EXTRAORDINARY PROCEDURES FORM
Student Paramedic's Name:
*
First Name
Last Name
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Shift End Time:
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Hospital Campus:
*
City Division
Mainland Division
AC HealthPlex
EHT HealthPlex
Other
Type a question
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
Service Quality
Cleanliness
Responsiveness
Friendliness
Department:
*
Emergency Department
Intensive Care Unit
Respiratory Therapy
Pediatrics
Maternity
Phlebotomy
Operating Room
Other
Heading
ICU Specialty:
Medical
Cardiac
Trauma
Only if assigned to the ICU
Patient Log Number:
*
Assessment Time:
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Hour
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Patient's Age:
*
Patient's Gender:
*
Male
Female
Other
Patient's Weight:
Kgs
Procedure performed/observed by student
*
Crisis Interview/Crisis Intervention
NG Tube Insertion
Cardiac Arrest
Intubation Outside of the Operating Room
Other
Detailed explanation of the extraordinary procedure:
Which best describes the level of participation that you were involved in for this event?
Observed only
Observed with some participation
Fully participated
Was the procedure you participated in successful for a better patient outcome? Explain in the notes section above.
Yes
No
Preceptor/Resource Staff's Name:
Dr.
Prefix
First Name
Last Name
Credential
Job Title:
*
Preceptor/Resource Staff's Signature:
*
I attest to my best abilities that this information is true and accurate.
Student Paramedic's Signature:
*
I attest to my best abilities that this information is true and accurate.
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