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NORTHERN VIRGINIA COMMUNITY

COLLEGE
EMERGENCY MEDICAL SERVICES
PROGRAM
EMS 120 Student Clinical/Ride-along
Report
Student Name:

Hospital

Date of Shift:
Facility: ________________________

___________
Rescue Squad Agency:
Time: ___________

_______________________

Start Time:
End

Total Hours:

___________
PRECEPTOR EVALUATION
Please complete the following evaluation for the NVCC EMT-Basic student after he/she has completed the
rotation with your department. Thank you.
1. Punctuality
On Time
Late (Reason:__________________________________________________________)
2. Appearance
Clean, appropriate attire
Acceptable, slightly rumpled
Rumpled, dirty
Inappropriate attire
3. Participation
Became an active member of the department
Participated most of the time
Needed to be reminded to stay busy
Did not participate, remained isolated
4. Communication
Followed instructions, asked thoughtful questions, took initiative in communicating with others
Followed instructions, asked appropriate questions, communicated clearly
Required repetition of instructions, asked questions without thinking, difficult for others to understand
Failed to follow instructions, did not ask questions, did not communicate effectively
5. Professional Conduct
Cooperated with staff, accepted constructive criticism and made conscious effort to correct problem
areas
Worked well with staff, accepted constructive criticism and worked on problem areas
Failed to cooperate with staff, took criticism but made excuses instead of working on problem areas
Uncooperative with staff, did not listen to criticism, blamed others
6. Student Affect
Was motivated & enthusiastic, seemed glad to be here and welcomed the learning opportunity
Accepted that had to be here, and participated in activities as they arose
Seemed disinterested in this learning opportunity, putting forth only minimum effort

 Did not appear to have any interest at all in being here, and couldnt wait to leave

Preceptor Name:

______

Signature:

I certify that these patient care reports and rotation documentation (date,
hours, location, preceptor) are accurate and correct to the best of my
knowledge.

Student Signature:

Date:

Patient Care Report #________

Narrative (SOAP, CHART, or CHARTED):

VITAL SIGNS (minimum 2 sets)

Time

LOC

Pulse

BP

Alert
Verbal
Pain
Unresp.

________
Reg.
Irreg.

_______
Normal
Labored
Shallow
Deep

Alert
Verbal
Pain
Unresp.

________
Reg.
Irreg.

_______
Normal
Labored
Shallow
Deep

Lung
Sounds

Resp
R

L
Clear
Diminsh.
Rales
Wheezing
Rhonchi
Absent
L
Clear
Diminsh.
Rales
Wheezing
Rhonchi
Absent

Skin

Normal
Hot
Cool
Moist
Pale
Flushed

Normal
Hot
Cool
Moist
Pale
Flushed

Pupils

Equal
Unequal
L
Sluggish
Dilated
Const.
Unreact.
Equal
Unequal
L
Sluggish
Dilated
Const.
Unreact.

Patient Care Report #

Narrative (SOAP, CHART, or CHARTED):

VITAL SIGNS (minimum 2 sets)

Time

LOC

Pulse

BP

Resp

Lung

Skin

Pupils

Sounds

Alert
Verbal
Pain
Unresp.

________
Reg.
Irreg.

_______
Normal
Labored
Shallow
Deep

Alert
Verbal
Pain
Unresp.

________
Reg.
Irreg.

_______
Normal
Labored
Shallow
Deep

L
Clear
Diminsh.
Rales
Wheezing
Rhonchi
Absent
L
Clear
Diminsh.
Rales
Wheezing
Rhonchi
Absent

Normal
Hot
Cool
Moist
Pale
Flushed

Normal
Hot
Cool
Moist
Pale
Flushed

Equal
Unequal
L
Sluggish
Dilated
Const.
Unreact.
Equal
Unequal
L
Sluggish
Dilated
Const.
Unreact.