The Major Problem I Anticipate Will Be the Lack of a Consistent Template on Which to Place

/ Texas Tech University
Health Sciences Center
Simulation Program / Select Primary Organ SystemBehavioral HealthCardiovascularDigestiveEndocrineHEENTHematologicImmunologicIntegumentaryMultisystemMusculoskeletalNeurologicObstetricalPulmonaryRenal/UrologicReproductiveSensoryWellness
Select Secondary Organ SystemBehavioral HealthCardiovascularDigestiveEndocrineHEENTHematologicImmunologicIntegumentaryMultisystemMusculoskeletalNeurologicObstetricalPulmonaryRenal/UrologicReproductiveSensoryWellness
Select Secondary PopulationPediatricAdultGeriatric / Patient Name
Ethnicity
Age YearsMonthsDays
GenderMaleFemaleUknown / AGMOP
Simulation Based Experience Template
(SelectA for Adult, G for Geriatric, M for Midwifery, O for OBGYN,or P for Pediatric)
Course/Activity:
Lead Faculty:
Simulation Modality: High FidelityMid FidelityLow Fidelity
Standardized Patient Use: No Yes, Role:N/A
Scenario will be for: Teaching Testing/OSCE
Unfolding Case: NoEvent 1 Event 2Event 3Event 4 / Birthdate:
Height:
Weight:
Allergies: / Acuity: HighMediumLow
Medical Diagnosis:
Chief/Presenting Complaint:
Learning Objectives (using Bloom’s Revised Taxonomy)
1.
2.
3.
4.
Critical Concept/s: (Please select all that apply) / IPE/CP No Yes
Professions involved:
How?
Patient Centered Care
Teamwork Collaboration
Evidenced Based Practice
Quality Improvement
Safety
Informatics
Leadership Delegation
Communication
Prioritization / Cultural Diversity
Teaching
Ethical/Legal
Other:
For Healthcare Practitioner’s Use Only
HPI
Physical Assessment
Diagnostics
Treatment Plan
Scenario Script
Case Overview – (Provide overview)
Pathology / Gender
SelectMaleFemaleUnknown / Patient Age
YearsMonthsDays / Date of Birth / Height / Weight
Scenario
Required Admitting and Standing Orders (e.g., insulin sliding scale, electrolyte replacement, protocols, etc.)
Physicians Orders
Diagnostics / Other (Activity Diet, etc.)
Medication Orders
Scheduled / Unscheduled / PRN / Continuous Infusion
Standardized Patient and/or Standardized Participant Instructions
SetupInformation for Simulation Personnel
Baseline simulator and/or environment set-up
Setting (e.g. clinic) / Oxygenation (e.g., O2 flow rate and device) / Pre-scenario Diagnostics (e.g., chest x-ray, left lower lobe pneumonia). Please list:
Neurological (e.g., Seizure) / Integument (e.g., Sweating) / Sensory (i.e., Ears, Nose, Throat)
Cardiovascular (e.g., Rhythm, Heart Sounds) / Circulation (e.g., Bleeding, Pulses) / Respiratory (e.g., Lung Sounds, Pneumothorax)
Musculoskeletal (e.g., Splints, Compression Devices) / Gastrointestinal (e.g., Nasogastric Tubes with 60 mL bile-colored secretions in collection device) / Renal/Urinary (e.g., Foley Catheter Inserted with 30 mL tea colored urine)
Moulage
IV Therapy/medication Infusing, location, gauge, and pump settings
Vital Signs Monitor Display
/ Primary ECG Visible / Yes No
SpO2 / Yes No
CO2 / Yes No
Blood Pressure / Yes No
Pulse / Yes No
Respiratory Rate / Yes No
Temperature / Yes No
Hemodynamic Critical Care Monitoring No Yes, ParametersN/A
Baseline Vital Signs
Heart Rate/Rhythm / SP02 / Blood Pressure / Respiration Rate / Temperature
Other Parameters or Equipment Needed (e.g., Door signs, pain scale, isolation or crash cart, glucometer, etc.)
Pre-Scenario Learner Activities (Pre-brief)
Required Pre-scenario Assignment/s
Does the Information Need to be Released to Learners? No Yes, Date
Report toLearners(Provide information to participant as appropriate to case)
Instructions to Learners:
Situation:
Patient Name:
Healthcare Provider:
Location:
Background:
Admitting Diagnosis:
PastMedicalHistory:
Home Medications: (Prescription and Over the Counter)
Allergies:
Diet:
Assessment:
Recommendation:
Intra-scenario
Diagnostic Data (e.g., X-rays, Labs)
Medications and/or IV fluids (use TTUHSC Sim Formulary)
Additional Equipment/Supplies
Intra-scenario Changes
IF / THEN
IF / THEN
IF / THEN
IF / THEN
IF / THEN
Contingency Plan
Contingency Plan (In the Event of a Technical Failure)
Debriefing
Debriefing Framework (e.g. GRASP)
Does Scenario Need Recording?YesNo
Does Debrief Session Need Recording?YesNo
Does Debrief Session Need to be Setup for Video Playback? YesNo
Socratic Questions
Evaluation Form/Assessment Tool(s)
Evidence Base
Literature Review (Include a minimum of 3 references within the past 5 years)
Clinical Expert Interprofessional Review Panel: (Include names)
Pilot Date
Assistance Needed With Pilot
Code Status
DNR/AND (Allow Natural Death) / Arm Bands Needed
ID Allergy Fall Risk DNR Partial Code Difficult Airway Limb Alert