Professional Documents
Culture Documents
GAUTENG
ni
ng
ni
ng
ai
tr
ncy
medic al
. E . L .
. L .
P
. E
em
er
ge
er
ai
ge
tr
ncy
medical
Members:
D J Taylor (Btech EMC), M J Taylor (A11SA)
FULL TIME
_______
DATE: _____________________
PART TIME
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BREATHING
CIRCULATION
PREPARATION
Suction Unit
Suction tubing
Suction catheter (yankauer)
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ACTIVITY
SUCTIONING
CONT.
CRITICAL PERFORMANCE
DONE/
NOT
DONE
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One:
Examiner Two:
Name:
_________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
PREPARATION OF
O2 CYLINDER
APPLICATION OF
THE REGULATOR
CONNECTION OF
DELIVERY
DEVICE
CRITICAL PERFORMANCE
Candidate opens the main valve slowly until an audible
rush of oxygen is heard.
Candidate closes the main valve rapidly
Candidate checks that the regulator is the correct one for
the cylinder and that the O-ring seal is present.
Candidate applies the regulator correctly.
Candidate opens the cylinder valve slowly, keeping
his/her face clear of the gauges.
Candidate listens for and notes any leaks.
ADJUSTMENT
Candidate selects the correct flow rate for the chosen
delivery device
Candidate correctly applies the delivery device to the
patient, after explaining the procedure.
TERMINATION OF
O2 THERAPY
*
*
*
*
*
DONE/
NOT
DONE
*
*
*
*
*
*
*
ACTIVITY
TERMINATION OF
O2 THERAPY
CONT
CRITICAL PERFORMANCE
DONE/
NOT
DONE
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BREATHING
CIRCULATION
OP TUBE
INSERTION
VENTILATION
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ACTIVITY
CRITICAL PERFORMANCE
Candidate attaches O2 tubing to O2 cylinder.
Candidate attaches O2 tubing to BVMR.
Candidate opens O2 cylinder and adjusts flow rate to 1215 litres/min.
Candidate resumes ventilations.
OXYGEN
DONE/
NOT
DONE
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BREATHING
CIRCULATION
COMPLETION OF
RESPIRATORY
ASSESSMENT
*
*
*
*
*
- Nebuliser
- Oxygen with tubing
- Syringe and needle
- B2 Stimulants
Candidate checks drug for:
*
*
*
*
- Correct drug
- Expiry date
- Cloudiness and leaks
- Dosage of drug.
Candidate calculates dose required.
Candidate injects required drug/s into nebuliser and
connects to oxygen source.
*
*
*
*
*
*
ACTIVITY
NEBULISATION
REASSESSMENT
CRITICAL PERFORMANCE
Candidate connects nebuliser to oxygen source.
Candidate selects an oxygen flow rate of 4-6 litres/min
and ensures that the nebuliser mask is misting
appropriately.
Candidate securely fits nebuliser mask to patients face.
Candidate instructs patient to take slow, deep breaths.
Candidate assesses the patient for effectiveness or sideeffects of nebulisation.
Candidate monitors the patients vital signs, including
noting the patients blood sugar level 5 minutes post
nebulisation.
Candidate records drug administration correctly.
Candidate repeats administration of B2 stimulant
nebulisation as required, and as per protocol.
DONE/
NOT
DONE
*
*
*
*
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
PREPARATION OF
ENTONOX
CYLINDER
APPLICATION OF
THE REGULATOR
EXPLANATION OF
PROCEDURE
TERMINATION OF
ENTONOX
THERAPY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
*
*
*
*
*
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
PULSE
MEASUREMENT
RESPIRATION
MEASUREMENT
DONE/
NOT
DONE
*
*
*
*
*
*
*
*
*
*
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
PREPARATION
PROCEDURE
EVALUATION
*
*
*
*
*
*
*
*
*
*
*
*
*
ACTIVITY
CRITICAL PERFORMANCE
EVALUATION
CONTINUED
DONE/
NOT
DONE
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BREATHING
CIRCULATION
*
*
*
*
*
*
*
*
GENERAL
APPEARANCE
HEAD-TO-TOE
SURVEY
*
*
*
*
*
*
ACTIVITY
HEAD-TO-TOE
SURVEY CONT.
CRITICAL PERFORMANCE
Candidate palpates the patients abdomen, and examines
for distension, tenderness, guarding and rigidity.
Candidate examines patients abdomen for any unusual
markings or bruising including surgical scars.
Candidate examines patient for signs of incontinence.
Candidate inspects the patients torso for signs of
oedema.
Candidate examines the patients limbs for signs of
oedema.
Candidate examines patients limbs for neurovascular
patency.
Candidate checks motor function in the patients limbs.
Candidate inspects patient for presence of medical
identification.
Candidate turns the patient and examines the patients
back for any unusual markings or bruising including
surgical scars.
DONE/
NOT
DONE
*
*
*
*
*
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
GENERAL
APPEARANCE
HEAD-TO-TOE
SURVEY
*
*
*
*
*
*
*
ACTIVITY
CRITICAL PERFORMANCE
Candidate checks for tracheal deviation and distended
neck veins.
Candidate correctly applies a cervical collar
Candidate examines patients chest for wounds and
stability.
Candidate observes patients respiratory excursion, and
auscultates for equal air entry and breath sounds.
Candidate examines patients chest for any implantable
devices.
Candidate examines patients chest for any unusual
markings or bruising including surgical scars.
Candidate palpates the patients abdomen, and examines
for wounds, distension, tenderness, guarding and
rigidity.
Candidate examines patients abdomen for any unusual
markings or bruising including surgical scars.
Candidate examines patients pelvis for wounds,
stability, signs of incontinence, and priapism (in males).
Candidate examines the patients limbs for wounds and
deformity.
Candidate examines patients limbs for neurovascular
patency.
Candidate checks motor function in the patients limbs.
Candidate inspects patient for presence of medical
identification.
Candidate logrolls the patient and examines his back for
wounds and deformity.
Candidate examines the patients back for any unusual
markings or bruising including surgical scars.
DONE/
NOT
DONE
*
*
*
*
*
*
*
*
*
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
__________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
The Examiner states that the patient is conscious and has a wound Examiner to point out
the wound site
PATIENT
ASSESSMENT 1O
SURVEY
WOUND CARE
OPENING OF
DRESSING
APPLICATION OF
THE DRESSING
*
*
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BREATHING
CIRCULATION
PATIENT
ASSESSMENT
*
*
*
*
*
The Examiner is to state which pressure point is to be used by giving examples of bleeding
sites
TEMPORAL
FACIAL
*
*
*
*
ACTIVITY
BRACHIAL
FEMORAL
CRITICAL PERFORMANCE
DONE/
NOT
DONE
*
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BREATHING
CIRCULATION
PATIENT
ASSESSMENT
SPLINTING
*
*
*
*
*
*
*
- Radial pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
Candidate assesses wrists, elbow and shoulder for
associated injuries.
*
*
*
*
*
ACTIVITY
SPLINTING CONT.
CRITICAL PERFORMANCE
Candidate ensures that the padded splint extends from
the hand to the mid-humerus.
Candidate ensures that any natural hollows between the
splint and the patients limb are filled with gauze or
similar material.
Candidate secures the padded splint to the patients arm
with roller bandages, ensuring to cover the entire length
of the splint.
Candidate performs the splinting procedure with minimal
movement of the injured limb.
Candidate requests that partner releases longitudinal
traction if applied.
Candidate re-assesses:
- Radial pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
Candidate elevates the splinted arm.
DONE/
NOT
DONE
*
*
*
*
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BREATHING
CIRCULATION
PATIENT
ASSESSMENT
SPLINTING
*
*
*
*
*
*
*
- Pedal pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
Candidate assesses ankle, knee and hip for associated
injuries.
*
*
*
*
*
ACTIVITY
SPLINTING CONT.
CRITICAL PERFORMANCE
Candidate ensures that the padded splint extends from
the foot to the mid-thigh.
Candidate ensures that any natural hollows between the
splint and the patients limb are filled with gauze or
similar material.
Candidate secures the padded splint to the patients leg
with roller bandages, ensuring to cover the entire length
of the splint.
Candidate performs the splinting procedure with minimal
movement of the injured limb.
Candidate requests that partner releases longitudinal
traction if applied.
Candidate re-assesses:
- Pedal pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
Candidate elevates the splinted leg.
DONE/
NOT
DONE
*
*
*
*
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
H.E.L.P.
CANDIDATE EXAM NUMBER: _____________________
_____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BREATHING
CIRCULATION
PATIENT
ASSESSMENT
SPLINTING
*
*
*
*
*
*
*
*
*
*
Pedal pulse
Movement in limb
Sensation in limb
Skin colour, temperature and condition in limb
Capillary refill
*
*
*
*
*
*
*
*
*
*
ACTIVITY
SPLINTING CONT.
CRITICAL PERFORMANCE
Candidate ensures that the splint is seated correctly
against the ischial tuberosity, and ensures that the splint
is not pressing against the patients genitals.
Candidate secures the ischial strap of the splint.
Candidate attaches ankle strap to traction mechanism,
and starts pulling mechanical traction.
Candidate requests that partner releases his grip slowly
as the traction splint takes over traction.
Candidate re-assesses:
- Pedal pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
Candidate adjusts traction as necessary.
Candidate secures traction splint to patients leg
ensuring not to strap over the fracture site.
Candidate elevates the foot of the splint.
DONE/
NOT
DONE
*
*
*
*
*
*
*
*
*
*
*
*
FINAL RESULT:
SATISFACTORY
______
UNSATISFACTORY
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BREATHING
CIRCULATION
C-SPINE
IMMOBILISATION
Spine Board
Base Plate
Head Blocks
Spider Harness/straps
*
*
*
*
*
*
*
ACTIVITY
PREPARATION
FOR LOGROLL
CONT.
CRITICAL PERFORMANCE
Candidate ensures that he/she has a proper grasp by
placing one hand on the patients furthermost shoulder
and another hand at the patients hip.
Candidate ensures that third person places one hand at
the patients buttocks and the other hand at the patients
mid-thigh.
Candidate instructs the person maintaining manual
stabilisation of the patients head to be in control of the
logroll procedure.
On the count of the person at the patients head, the
patient is rolled onto his/her side as a unit whilst the
patients head and neck remains in alignment with the
rest of the patients body.
Candidate requests that spine board is pulled under and
aligned with the patient.
On the count of the person at the patients head, the
patient is lowered, as a unit, onto the spine board.
LOGROLL
SECURING THE
PATIENT TO THE
SPINE BOARD
DONE/
NOT
DONE
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BREATHING
CIRCULATION
C-SPINE
IMMOBILISATION
HEAD-TO-TOE
SURVEY
*
*
*
*
*
*
*
*
*
PREPARATION
FOR EXTRICATION
*
*
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
PREPARATION
FOR
EXTRICATION
CONT.
EXTRICATION
SECONDARY
SURVEY
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BREATHING
CIRCULATION
PREPARATION
DELIVERY
Cord clamps.
Scissors/blade
Pads
Warm blanket
Mucous extractor
Resuscitation equipment
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ACTIVITY
DELIVERY CONT.
CRITICAL PERFORMANCE
Once the babys head is delivered, candidate removes
mucous and blood from the babys mouth and nose, and
suctions gently if necessary.
Candidate checks for the umbilical cord around the
babys neck:
a. If present, slip it over the babys head.
b. If it is too tight to slip over the babys head, it
must be double clamped and cut between the
clamps.
Candidate allows restitution to take place.
Candidate places palms on either cheek to apply gentle
downward traction to deliver the anterior shoulder.
Candidate applies gentle upward traction on the head to
deliver the posterior shoulders.
Candidate grasps the baby firmly as it delivers.
Candidate holds the infants head down to allow fluid to
drain from its airway.
Candidate places the infant in the lateral position and
clears the airway if necessary.
Candidate double clamps the umbilical cord and cuts the
cord between the clamps.
Candidate cleans and dries the infant.
Candidate takes the APGAR score one minute after birth
of the infant.
Candidate inspects the cord for bleeding.
Candidate wraps the infant in a warm blanket and gives
it to the mother.
DELIVER OF THE
PLACENTA
DONE/
NOT
DONE
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ACTIVITY
DELIVER OF THE
PLACENTA CONT.
CRITICAL PERFORMANCE
Candidate continues to massage the uterus.
DONE/
NOT
DONE
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BREATHING
CIRCULATION
PREPARATION
LOVESET
MANOEUVRE
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ACTIVITY
MAURICEAUSMELLIE-VEIT
MANOEUVRE
CRITICAL PERFORMANCE
DONE/
NOT
DONE
*
*
*
*
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
H.E.L.P.
CANDIDATE EXAM NUMBER: _____________________
_____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
*
*
*
*
*
*
*
ACTIVITY
VENIPUNCTURE
CRITICAL PERFORMANCE
Candidate selects suitable vein and cleans site with
alcohol swab.
Candidate stabilises vein with non-dominant hand.
Candidate inserts needle through the skin, bevel facing
upward, into a vein.
Candidate advances needle until backflow is seen.
Candidate slides the catheter over the needle into the
vein and withdraws the needle.
Candidate attaches IV administration set to catheter and
deflates the BP cuff.
Candidate opens the flow clamp wide open, and checks
the placement and checks the patients arm for swelling
indicating infiltration of the tissue.
Candidate adjusts the flow rate as desired.
Candidate secures cannula and tubing with appropriate
strapping.
DONE/
NOT
DONE
*
*
*
*
*
*
*
SATISFACTORY
______
UNSATISFACTORY
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
COMPLETION OF
SECONDARY
SURVEY
ADMINISTRATION
- Correct drug
- Expiry date
- Cloudiness and leaks
- Dosage of drug.
Candidate calculates dose required.
Candidate draws up correct dose into syringe and
eliminates excess air.
*
*
*
*
*
*
*
*
ACTIVITY
REASSESSMENT
CRITICAL PERFORMANCE
Candidate assesses the patient for effectiveness or sideeffects of 50% dextrose administration.
Candidate monitors the patients vital signs, especially
noting the patients blood sugar level 5 minutes post
dextrose administration.
Candidate records drug administration correctly.
Candidate repeats administration of 50% dextrose as
required, and as per protocol.
DONE/
NOT
DONE
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
*
*
*
*
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
*
*
*
*
*
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
PREPARATION
APPLICATION
*
*
*
*
*
*
*
*
*
*
*
ACTIVITY
ASSESSMENT
CRITICAL PERFORMANCE
Candidate checks that pulse oximeter shows adequate
signal generation.
Candidate checks that an adequate waveform is seen on
pulse oximeter screen (if available).
Candidate notes pulse oximeter reading.
Candidate is aware of the difference between a false
positive and false negative pulse oximetry reading,
and the causes thereof.
DONE/
NOT
DONE
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
ACTIVITY
ALS ASSISTANCE
CRITICAL PERFORMANCE
DONE/
NOT
DONE
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One:
Examiner Two:
Name: __________________
Name: _________________
Qualific:
_____________________
Qualific:
____________________
Signature:
_____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
SAFETY
AIRWAY
BREATHING
CIRCULATION
VENTILATION
CRITICAL PERFORMANCE
Candidate assesses the area with regards to scene
safety.
DONE/
NOT
DONE
*
*
*
*
*
*
*
*
*
*
*
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
VENTILATION
*
*
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
*
*
BREATHING
VENTILATION
REMOVAL OF
OBSTRUCTION
MANUAL
MANOEUVRES
Tongue depressor
Magills forceps
*
*
*
*
*
*
*
*
*
*
ACTIVITY
CRITICAL PERFORMANCE
If effective, candidate assesses patients circulation.
Candidate resumes ventilations as necessary.
DONE/
NOT
DONE
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
HELLO
ABC
PATIENT
ASSESSMENT
BREATHING
*
*
*
*
ACTIVITY
DECOMPRESSION
CRITICAL PERFORMANCE
Candidate prepares equipment:
a. 14G IV cannula
b. Alcohol swab
c. Syringe with saline and air-space (for air
bubbling)
Candidate locates 2nd intercostals space, mid-clavicular
line on the side of the tension pneumothorax
Candidate cleans the intended area of centesis.
Candidate inserts the 14G IV cannula just over the 3rd
rib.
Candidate punctures the parietal pleura.
Candidate watches for air bubbles in saline.
Candidate removes syringe and listens for sudden
escape of air-relief from tension pneumothorax.
Using the Seldinger technique, candidate fully advances
the catheter to the hub and then removes the needle.
Candidate leaves the catheter in place as a marker.
Candidate reassesses the patients respiratory status.
Candidate assesses the patients circulation:
- assess pulse and perfusion
- treat accordingly
DONE/
NOT
DONE
*
*
*
*
*
*
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
__________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
*
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
USE OF PASG
*
*
*
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:
COMPETENT
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________
DATE: __________________
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
SAFETY
CRITICAL PERFORMANCE
Candidate assesses the area with regards to scene safety.
DONE/
NOT
DONE
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
ACTIVITY
DONE/
NOT
DONE
CRITICAL PERFORMANCE
FINAL RESULT:
SATISFACTORY
______
UNSATISFACTORY
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
__________________
Qualific:
____________________
Qualific:
__________________
Signature:
____________________
Signature:
__________________
DATE: __________________
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
PATIENT
REASSESSMENT
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SUCCESSFUL CPR
FINAL RESULT:
SATISFACTORY
______
UNSATISFACTORY
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
__________________
Qualific:
____________________
Qualific:
__________________
Signature:
____________________
Signature:
__________________
DATE: __________________
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SUCCESSFUL CPR
FINAL RESULT:
SATISFACTORY
______
UNSATISFACTORY
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
__________________
Qualific:
____________________
Qualific:
__________________
Signature:
____________________
Signature:
__________________
DATE: __________________
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
ABDOMINAL
THRUSTS
SUCCESSFUL
*
*
FINAL RESULT:
SATISFACTORY
______
UNSATISFACTORY
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
__________________
Qualific:
____________________
Qualific:
__________________
Signature:
____________________
Signature:
__________________
DATE: __________________
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
PATIENT
REASSESSMENT
*
*
*
ACTIVITY
PATIENT
ASSESSMENT
CONT.
SUCCESSFUL CPR
CRITICAL PERFORMANCE
DONE/
NOT
DONE
FINAL RESULT:
SATISFACTORY
______
UNSATISFACTORY
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
__________________
Qualific:
____________________
Qualific:
__________________
Signature:
____________________
Signature:
__________________
DATE: __________________
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
ABDOMINAL
THRUSTS
*
*
*
*
*
*
ACTIVITY
SUCCESSFUL
DONE/
NOT
DONE
CRITICAL PERFORMANCE
If the patient is breathing normally or resumes adequate
breathing, place the patient in the recovery position.
FINAL RESULT:
SATISFACTORY
______
UNSATISFACTORY
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
__________________
Qualific:
____________________
Qualific:
__________________
Signature:
____________________
Signature:
__________________
DATE: __________________
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
PATIENT
REASSESSMENT
*
*
*
ACTIVITY
PATIENT
ASSESSMENT
CONT.
SUCCESSFUL CPR
CRITICAL PERFORMANCE
DONE/
NOT
DONE
FINAL RESULT:
SATISFACTORY
______
UNSATISFACTORY
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
__________________
Qualific:
____________________
Qualific:
__________________
Signature:
____________________
Signature:
__________________
DATE: __________________
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AIRWAY
BACK
BLOWS/CHEST
COMPRESSIONS
*
*
ACTIVITY
SUCCESSFUL
DONE/
NOT
DONE
CRITICAL PERFORMANCE
If the patient is breathing normally or resumes adequate
breathing, place the patient in the recovery position.
FINAL RESULT:
SATISFACTORY
______
UNSATISFACTORY
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
__________________
Qualific:
____________________
Qualific:
__________________
Signature:
____________________
Signature:
__________________
DATE:
COURSE:
PART TIME
FULL TIME
_______
_______
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY
AED USE
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
The AED will only deliver one shock and will then instruct the candidate to continue with
CPR starting with chest compressions. The internal AED timer will now also commence
timing for 2 minutes.
Candidate continues with CPR until ALS arrives or until
the patient begins breathing normally
Pulse, breathing, coughing and movement are present
CPR
PATIENT CARE
*
*
FINAL RESULT:
SATISFACTORY
______
UNSATISFACTORY
______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One:
Examiner Two:
Name:
____________________
Name:
____________________
Qualific:
____________________
Qualific:
____________________
Signature:
____________________
Signature:
____________________