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Washington State Department of HealthOffice of Community Health SystemsApprovedEMR, EMT & AEMT LevelPractical Evaluation Skill SheetsDOH 530-226 October 2018
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SKILL EVALUATION PROCESS WAC 246-976Practical Skill EvaluationsThe evaluation sheets are used to document the performance of required skills throughoutinitial EMS courses and for recertification under either OTEP or Traditional CME methods.Initial EMS Courses (WAC 246-976-022)Students should receive copies of evaluation sheets at the beginning of their EMS course.Evaluation sheets are used to document the performance of required skills throughout thecourse. Evaluation sheets identified as required on page 05 of this document must be testedon as part of initial training. A training program may use skill sheets identified as optional todetermine competency in a specific skill or as required by MPD local protocol.Initial EMS Course Practical Skills Evaluation Summary SheetThe Practical Skills Evaluation Summary Sheet located on page 99 is used to document thefinal results of each student’s skill evaluations. The SEI is required to document the results ofthe evaluation.DOH-approved EMS Evaluators must complete all evaluations.This document combines and replaces skill sheets from the followingdocuments: DOH 530-169 Feb 2016 Emergency Medical Responder PracticalEvaluation Skill Sheets DOH 530-170 Feb 2016 Emergency Medical Responder PracticalEvaluation Addendum Skill Sheets DOH 530-093 Jan 2013 Emergency Medical Technician PracticalEvaluation Skill Sheets DOH 530-094 Emergency Medical Technician Practical EvaluationAddendum Skill Sheets DOH 530-138 Dec 2011 EMT-Special Skill Curriculum Supraglottic Airway DOH 530-136 Dec 2011 EMT-Special Skill Curriculum intravenous TherapyBLS Skills Examination GuideInstructors and EMS Evaluators should refer to this guide for assistance in planning andperforming these skills evaluations. It is an addendum to the EMS Instructor Manual.EMS Initial and Subsequent Certification (WAC 246-976-162 and WAC 246-976-163)An EMS agency or training program may use skill sheets contained within this document todetermine competency in a specific skill. The process for initial certification and recertification isprovided on the office website at: aramedic level skills sheets- can be downloaded for use from the NREMT website foruse in initial courses, paramedic level continuing education, and OTEP.DOH 530-226 April 2019EMR, EMT & AEMT Level Practical Evaluation Skill SheetsPage 3
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PageNumbersPRACTICAL SKILLS EVALUATION SHEET REQUIREMENTSPractical equiredAEMT7BVM Ventilation of an Apneic Adult PatientXX11Oxygen Administration by Non-Rebreather MaskXX13Patient Assessment / Mgmt- Medical-EMR/EMTXX17Patient Assessment / Mgmt- Medical- AEMT21Patient Assessment / Management- TraumaXXX25Cardiac Arrest Management / AEDXXX29Bleeding Control / Shock ManagementXXX31Long Bone ImmobilizationXXX33Joint ImmobilizationXXX35Spinal Immobilization (Supine Patient)XXX37Spinal Immobilization (Seated Patient)XXX39Supraglottic Airway Device43Pediatric Respiratory CompromiseX47Pediatric Intraosseous Infusion AEMTX49Intravenous Therapy w/ IV Bolus MedicationsXOptionalAEMTXSPECIALXSkill Lab Forms to be used as teaching/learning tools53Acetaminophen AdministrationX55Activated Charcoal AdministrationX57Aspirin AdministrationX59Epinephrine Auto-Injector61Oral Glucose Administration63Naloxone (Narcan) Administration IN65Nitroglycerin Administration67Nerve-Agent Antidote Administration69IM Medication Administration from Amp/VialX71Metered Dose Inhaler AdministrationX73Blood GlucometerXX75Capnography (End Tidal CO2 Monitoring)XX77Continuous Positive Airway Pressure (CPAP)X79ECG AcquisitionX81IO Infusion w/ IV Solution BolusSPECIAL83IV Infusion w/ IV Solution BolusSPECIAL85IV Monitor/MaintenanceX87Nasopharyngeal AirwayX89Traction Splint ImmobilizationX93Comprehensive Evaluation- Major Medical ScenarioXX95Comprehensive Evaluation- Major Trauma ScenarioXX97Practical Skill Evaluation Summary SheetXXDOH 530-226 April 2019XXXXXXXEMR, EMT & AEMT Level Practical Evaluation Skill SheetsXXXXPage 5
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BVM Ventilation of an Apneic Adult PatientCandidate Name DateScenario Actual Time Started:PointsPossible*Takes or verbalizes appropriate PPE precautions1*Checks responsiveness1Requests additional EMS assistance1*Checks breathing and pulse simultaneously1PointsAwardedNOTE: After checking responsiveness, then checking breathing and pulse for no more than 10 seconds,evaluator informs candidate, “The patient is unresponsive, apneic and has a weak pulse of 60.”1Opens airway properlyNOTE: The evaluator must now inform the candidate, “The mouth is full of secretions and vomitus.”Prepares rigid suction catheter1Turns on power to suction device or retrieves manual suction device1Inserts rigid suction catheter without applying suction1*Suctions the mouth and oropharynx1NOTE: The evaluator must now inform the candidate, “The mouth and oropharynx are clear.”Opens airway manually1Inserts oropharyngeal airway1NOTE: The evaluator must now inform the candidate, “No gag reflex is present and the patient accepts theairway adjunct.”*Ventilates the patient immediately using a BVM device unattached to oxygen1(Award this point if candidate elects to ventilate initially with BVM attached to reservoirand oxygen so long as first ventilation is delivered within 30 seconds)NOTE: The evaluator must now inform the candidate that ventilation is being properly performed withoutdifficulty.Re-checks pulse for no more than 10 seconds1*Attaches the BVM assembly (mask, bag, reservoir) to oxygen (15L/minute)1*Ventilates the patient adequately-Proper volume to cause visible chest rise (1 point)-Proper rate [10-12/minute (1 ventilation every 5 – 6 seconds)] (1 point)2NOTE: The evaluator must now ask the candidate, “How would you know if you are delivering appropriatevolumes with each ventilation?”Passing score is 13 (at least 80%)Total:Actual Time Ended: Elapsed Time: Max Time Allowed: 5DOH 530-226 April 2019EMR, EMT & AEMT Level Practical Evaluation Skill Sheets16PASS / FAILPage 7
CRITICAL CRITERIA - Note: Blocks above with an * have corresponding Critical Criteria below.After suctioning the patient, failure to initiate ventilations within 30 seconds or interrupts ventilations forgreater than 30 seconds at any timeFailure to take or verbalize appropriate PPE precautionsFailure to suction airway before ventilating the patientSuctions the patient for an excessive and prolonged timeFailure to check responsiveness, then check breathing and pulse simultaneously for no more than 10secondsFailure to voice and ultimately provide high oxygen concentration (at least 85%)Failure to ventilate the patient at a rate of 10-12/minute (1 ventilation every 5 – 6 seconds)Failure to provide adequate volumes per breath (maximum 2 errors/minute permissible)Insertion or use of any adjunct in a manner dangerous to the patientFailure to manage the patient as a competent EMS providerExhibits unacceptable affect with patient or other personnelUses or orders a dangerous or inappropriate interventionYou must factually document your rationale for checking any of the above critical items on the form.Evaluator Name:PrintedDOH 530-226 April 2019SignatureEMR, EMT & AEMT Level Practical Evaluation Skill SheetsPage 8
EVALUATOR NOTESPROSCONSADDITIONAL COMMENTS:DOH 530-226 April 2019EMR, EMT & AEMT Level Practical Evaluation Skill SheetsPage 9
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Oxygen Administration by Non-Rebreather MaskCandidate Name DateScenario Actual Time Started:PointsPointsPossible Awarded*Takes or verbalizes appropriate PPE precautions1Gathers appropriate equipment1Cracks valve on the oxygen tank1*Assembles the regulator to the oxygen tank1*Opens the oxygen tank valve1Checks oxygen tank pressure1*Checks for leaks1Attaches non-rebreather mask to correct port of regulator1*Turns on oxygen flow to prefill reservoir bag1*Adjusts regulator to assure oxygen flow rate of at least 10 L/minute1*Attaches mask to patient’s face and adjusts to fit snugly1Passing score is 9 (at least 80%)Total:Actual Time Ended: Elapsed Time: Max Time Allowed: 511PASS / FAILCRITICAL CRITERIA - Note: Blocks above with an * have corresponding Critical Criteria below.Failure to take or verbalize appropriate PPE precautionsFailure to assemble the oxygen tank and regulator without leaksFailure to prefill the reservoir bagFailure to adjust the oxygen flow rate to the non-rebreather mask of at least 10 L/minuteFailure to ensure a tight mask seal to the patient’s faceFailure to manage the patient as a competent EMS providerExhibits unacceptable affect with patient or other personnelUses or orders a dangerous or inappropriate interventionYou must factually document your rationale for checking any of the above critical items on the form.Evaluator Name:PrintedDOH 530-226 April 2019SignatureEMR, EMT & AEMT Level Practical Evaluation Skill SheetsPage 11
EVALUATOR NOTESPROSCONSADDITIONAL COMMENTS:DOH 530-226 April 2019EMR, EMT & AEMT Level Practical Evaluation Skill SheetsPage 12
Patient Assessment / Management – Medical – EMR/EMTCandidate Name DateScenario Actual Time Started:PointsPossible*Takes or verbalizes appropriate PPE precautionsPointsAwarded1SCENE SIZE-UP*Determines the scene/situation is safe1Determines mechanism of injury/nature of illness1Determines the number of patients1Requests additional EMS assistance if necessary1Considers stabilization of spine1PRIMARY SURVEY / RESUSCITATIONVerbalizes general impression of the patient1Determines responsiveness/level of consciousness (AVPU)1Determines chief complaint/apparent life threats1Assesses airway and breathing*- Assessment (1 point)*- Assures adequate ventilation (1 point)*- Initiates appropriate oxygen therapy (1 point)3Assesses circulation*- Assesses/controls major bleeding (1 point) - Checks pulse (1 point)- Assesses skin (either skin color, temperature, or condition) (1 point)3*Identifies patient priority and makes treatment/transport decision1HISTORY TAKINGHistory of present illness - Signs and Symptoms-Onset (1 point)-Quality (1 point)-Severity (1 point)-Provocation (1 point) -Radiation (1 point)-Time (1 point)-Clarifying questions of associated signs and symptoms related to OPQRST (2 points)Past medical history-Allergies (1 point)-Past pertinent history (1 point) -Events leading to present-Medications (1 point) -Last oral intake (1 point)illness (1 point)SECONDARY ASSESSMENTAssesses affected body ary-Reproductive-Pulmonary-Musculoskeletal -GI/GU-Psychological/SocialVITAL SIGNS-Blood Pressure (1 point) -Pulse (1 point) -Respiratory rate and quality (1 point each)States field impression of patientInterventions (verbalizes proper interventions/treatment)REASSESSMENTDemonstrates how and when to reassess the patient to determine changes inconditionProvides accurate verbal report arriving EMS unit or receiving facilityPassing score is 34 (at least 80%)TOTAL:Actual Time Ended: Elapsed Time: Max Time Allowed: *15DOH 530-226 April 2019EMR, EMT & AEMT Level Practical Evaluation Skill Sheets8554111142PASS / FAILPage 13
CRITICAL CRITERIA - Note: Blocks above with an * have corresponding Critical Criteria below.Failure to initiate or call for transport of the patient within 15 minute time limitFailure to take or verbalize appropriate PPE precautionsFailure to determine scene safety before approaching patientFailure to voice and ultimately provide appropriate oxygen therapyFailure to assess/provide adequate ventilationFailure to find or appropriately manage problems associated with airway, breathing, hemorrhage orshockFailure to differentiate patient’s need for immediate transportation versus continued assessment ortreatment at the scenePerforms secondary examination before assessing and treating threats to airway, breathing andcirculationFailure to provide an accurate report to arriving EMS unit or receiving facilityFailure to manage the patient as a competent EMS providerExhibits unacceptable affect with patient or other personnelUses or orders a dangerous or inappropriate interventionYou must factually document your rationale for checking any of the above critical items on the form.Evaluator Name:PrintedDOH 530-226 April 2019SignatureEMR, EMT & AEMT Level Practical Evaluation Skill SheetsPage 14
EVALUATOR NOTESPROSCONSADDITIONAL COMMENTS:DOH 530-226 April 2019EMR, EMT & AEMT Level Practical Evaluation Skill SheetsPage 15
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Patient Assessment / Management – Medical - AEMTCandidate Name DateScenario Actual Time Started:PointsPossible*Takes or verbalizes appropriate PPE precautionsSCENE SIZE-UP*Determines the scene/situation is safe111111Determines mechanism of injury/nature of illnessDetermines the number of patientsRequests additional help if necessary*Considers stabilization of spinePRIMARY SURVEYVerbalizes general impression of the patientDetermines responsiveness/level of consciousness*Determines chief complaint/apparent life threatsAssesses airway and breathing*- Assessment (1 point)*- Assures adequate ventilation (1 point)*- Initiates appropriate oxygen therapy (1 point)Assesses circulation*- Assesses/controls major bleeding (1 point) - Assesses pulse (1 point)- Assesses skin (either skin color, temperature, or condition) (1 point)*Identifies priority patients/makes transport decisionHISTORY TAKING and SECONDARY ASSESSMENTHistory of present illness-Onset (1 point)-Provocation (1 point)-Quality (1 point)PointsAwarded-Radiation (1 point)-Severity (1 point)-Time (1 point)1113318-Clarifying questions of associated signs and symptoms as related to OPQRTS (2 points)Past medical history-Allergies (1 point)-Medications (1 point)-Past pertinent history (1 point)-Last oral intake (1 point)-Events leading to present illness (1 point)Performs secondary assessment(assesses affected body part/system or, if indicated, completes rapid ry-Reproductive-Pulmonary-Musculoskeletal -GI/GU-Psychological/SocialVital signs-Pulse (1 point)-Respiratory rate and quality (1 point each)-Blood Pressure (1 point))-AVPU (1 point)Diagnostics (blood glucose test, pulse oximeter, etc) as needed21111111TOTAL:Actual Time Ended: Elapsed Time: Max Time Allowed: 15*DOH 530-226 April 201955States field impression of patientVerbalizes treatment plan for patient and calls for appropriate intervention(s)Transport decision re-evaluatedREASSESSMENTRepeats primary surveyRepeats vital signsEvaluates response to treatmentsRepeats secondary assessment regarding patient complaints or injuriesPassing score is 39 (at least 80%)5EMR, EMT & AEMT Level Practical Evaluation Skill Sheets48PASS / FAILPage 17
CRITICAL CRITERIA - Note: Blocks above with an * have corresponding Critical Criteria below.Failure to initiate or call for transport of the patient within 15 minute time limitFailure to take or verbalize appropriate PPE precautionsFailure to determine scene safety before approaching patientFailure to provide for spinal protection when indicatedFailure to voice and ultimately provide appropriate oxygen therapyFailure to assess/provide adequate ventilationFailure to find or appropriately manage problems associated with airway, breathing, hemorrhage orshock (hypoperfusion)Failure to differentiate patient’s need for immediate transportation versus continued assessment andtreatment at the sceneDoes other detailed history or physical examination before assessing and treating threats to airway,breathing, and circulationFailure to determine the patient’s primary problemOrders a dangerous or inappropriate interventionYou must factually document your rationale for checking any of the above critical items on the form.Evaluator Name:PrintedDOH 530-226 April 2019SignatureEMR, EMT & AEMT Level Practical Evaluation Skill SheetsPage 18
EVALUATOR NOTESPROSCONSADDITIONAL COMMENTS:DOH 530-226 April 2019EMR, EMT & AEMT Level Practical Evaluation Skill SheetsPage 19
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Patient Assessment / Management – TraumaCandidate Name DateScenario Actual Time Started:PointsPossible*Takes or verbalizes appropriate PPE precautionsPointsAwarded1SCENE SIZE-UP*Determines the scene/situation is safe1Determines mechanism of injury/nature of illness1Determines the number of patients1Requests additional EMS assistance if necessary1*Considers stabilization of the spine1*PRIMARY SURVEY / RESUSCITATION (Must be completed prior to the secondary assessment)Verbalizes general impression of patient1Determines responsiveness/level of consciousness1*Determines chief complaint/apparent life threatsAirway*-Opens and assesses airway (1 point)-Inserts adjunct as indicated (1 point)Breathing*-Assess breathing (1 point)*-Assures adequate ventilation (1 point)*-Initiates appropriate oxygen therapy (1 point)*-Manages any injury which may compromise breathing/ventilation (1 point)Circulation-Checks pulse (1 point) -Assesses skin (either skin color, temperature, or condition) (1 point)-*Assesses for and controls major bleeding if present (1 point)-*Initiates shock management (positions patient properly, conserves body heat) (1 point)1*Identifies patient priority and makes treatment/transport decision (based upon GCS/Trauma Triage Tool)2441HISTORY TAKINGObtains baseline vital signs (must include BP, P, and R)1Attempts to obtain SAMPLE history1SECONDARY ASSESSMENT Areas denoted by “**” may be integrated within sequence of Primary Survey/ResuscitationHead-Inspects and palpates scalp and ears** (1 point)-Assesses eyes (1 point)-Inspects mouth**, nose**, and assesses facial area (1 point)Neck**-Checks position of trachea (1 point)-Checks jugular veins (1 point)-Palpates cervical spine (1 point)Chest**-Inspects chest (1 point)-Palpates the chest (1 point)-Auscultates chest (1 point)Abdomen/pelvis**-Inspects and palpates abdomen (1 point)-Assesses pelvis (1 point)-Verbalizes assessment of genitalia/perineum as needed (1 point)Lower extremities**-Inspects, palpates, and assesses motor, sensory and distal circulatory functions (1 point/leg)Upper extremities-Inspects, palpates, and assesses motor, sensory and distal circulatory functions (1 point/arm)Posterior thorax, lumbar and buttocks**-Inspects and palpates posterior thorax (1 point)-Inspects and palpates lumbar and buttocks areas (1 point)Manages secondary injuries and wounds appropriatelyDOH 530-226 April 2019EMR, EMT & AEMT Level Practical Evaluation Skill Sheets33332221Page 21
es how and when to reassess the patientPassing score is 34 (at least 80%)TOTAL:Actual Time Ended: Elapsed Time: Max Time Allowed: *1042PASS / FAILCRITICAL CRITERIA - Note: Blocks above with an * have corresponding Critical Criteria below.Failure to initiate or call for transport o
DOH 530-226 April 2019 EMR, EMT & AEMT Level Practical Evaluation Skill Sheets Page 3 SKILL EVALUATION PROCESS WAC 246-976
