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