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Candidate:
EMT student ID’s are usually in this format: 123456FT-01. For refresher or skills only, place “CE” in this field
Examiner:
Military Time Only (example: 1523)

Skills Section

Action

Points Possible

Points Awarded

Identifies the need for obtaining a blood glucose level

1

Identifies the normal parameters for blood glucose level

1

Identifies contraindications

1

Identifies potential complications:

Erroneous reading

1

BSI exposure

1

Clearly explains procedure to patient

1

Selects, checks, and assembles equipment

Glucometer

1

Test strip

1

Needle or spring-loaded puncture device

1

Alcohol swabs

1

Checks blood glucose

Takes or verbalizes appropriate PPE precautions

 

1

Turns on glucometer and inserts test strip

1

Preps finger tip with alcohol prep

1

Lances the prepped site with needle/lancet device, drawing capillary blood

1

Disposes/verbalizes disposal of needle/lancet in appropriate container

1

Expresses blood sample and transfers it to the test strip

1

Dresses fingertip wound with pressure and alcohol prep

1

Records reading from glucometer and documents appropriately

1

Affective

Accepts evaluation and criticism professionally

1

Shows willingness to learn

1

Interacts with simulated patient and other personnel in professional manner

1

Military Time Only (example: 1523)

Critical Criteria Section

Critical Criteria

Administrative Section

Clear Signature