Glucometer Operation (California Only)

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Student ID:

EMT student ID's are usually in this format: 123456FT-01. For refresher or skills only, place "CE" in this field.

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Date:

Actual Time Started:

Military Time Only (example: 1523)

Skills Section

Point Point Point

Action

Points Possible

Points Awarded

Identifies the need for obtaining a blood glucose level

Point 1

Identifies the normal parameters for blood glucose level

Point 2

Identifies contraindications

Point 3

Identifies potential complications:

Erroneous reading

Point 4

BSI exposure

Point 5

Clearly explains procedure to patient

Point 6

Selects, checks, and assembles equipment

Glucometer

Point 7

Test strip

Point 8

Needle or spring-loaded puncture device

Point 9

Alcohol swabs

Point 10

Checks blood glucose

Takes or verbalizes appropriate PPE precautions

Point 11

Turns on glucometer and inserts test strip

Point 12

Preps finger tip with alcohol prep

Point 13

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

Point 14

Disposes/verbalizes disposal of needle/lancet in appropriate container

Point 15

Expresses blood sample and transfers it to the test strip

Point 16

Dresses fingertip wound with pressure and alcohol prep

Point 17

Records reading from glucometer and documents appropriately

Point 18

Affective

Accepts evaluation and criticism professionally

Point 19

Shows willingness to learn

Point 20

Interacts with simulated patient and other personnel in professional manner

Point 21

Total Points (Out of 21)

Actual Time Ended:

Military Time Only (example: 1523)

Critical Criteria Section

Critical Criteria

Failure to take or verbalize appropriate PPE precautions
Failure to dispose of blood contaminated sharps immediately at the point of use
Contaminates equipment or site without appropriately correcting situation
Failure to identify 2 indications
Failure to identify 2 potential complications
Failure to identify normal blood glucose parameters
Failure to obtain a viable capillary blood sample on first attempt
Exhibits unacceptable affect with patient or other personnel

Notes

Administrative Section

Note: EMT Student Candidate Name (Not Refresher) will populate automatically below. If the name has not been populated or the name is incorrect, contact customer service to get the correct STUDENT ID NUMBER.

Candidate:

First

Last

Examiner:

First

Last

Instructor State

Exam Location:

Instructor Certification Number:

Attempt 1 Result

Attempt 2 Result

Attempt 3 Result

Instructor Signature

Clear Signature

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EMS University

Note: Validation of a Student ID may take up to 30 seconds to complete. You may continue filling out this form while validation is in progress.

Skills Section

Critical Criteria Section

Administrative Section

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