Naloxone Administration (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)

Criteria Layout Point

Skills Section

Action

Points Possible

Points Awarded

Takes appropriate PPE precautions

Point 1

Ensures the scene is safe

Point 2

Completes a primary assessment of the patient

Point 3

Point 4

Completes a secondary asessment of an opiod overdose

Point 5

Verbalizes the signs and symptoms of an opiod overdose

Point 6

Verbalizes the criteria for assisting the patient with their medication

Point 7

Verbalizes the mechanism of action for naloxone

Point 8

SELECTS CORRECT MEDICATION BY IDENTIFYING

Right Patient

Point 9

Right Medication

Point 10

Right dosage/concentration

Point 11

Right time

Point 12

Right route

Point 13

ALSO CHECKS MEDICATION FOR

Clarity

Point 14

Expiration Date

Point 15

VERBALIZES MEDICATION SPECIFIC INFORMATION

Verbalizes the onset of action and duration of naloxone

Point 16

Verbalizes the indications for administration of naloxone

Point 17

Verbalizes the contraindications for administration of naloxone

Point 18

Verbalizes the side effects of naloxone

Point 19

CONTINUED CARE, ADMINISTRATION AND DISPOSAL

Calls for an ALS support unit

Point 20

Demonstrates safe and proper administration of naloxone

Point 21

Verbalizes proper disposal of naloxone

Point 22

Total Points (Out of 29)

Actual Time Ended:

Military Time Only (example: 1523)

Critical Criteria Section

Critical Criteria

Failure to take or verbalize appropriate PPE precautions
Contaminates equipment without appropriately correcting situation
Injects improper medication or dosage (wrong medication, incorrect amount, or administers at an inappropriate rate)
Recaps needle or failure to dispose/verbalize disposal of needle, syringe and mucosal atomizer device in proper container
Failure to observe the patient for desired effect and adverse side effects after administering medication
Failure to manage the patient as a competent EMT
Exhibits unacceptable affect with patient or other personnel
Uses or orders a dangerous or inappropriate intervention

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

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Skills Section

Critical Criteria Section

Administrative Section

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