EMR

Skills Checklist
Measuring Vital Signs
Student Name: ________________________________ Date:
__________________________
Company: ________________________________ Group No. :
______________________

Instructions: Check the box showing on which attempt the participant was able to perform the step
successfully. UTP indicates unable to perform successfully within four attempts.
Performance Guidelines SCORE
5 4 3 2 1
1. Proper use of PPE
2. Introduce, ask permission and explain to the patient
that you will be measuring and recording his/her vital
signs
3. Measure Blood Pressure without Stethoscope
(Systolic)
4. Measure Blood Pressure (Systolic and Diastolic)
5. Check and count for the pulse rate
6. Check and count for the respiratory rate
7. Check relative body temperature
8. Check Pupils
9. Obtain SAMPLE
TOTAL
PERFECT SCORE 45

Comments:________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________________________ RATING
________________________________________________________
________________________________________________________ Performs beyond
5 expectations
________________________________________________________
_______________________ Performs without
4 corrections

Performs with minimal

Instructor: 3 corrections
_______________________________________________
2 Performs poorly

1 Unable to perform (UTP)

EMR
Skills Checklist
Patient Assessment
Student Name: ________________________________ Date: __________________________
Company: ________________________________ Group No. : ______________________
Instruction: In this station, the participant will say out loud what he or she is doing, stating
possible findings, while demonstrating each of the following procedures. Check the box showing on
which attempt the participant was able to perform the step successfully. Mark UTP with an X to
indicate the participant was unable to perform successfully within two (2) attempts.
Performance Objectives SCORE
5 4 3 2 1
1. Ensure personal safety and proper use of PPE
2. Identify yourself (to the victim, the family or bystanders)
3. Perform all steps for the initial assessment.
• Check Level of Consciousness
• Maintain open airway (Jaw-Thrust)
• Check ABC (administer oxygen if needed)
• Check Trachea for alignment and inspect back of neck for bleeding
• Measure neck and apply C-Collar
4. Perform all steps for physical exam.
• Inspect and palpate the head, eyes, mouth, nose and ears
• Inspect and palpate the shoulders, chest and lung sounds
• Inspect and palpate the abdomen and pelvic area
• Inspect and palpate lower and upper extremities and check for PMS
• Rotate the body and inspect the back
5. Obtain patient history. (SAMPLE)
 Measure Vital Signs (Verbalize)
TOTAL

Comments:________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Instructor: _______________________________________

RATING
Performs beyond
5 expectations

Performs without
4 corrections

Performs with minimal

3 corrections

2 Performs poorly
1 Unable to perform (UTP)
 EMR
Skills Checklist
Adult FBAO – Conscious/Unconscious
Student Name: ________________________________ Date: __________________________
Company: ________________________________ Group No. : ______________________

Instructions: Check the box showing on which attempt the participant was able to perform the step
successfully. UTP indicates unable to perform successfully within four attempts.
Performance Guidelines SCORE
5 4 3 2 1
1. Proper use of PPE
2. Scene survey, introduce and ask permission.
3. Ask the patient, “Are you choking?”
4. Give abdominal thrusts ( chest thrusts for pregnant or
obese patient )
5. Repeat thrusts until effective or victim becomes
unconscious
Victim Becomes Unconscious --- --- --- ---
6. Activate the EMS system. Place patient in supine position.
7. Perform 30 chest compressions
8. Look into the patient’s airway and attempt to ventilate. If
air bounces back, reposition the head and attempt to
ventilate.
Continue cycle until the foreign object is expelled.
9. If object is visible, remove the object by doing tongue-jaw
lift and finger sweep.
10. Give two confirmatory blows and check Pulse and
Breathing.
 If the victim is breathing or resumes adequate
breathing, place in recovery position and continue
monitoring
TOTAL

Comments:________________________________________________________________________
________________________________________________________ RATING
________________________________________________________
_____________________________________________________ 5
Performs beyond
expectations

Performs without
4 corrections
Instructor:
_______________________________________________ Performs with minimal
3 corrections

2 Performs poorly

EMR 1 Unable to perform (UTP)

Skills Checklist
Infant FBAO – Conscious/Unconscious
Student Name: ________________________________ Date: __________________________
Company: ________________________________ Group No. : ______________________
Instructions: Check the box showing on which attempt the participant was able to perform the step
successfully. UTP indicates unable to perform successfully within four attempts.
Performance Guidelines SCORE
5 4 3 2 1
1. Proper use of PPE
2. Scene survey, introduce and ask permission.
3. Confirm airway obstruction and position the infant.
4. Give 5 back blows followed by 5 chest thrusts.
5. Repeat Step 4 until effective or victim becomes unconscious
Victim becomes unconscious
6. Activate EMS, Place patient in supine position
7. Perform 30 chest compressions and check the patient’s
airway and attempt to give two ventilations. Repeat the
sequence until object is expelled
8. Perform a tongue – jaw lift. Then only if you see the object,
perform a finger sweep to remove it.
9. Give two confirmatory blows and check for pulse and
breathing
10. If the victim is breathing or resumes adequate breathing,
place in recovery position and continue monitoring
TOTAL

Comments:________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_

Instructor: RATING
_________________________________________________
Performs beyond
5 expectations

Performs without
4 corrections
EMR
Performs with minimal
Skills Checklist 3 corrections
Adult – One – Rescuer CPR
Student Name: ________________________________ Date: 2 Performs poorly
__________________________
1 Unable to perform (UTP)
Company: ________________________________ Group No. :
______________________

Instructions: Check the box showing on which attempt the participant was able to perform the step
successfully. UTP indicates unable to perform successfully within four attempts.
Performance Guidelines SCORE
5 4 3 2 1
1. Proper use of PPE.
2. Scene survey, introduce and ask permission.
3. Determine responsiveness (tap shoulders)
4. Call for help if unresponsive. Activate EMS; get an AED
 5. CHECK CIRCULATION & BREATHING FOR< 10SECONDS
Locate and assess carotid pulse
Head Tilt –Chin Lift; Look Listen and Feel
NO PULSE NO BREATH PROCEED TO:
CHEST COMPRESSION / VENTILATION 30:2
6. Locate the compression area, position hands and start
compression. Give 30 chest compressions (depth: 2-2.4
inches) and give Two (2) ventilation (1 second each).
Observe for visible chest rise and fall. Pinch nose during
giving breath. Continue uninterrupted cycle of 30:2 for 5
cycles
7. Reassess pulse and breathing simultaneously for no more
than 10 seconds (5-10 seconds).
8. If with Pulse and No Breathing: Rescue Breathing
Give 1 breath every 5 seconds; Head-Tilt-Chin-Lift; Pinch
nose during breaths; proper mouth seal; continue to
complete for 2 minutes (24 cycles)
9. Reassess pulse and breathing simultaneously for no more
than 10 seconds (5-10 sec.)
10. If the victim has pulse and started breathing, place the
victim on recovery position and continue monitoring.
TOTAL

Instructor:________________________________________________________________________
_

EMR
Skills Checklist
Infant – One – Rescuer CPR
Student Name: ________________________________ Date: __________________________
Company: ________________________________ Group No. : RATING
______________________
Performs beyond
5 expectations
Instructions: Check the box showing on which attempt the Performs without
participant was able to perform the step successfully. UTP indicates 4 corrections
unable to perform successfully within four attempts.
Performs with minimal
Performance Guidelines SCORE 3 corrections
5 4 3 2 1
1. Proper use of PPE. 2 Performs poorly
2. Scene survey, introduce and ask 1 Unable to perform (UTP)
permission.
3. Determine unresponsiveness, check
for pulse and breathing
 simultaneously for no more than 10 seconds.
4. If there is no pulse and breathing, activate EMS and instruct
someone to get AED if available.
NO PULSE NO BREATH PROCEED TO:
CHEST COMPRESSION / VENTILATION 30:2
5. Locate the compression area, position fingers, Head: neutral/
sniffing position. Give 30 chest compressions (depth: about
1.5inches) and give Two (2) ventilation (1 second each).
Observe for visible chest rise and fall. Mouth-to-mouth and
nose. Continue uninterrupted cycle of 30:2 for 5 cycles
6. Reassess pulse and breathing simultaneously for no more
than 10 seconds.
If with Pulse and No Breathing: Rescue Breathing
7. Give 1 breath every 3 seconds; Head: neutral/ sniffing
position; proper mouth-to-mouth and nose seal; continue to
complete for 2 minutes (40 cycles)
8. Reassess pulse and breathing simultaneously for no more
than 10 seconds.
9. If the victim has pulse and started breathing, place the
victim on recovery position and continue monitoring.
TOTAL

Comments:________________________________________________________________________
_Instructor: ________________________________________

EMR
Skills Checklist
Adult – Two – Rescuer CPR
Student Name: ________________________________ Date: __________________________
Company: ________________________________ Group No. : ______________________
Instructions: Check the box showing on which attempt the participant was able to perform the step
successfully. UTP indicates unable to perform successfully within four attempts.
Performance Guidelines SCORE
5 4 3 2 1
1. Proper use of PPE.
2. Scene survey, introduce and ask
permission.
3. Determine unresponsiveness, check
for pulse and breathing
simultaneously for no more than 10
seconds.
4. If there is no pulse and breathing, RATING
activate EMS and get AED if
available. Performs beyond
5 expectations
5. Begin CPR until an AED is available.
Give 30 chest compressions at a rate Performs without
4 corrections
of at least 100 – 120 beats per minute
and give two ventilations of 1 second Performs with minimal
each and observe for visible chest 3 corrections
rise. Continue cycles of 30 chest
compressions and 2 ventilations for 4 2 Performs poorly
cycles.
6. Immediately operate and place AED 1 Unable to perform (UTP)
pads to patient’s bare chest and the
AED will automatically analyze the
victim.
 7. If prompted by the AED to shock, Clear the patient and
press the shock button then continue chest compressions for
4 cycles and reassess pulse and breathing simultaneously for
no more than 10 seconds.
8. If the victim has pulse and started breathing, place the
victim on recovery position and continue monitoring.
TOTAL

Comments:________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_

Instructor: ________________________________________________________________________

EMR
Skills Checklist
Soft Tissue Injuries
Student Name: ________________________________ Date: __________________________
Company: ________________________________ Group No. : ______________________

Instructions: Check the box showing on which attempt the participant was able to perform the step
successfully. UTP indicates unable to perform successfully within four attempts.
Performance Guidelines SCORE
5 4 3 2 1
Station Bleeding Neck
1 Proper use of PPE, introduce and ask
permission.
•Check ABC. RATING
• Apply pressure to affected area. Performs beyond
• Apply occlusive dressing. 5 expectations
• Stabilize the occlusive dressing
Performs without
using bulky dressing. 4 corrections
• Secure dressing with elastic
bandage. Performs with minimal
3 corrections
Station Bleeding forearm
2 Proper use of PPE, introduce and ask
2 Performs poorly
permission.
• Apply pressure on the affected area 1 Unable to perform (UTP)
and elevate.
• Apply sterile gauze.
• Stabilize sterile gauze with bulky
dressing.
• If bleeding persists, apply pressure
on brachial artery.
• Use tourniquet as a last resort for
profuse bleeding.
Station Extruded Eyeball and Impaled
3 object in the eye
 Proper use of PPE, introduce and ask permission.
• Cover with moist dressing and protective cup.
• Bandage both eyes
Isolate and bandage impaled object in eye.
• Place padding around the object
• Stabilize the object with a cup
• Secure the cup in place
Station 4 Impaled object
Proper use of PPE, introduce and ask permission.
• Manually stabilize the body part
• Expose the area
• Apply direct pressure on the edges of the wound
• Stabilize the object with bulky dressing.
• Wrap the bulky dressings in place using an elastic
bandage

Instructor:
_________________________________________________________________________

EMR
Skills Checklist
Musculoskeletal Injuries
(Upper Extremities)
Student Name: ________________________________ Date: __________________________
Company: ________________________________ Group No. : ______________________

Instructions: Check the box showing on which attempt the participant was able to perform the step
successfully. UTP indicates unable to perform successfully within four attempts.
Performance Guidelines SCORE
5 4 3 2 1
Station 1 Use of PPE.
Splint a fracture or a dislocation of the shoulder
Or • Stabilize using pads/splints
• Apply Sling and swathe
Station 3 Splint a fracture of the upper arm.
• Stabilize with rigid splints
• Secure in place with swathe
Splint dislocation of a bent elbow.
• Stabilize with rigid splits
• Support with sling
Splint fracture of the forearm.
• Stabilize with rigid splint
• Support with sling
Split fracture of the wrist using rigid splint or pillow.
• Stabilize with rigid splint
• Support with sling
 TOTAL

Comments:________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_
Instructor: ______________________________________

EMR
Skills Checklist
Musculoskeletal Injuries
(Lower Extremities)
Student Name: ________________________________ Date: __________________________
Company: ________________________________ Group No. : ______________________

Instructions: Check the box showing on which attempt the participant was able to perform the step
successfully. UTP indicates unable to perform successfully within four attempts.
Performance Guidelines SCORE
5 4 3 2 1
Stati Use of PPE.
on 2 Splint hip injury using two rigid
splints.
Or • Place blanket between legs
• Place rigid splints inside and outside
Stati legs RATING
on 4 • Secure in place
Performs beyond
Split fracture of the thigh. 5 expectations
• Place rigid splint on inside of
patients’ leg and on patients’ affected Performs without
4 corrections
side.
• Secure in place Performs with minimal
Splint fracture or dislocation of a 3 corrections
bent knee.
• Stabilize with rigid splint 2 Performs poorly
• Support in place
1 Unable to perform (UTP)
Splint fracture of the lower leg.
• Place rigid splint on inside of
patients’ leg and on patients’ affected
side.
• Secure in place
Split ankle injury using rigid splints or
pillow.
• Stabilize with rigid splints/pillow
• Secure in place
TOTAL
Comments:________________________________________________________________________
_Instructor: ________________________________________

EMR
Skills Checklist
Lifting and moving, Rapid Extrication, Patient packaging,
Loading and strapping

Student Name: ________________________________ Date:

__________________________
Company: ________________________________ Group No. :
______________________
Instructions: Check the box showing on which attempt the participant was able to perform the step
successfully. UTP indicates unable to perform successfully within four attempts.
Performance Guidelines SCORE
5 4 3 2 1
Station Use PPE
1
Blanket drag
Shoulder or Forearm drag
Direct ground lift
Extremity lift
SUB-TOTAL (25)
Station Use PPE
2
Remove a patient from an
automobile using a long backboard RATING
SUB-TOTAL (10) Performs beyond
Station Use PPE 5 expectations
3
Performs without
Strapping a patient to a long 4 corrections
backboard
SUB-TOTAL (10) Performs with minimal
3 corrections
Station Use of PPE
4 2 Performs poorly
Removing a patient from an
automobile using a short backboard 1 Unable to perform (UTP)
SUB-TOTAL (10)
TOTAL
PERFEC 5
T SCORE 5
Comments:________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________

Instructor: ________________________________________

EMR
Skills Checklist
Oxygen Therapy
Student Name: ________________________________ Date:
__________________________
Company: ________________________________ Group No. :
______________________

Instructions: Check the box showing on which attempt the participant was able to perform the step
successfully. UTP indicates unable to perform successfully within four attempts.
Performance Guidelines SCORE
5 4 3
RATING 2 1
1. Proper use of PPE.
Performs beyond
2. Introduce and ask permission. 5 expectations
3. Prepare and identify necessary equipments.
4. Check and test the oxygen tank for leaks and defects 4
Performs without
 Crank the tank before connecting the regulator corrections
 Turn on valve and check on the content remaining on the tank Performs with minimal
 Attach the proper oxygen delivery device (Nasal Cannula or 3 corrections
Non-Rebreather Mask)
 Place the oxygen delivery device properly to the patient 2 Performs poorly

5. Remove oxygen delivery device before turning off the flow 1 Unable to perform (UTP)
meter and the tank valve.
TOTAL RATING
Performs beyond
Comments:______________________________________________ 5 expectations
________________________________________________________
Performs without
________________________________________________________ 4 corrections
________________________________________________________
________________________________________________________ Performs with minimal
3 corrections
________________________________________________________
________________________________________________________
2 Performs poorly
________________________________________________________
________________________________________________________ 1 Unable to perform (UTP)
______________________________________________
Instructor: __________________________________

EMR
Skills Checklist
Suctioning
Student Name: ________________________________ Date:
__________________________
Company: ________________________________ Group No. :
______________________

Instructions: Check the box showing on which attempt the participant was able to perform the step
successfully. UTP indicates unable to perform successfully within four attempts.
Performance Guidelines SCORE
5 4 3 2 1
1. Proper use of PPE.
2. Introduce and ask permission.
3. Prepare and identify necessary
equipments. (oxygen tank)
4. Operate and attach suction catheter and
turn on the machine
 Maintain sterility of the suction tip
and use sterile water
 Measure catheter against the patient.
5. Hyperoxygenate patient for 10 seconds.
6. Start suctioning the patient for no more
than 10 seconds and hyperoxygenate RATING
patient after suctioning. Performs beyond
7. Clean the suction catheter using sterile 5 expectations
water and sterile gauze.
Performs without
TOTAL 4 corrections

Performs with minimal

Comments:______________________________________________ 3 corrections
________________________________________________________
________________________________________________________ 2 Performs poorly
________________________________________________________
1 Unable to perform (UTP)
________________________________________________________
________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________

Instructor: ________________________________________