ASTEC Scenario Template for Simulation Exercises
Instructions: Fill out this template as best as you can and email it to One of the ASTEC simulation staff will review it and follow up on any specific questions.
Case Title:
Facilitator:
Basic Information:Target Audience: Specialty: Other:
Learning Objectives: (2-3 specific technical, cognitive, and/or behavioral skills desired)
Provide a brief overview of the case: (Include age, gender, nature of the scenario, etc. This will be read to the learners at the beginning of the simulation)
Initial State:Mental Status: Level of Orientation: Behavior:
Discernible Sounds
Discernible Odors
Patency
Status
Mucosa
Obstructions
Eyes Opening
Verbal Response
Motor Response
Glasgow:Airway:
Excursion
Inspiratory:Expiratory
RRper min.
HRbpm
Bp / mmHg
SpO2%
Temp°C °F
FSBS mg/dL
Breathing: Pulses: Initial Vital Signs:
Rate
Depth
Quality
Location
Rate
Strength & Quality
EKG Standard
12 Lead EKG Map
Axes
Skin Color
Skin Condition
Skin Integrity
Sounds: Other: Biotelemetry:
Lung sounds, Left
Lung sounds, Right
Heart Tones
Vocal Sounds
Pupils. Left
Pupils. Right
Additional: Patient Progression: (Include time intervals, critical actions, and desired endpoints).
Wave FormsSettings
1.
2.
3.
Critical Actions & Patient Response If Taken and If Omitted: Vital Signs:
RRper min.
HRbpm
Bp / mmHg
SpO2%
RRper min.
HRbpm
Bp / mmHg
SpO2%
Critical Actions & Patient Response If Taken and If Omitted: Vital Signs:
Critical Actions & Patient Response If Taken and If Omitted: Vital Signs:
RRper min.
HRbpm
Bp / mmHg
SpO2%
Patient History: (Brief summary of the patient’s history; use the following as a guide):
OnsetSigns/SymptomsSocial Hx
Timing/FrequencyAllergiesFamily Hx
Quality DescriptorsMedicationsPast Med. Hx
Region/RadiationIntakes/OutputsPt. Surgical Hx
Severity (0 to 10)Review of Systems
Environmental Setup: (Brief description of the setting. May include temperature, climate,personnel needs, etc)
Separate Files: (Indicate the documents or supplements that support the case and attach in an email).
12-Lead EKG Misc Diagnostics Labs CT Scan MRI Ultrasound X-ray
Physician Orders Medical Record/SBAR Cardiac Echo
Other:
Equipment and Supplies Checklist:
Arterial Line C-MACCentral Lines Chest Tube Insertion Tray
Code Cart Cricothyrotomy Kit ECMO Set-up IO Drill
Lumbar Puncture OB KitPPE/Sterile Wear Sutures
Thoracotomy Tray Tracheostomy Kit UVC
Other:
Interpersonal/Inter-professional Variables:
Anything else you would like to include?
Revised 12/18/12
ASTEC Scenario Template for Simulation Exercises
References:(Please give us 2 references to support the above case)
Revised 12/18/12