Oxygen Administration by Non-Rebreather Mask

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Candidate:

First

Last

Student ID:

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

Examiner:

First

Last

Date:

Actual Time Started:

Military Time Only (example: 1523)

Skills Section

Points Layout Actual

Action

Points Possible

Points Awarded

Takes or verbalizes appropriate PPE precautions

Point 1

Gathers appropriate equipment

Point 2

Cracks valve on the oxygen tank

Point 3

Assembles the regulator to the oxygen tank

Point 4

Opens the oxygen tank valve

Point 5

Checks oxygen tank pressure

Point 6

Checks for leaks

Point 7

Attaches non-rebreather mask to correct port of regulator

Point 8

Turns on oxygen flow to prefill reservoir bag

Point 9

Adjusts regulator to assure oxygen flow rate of at least 10 L/minute

Point 10

Attaches mask to patient’s face and adjusts to fit snugly

Point 11

Total Points (Out of 11)

Actual Time Ended:

Military Time Only (example: 1523)

Critical Criteria Section

Critical Criteria

Failure to take or verbalize appropriate PPE precautions
Failure to assemble the oxygen tank and regulator without leaks
Failure to prefill the reservoir bag
Failure to adjust the oxygen flow rate to the non-rebreather mask of at lease 10 L/minute
Failure to ensure a tight mask seal to patient’s face
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

Instructor State

Exam Location:

Instructor Certification Number:

Attempt 1 Result

Attempt 2 Result

Attempt 3 Result

Instructor Signature

Clear Signature

EMS University

Skills Section

Critical Criteria Section

Administrative Section

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