A minimum of 10 GEMSIS Elite ePCRs must be completed.
Age Category
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
A minimum of 20 patient contacts must be achieved, including 2 Pediatrics, 5 Adults, and 5 Geriatrics.
Patient DOB
Please use the patient's real date of birth.
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
Vital Signs - Minimum of 20
Transported Patient - Minimum of 10
Defibrillation
BVM
Chest Compressions
Suctioning
Medication Intranasal
Medication PO/SL
Inserting OPA/NPA
Other
Medication Administration
Comments
Patient Number 5 For This Clinical Date
Run Number
A minimum of 10 GEMSIS Elite ePCRs must be completed.
Age Category
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
A minimum of 20 patient contacts must be achieved, including 2 Pediatrics, 5 Adults, and 5 Geriatrics.
Patient DOB
Please use the patient's real date of birth.
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
Vital Signs - Minimum of 20
Transported Patient - Minimum of 10
Defibrillation
BVM
Chest Compressions
Suctioning
Medication Intranasal
Medication PO/SL
Inserting OPA/NPA
Other
Medication Administration
Comments
Patient Number 6 For This Clinical Date
Run Number
A minimum of 10 GEMSIS Elite ePCRs must be completed.
Age Category
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
A minimum of 20 patient contacts must be achieved, including 2 Pediatrics, 5 Adults, and 5 Geriatrics.
Patient DOB
Please use the patient's real date of birth.
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
Vital Signs - Minimum of 20
Transported Patient - Minimum of 10
Defibrillation
BVM
Chest Compressions
Suctioning
Medication Intranasal
Medication PO/SL
Inserting OPA/NPA
Other
Medication Administration
Comments
Patient Number 7 For This Clinical Date
Run Number
A minimum of 10 GEMSIS Elite ePCRs must be completed.
Age Category
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
A minimum of 20 patient contacts must be achieved, including 2 Pediatrics, 5 Adults, and 5 Geriatrics.
Patient DOB
Please use the patient's real date of birth.
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
Vital Signs - Minimum of 20
Transported Patient - Minimum of 10
Defibrillation
BVM
Chest Compressions
Suctioning
Medication Intranasal
Medication PO/SL
Inserting OPA/NPA
Other
Medication Administration
Comments
Patient Number 8 For This Clinical Date
Run Number
A minimum of 10 GEMSIS Elite ePCRs must be completed.
Age Category
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
A minimum of 20 patient contacts must be achieved, including 2 Pediatrics, 5 Adults, and 5 Geriatrics.
Patient DOB
Please use the patient's real date of birth.
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
Vital Signs - Minimum of 20
Transported Patient - Minimum of 10
Defibrillation
BVM
Chest Compressions
Suctioning
Medication Intranasal
Medication PO/SL
Inserting OPA/NPA
Other
Medication Administration
Comments
Patient Number 9 For This Clinical Date
Run Number
A minimum of 10 GEMSIS Elite ePCRs must be completed.
Age Category
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
A minimum of 20 patient contacts must be achieved, including 2 Pediatrics, 5 Adults, and 5 Geriatrics.
Patient DOB
Please use the patient's real date of birth.
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
Vital Signs - Minimum of 20
Transported Patient - Minimum of 10
Defibrillation
BVM
Chest Compressions
Suctioning
Medication Intranasal
Medication PO/SL
Inserting OPA/NPA
Other
Medication Administration
Comments
Patient Number 10 For This Clinical Date
Run Number
A minimum of 10 GEMSIS Elite ePCRs must be completed.
Age Category
Please Select
Pediatric (0-18)
Adult (19-64)
Geriatric (65+)
A minimum of 20 patient contacts must be achieved, including 2 Pediatrics, 5 Adults, and 5 Geriatrics.
Patient DOB
Please use the patient's real date of birth.
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
Vital Signs - Minimum of 20
Transported Patient - Minimum of 10
Defibrillation
BVM
Chest Compressions
Suctioning
Medication Intranasal
Medication PO/SL
Inserting OPA/NPA
Other
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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