Ambulance Clinical Documentation
Student and clinical site Information
Clinical Site
Student Name
Student Name
Clinical Site
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
hours today
PATIENT #1 AGE
PATIENT #1 SEX
Please Select
MALE
FEMALE
CHIEF COMPLAINT
PRIORITY
Please Select
CRITICAL
NON-CRITICAL/STABLE
BRIEF DESCRIPTION OF TREATMENT AND DISPOSITION OF PATIENT #1
PATIENT #2 AGE
SEX
Please Select
MALE
FEMALE
CHIEF COMPLAINT
PRIORITY
Please Select
CRITICAL
NON-CRITICAL/STABLE
BRIEF DESCRIPTION OF TREATMENT AND DISPOSITION OF PATIENT
PATIENT #3 AGE
SEX
Please Select
MALE
FEMALE
CHIEF COMPLAINT
PRIORITY
Please Select
CRITICAL
NON-CRITICAL/STABLE
BRIEF DESCRIPTION OF TREATMENT AND DISPOSITION OF PATIENT
PATIENT #4 AGE
SEX
Please Select
MALE
FEMALE
CHIEF COMPLAINT
PRIORITY
Please Select
CRITICAL
NON-CRITICAL/STABLE
BRIEF DESCRIPTION OF TREATMENT AND DISPOSITION OF PATIENT
PATIENT #5 AGE
SEX
Please Select
MALE
FEMALE
CHIEF COMPLAINT
PRIORITY
Please Select
CRITICAL
NON-CRITICAL/STABLE
BRIEF DESCRIPTION OF TREATMENT AND DISPOSITION OF PATIENT
PATIENT #6 AGE
SEX
Please Select
MALE
FEMALE
CHIEF COMPLAINT
PRIORITY
Please Select
CRITICAL
NON-CRITICAL/STABLE
BRIEF DESCRIPTION OF TREATMENT AND DISPOSITION OF PATIENT
PATIENT #7 AGE
SEX
Please Select
MALE
FEMALE
CHIEF COMPLAINT
PRIORITY
Please Select
CRITICAL
NON-CRITICAL/STABLE
BRIEF DESCRIPTION OF TREATMENT AND DISPOSITION OF PATIENT
PATIENT #8 AGE
SEX
Please Select
MALE
FEMALE
CHIEF COMPLAINT
PRIORITY
Please Select
CRITICAL
NON-CRITICAL/STABLE
BRIEF DESCRIPTION OF TREATMENT AND DISPOSITION OF PATIENT
Student comments regarding the clinical experience and lessons learned
PRECEPTOR EVALUATION- STUDENT SHOWED UP ON TIME AND SEEMED READY TO WORK/LEARN
Please Select
1- DISAGREE WITH STATEMENT
2- AGREE WITH STATEMENT
3- STUDENT EXCEEDS EXPECTATIONS
PRECEPTOR EVALUATION - DRESSED AND ACTS PROFESSIONALLY
Please Select
1- DISAGREE WITH STATEMENT
2- AGREE WITH STATEMENT
3- STUDENT EXCEEDS EXPECTATIONS
PRECEPTOR EVALUATION - MOTIVATED TO STUDY AND/OR ASKS QUESTIONS
Please Select
1- DISAGREE WITH STATEMENT
2- AGREE WITH STATEMENT
3- STUDENT EXCEEDS EXPECTATIONS
PRECEPTOR EVALUATION - SEEKS OUT PATIENT CONTACT/ STUDIES BETWEEN CALLS
Please Select
1- DISAGREE WITH STATEMENT
2- AGREE WITH STATEMENT
3- STUDENT EXCEEDS EXPECTATIONS
PRECEPTOR EVALUATION - ABLE TO INITIATE PATIENT CONTACT (FIRST TO TALK TO THE PATIENT)
Please Select
1- DISAGREE WITH STATEMENT
2- AGREE WITH STATEMENT
3- STUDENT EXCEEDS EXPECTATIONS
PRECEPTOR EVALUATION - ABLE TO FORM AN ACTION PLAN OR TREATMENT PLAN FOR PATIENTS
Please Select
1- DISAGREE WITH STATEMENT
2- AGREE WITH STATEMENT
3- STUDENT EXCEEDS EXPECTATIONS
PRECEPTOR EVALUATION - REMAINED INVOLVED DURING PATIENT CARE INTERACTIONS
Please Select
1- DISAGREE WITH STATEMENT
2- AGREE WITH STATEMENT
3- STUDENT EXCEEDS EXPECTATIONS
PRECEPTOR EVALUATION - SEEMS CONFIDENT WITH SKILLS THAT HAVE BEEN LEARNED IN CLASS
Please Select
1- DISAGREE WITH STATEMENT
2- AGREE WITH STATEMENT
3- STUDENT EXCEEDS EXPECTATIONS
PRECEPTOR EVALUATION - PRECEPTOR TRUSTS THE TO START IVS
Please Select
1- DISAGREE WITH STATEMENT
2- AGREE WITH STATEMENT
3- STUDENT EXCEEDS EXPECTATIONS
NOT APPLICABLE
PRECEPTOR EVALUATION - PRECEPTOR TRUSTS THE STUDENT TO INTUBATE
Please Select
1- DISAGREE WITH STATEMENT
2- AGREE WITH STATEMENT
3- STUDENT EXCEEDS EXPECTATIONS
NOT APPLICABLE
Preceptor comments
Preceptor Name
Preceptor Signature
Preview PDF
Save
Submit
Should be Empty: