Respiratory Therapist Clinical Handbook respiratory therapist . clinical handbook . 515-175, 178,...

RESPIRATORY THERAPIST CLINICAL HANDBOOK

515-175, 178, 179, 182, 183

MORAINE PARK TECHNICAL COLLEGE 235 N. NATIONAL AVENUE

PO BOX 1940 FOND DU LAC WI 54936-1940

May 2019

Respiratory Therapist Program Program Director – Instructor Mary Bandler, MS, RRT 920-924-3339 (office)262-707-4711 (cell)[email protected]

Respiratory Therapist Program Director of Clinical Education Instructor Jackie Schoener, BA, RRT 920-924-3255 (office)920-539-0673 (cell)[email protected]

mailto:[email protected]:[email protected]

Table of Contents

Introduction ................................................................................................ ................................................................................................

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................ 1Clinical Sites ....................... 1Assessment ........................ 1Remediation Procedure ...... 1Moraine Park Technical College Vision Statement .............................. 2Moraine Park Technical College Mission Statement ........................... 2Respiratory Therapist Program Mission Statement ............................. 2Program Goals .................... 2

................................................................Technical Skills Assessment Program ................ 2 ................................

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AARC Statement of Ethics and Professional Conduct ......................... 3Clinical Experience and Training ................ 4Clinical Training Assignment Process ................. 4Clinical Experience Objectives ............................ 4

Orientation to Clinical Site .............................. 4Professional Ethics ......... 4Equipment Operation and Safety................................................................

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.................... 4Clinical Site Responsibilities ............................... 5

Safety Orientation .......... 5Department Policy and Procedures ................................................................

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................ 5Equipment ...................... 5Communication .............. 5Incident Reporting .......... 5Confidentiality ................. 5

Clinical Site Preceptor ......... 6Qualifications .................. 6Supervision of Respiratory Therapist Students ............................... 6Student Assessment ...... 6

MPTC Director of Clinical Education Responsibilities .......................... 7Student Responsibilities ...... 8

General .......................... 8Clinical Site Attendance . 8Record-Keeping ............. 8Medical Treatment or Disability As a Result of Training .................. 8Transportation and expenses ......................... 9

Allied Health Dress Code .... 9Social Media Policy ............................................................................................................10Miscellaneous Information .................................................................................................10

Attendance and Leave Policies ..........................................................................................11 Clinical Attendance Policy .............................................................................................11 Sick Time Policy ............................................................................................................11 Medical Leave Policy .....................................................................................................12

Clinical Assessment and Grading ............................................................................ 13 Clinical Training Grading Process ......................................................................................13

MPTC Respiratory Therapist Program Inter-Rater Variability Reduction Plan ...............13 Clinical Training Complaint Resolution ...............................................................................13

Probation .......................................................................................................................13 Dismissal from the Clinical Site ..........................................................................................14

Moraine Park Respiratory Therapy Program Clinical Manual Review Acknowledgement .................................................................................................... 14 Appendices .............................................................................................................. 15

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Introduction

This handbook explains the responsibilities of MPTC, the clinical sites, and the student, as well as describing the format for evaluation of student progress and competency in the clinical setting. Students, clinical preceptors, school program officials and College officials keep an ongoing accurate picture of the student’s clinical progress through recorded core ability performance assessments.

Our goal is to create highly competent and professional Respiratory Therapists that will enjoy a successful career in Respiratory Therapy.

Clinical Sites All clinical sites are considered part of Moraine Park Technical College while students are present. The rules and regulations stated in this manual represent a contractual agreement between Moraine Park Technical College (MPTC) and the Respiratory Therapist (RT) student. Failure to comply with the rules and regulations in this handbook will affect student evaluations and can result in dismissal from the Respiratory Therapist Program.

Students are required to keep this handbook along with any completed forms with them while they are at their clinical site.

Assessment Feedback from the student and their clinical site is solicited and is essential in making this program successful. This information is used to assess the student’s clinical experience and the clinical evaluation assessment forms evaluate the student’s performance in the respiratory therapy department and ensure performance meets program goals/outcomes. Site surveys assess the viability of the site and its preceptors.

Due to Wisconsin licensure, students may not be employed as respiratory therapists while attending the Moraine Park Technical College Respiratory Therapist Program.

Remediation Procedure If you are not meeting core ability guidelines you will be referred to the MPTC Academic Referral Process. This is to ensure you are using all recourses available to you to be successful. You may also be placed in an Action Planning/Student Progress process to assist you improving any core abilities/competencies that are deficient.

The student is responsible for all of the policies within this document.

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Moraine Park Technical College Vision Statement A college of choice for students and a strategic partner for business and industry.

Moraine Park Technical College Mission Statement Preparing students for success in a diverse and globally connected world.

Respiratory Therapist Program Mission Statement The mission of this program is to develop skilled advanced Respiratory Therapists that are nationally recognized and state licensed. We also dedicate our efforts to support the growth of the Respiratory Therapy profession and all health care professionals to the mutual benefit of the College, the health care industry, and ultimately to the health of the clients to which our profession is dedicated and focused.

Program Goals The goals of the Moraine Park Technical College’s Respiratory Therapist Program are:

• Apply advanced-level respiratory therapy concepts to patient care situations• Demonstrate technical proficiency required to fulfill the role of an advanced- level

Respiratory Therapist• Practice respiratory therapy according to established professional and ethical

standards

Technical Skills Assessment Program Moraine Park Respiratory Therapist program is participating in the state Technical Skills Assessment Program (TSA program). This requires data collection and data submission to the state in reference to:

• Pass rates on competencies• Pass rates for any exit exams• Pass rates for NBRC written RRT/CRT exam that is taken after graduation

If you have any questions or concerns regarding program participation in the TSA program, please contact the MPTC Respiratory Therapist Program Director.

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AARC Statement of Ethics and Professional Conduct In the conduct of professional activities the Respiratory Therapist shall be bound by the following ethical and professional principles. Respiratory Therapists shall:

• Demonstrate behavior that reflects integrity, supports objectivity, and fosters trustin the profession and its professionals. Actively maintain and continually improvetheir professional competence, and represent it accurately.

• Perform only those procedures or functions in which they are individuallycompetent and which are within the scope of accepted and responsible practice.

• Respect and protect the legal and personal rights of patients they care for,including the right to informed consent and refusal of treatment.

• Divulge no confidential information regarding any patient or family unlessdisclosure is required for responsible performance of duty, or required by law.

• Provide care without discrimination on any basis, with respect for the rights anddignity of all individuals.

• Promote disease prevention and wellness.• Refuse to participate in illegal or unethical acts, and refuse to conceal illegal,

unethical or incompetent acts of others.• Follow sound scientific procedures and ethical principles in research. Comply

with state or federal laws which govern and relate to their practice.• Avoid any form of conduct that creates a conflict of interest, and shall follow the

principles of ethical business behavior.• Promote health care delivery through improvement of the access, efficacy, and

cost of patient care.• Refrain from indiscriminate and unnecessary use of resources.

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Clinical Experience and Training

Clinical Training Assignment Process Students enrolled in the Respiratory Therapist program at MPTC must successfully complete all competencies in required coursework prior to scheduled clinical rotation.

The program officials make all the arrangements, and students may NOT contact the clinical training sites unless directed to do so by a program official.

Students may be placed in a clinical training site outside of the Fond du Lac area.

Individual student needs will be considered and students may express a preference for a specific clinical site. However, the final decision is the program official’s and students will be required to do some traveling. Students who refuse a clinical site assignment without just cause will be terminated from the program.

Clinical Experience Objectives Orientation to Clinical Site After receiving information about the clinical site, the student will be able to:

• Locate the various departments found within the clinical site.• Return or obtain supplies from various departments at the clinical site.• Locate fire and emergency equipment and exits.

Professional Ethics Given the essential information through class lecture relating to the practice of professional ethics, the students will:

• Practice professional behavior within the Respiratory Department.• Observe confidentiality and treat patients with respect and empathy.• Observe departmental policy and procedures.• Practice effective, accurate, and clear communication.• Come prepared, rested, show enthusiasm and be ready to learn. Do not work the

night prior to clinical day.• Be aware of legal responsibilities in the health care environment.

Equipment Operation and Safety After completing clinical departmental rotations, the student will be able to:

• Identify and use equipment in the Respiratory Department.• Demonstrate proficiency in the operation and troubleshooting of the equipment.• Follows safety and infection control procedures in the clinical site.• Consistently uses personal protective equipment as procedure indicates.

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Clinical Site Responsibilities Safety Orientation Each clinical training site should orientate the student to the safety procedures. This orientation should include:

• Fire Safety• Location of safety equipment• Instruction in safety procedures

Students are required to adhere to all safety regulations and procedures. Failure to do so is grounds for dismissal from MPTC RT program.

Department Policy and Procedures Each clinical training site should orientate the student to department policies and procedures to ensure that proper protocol is followed.

An MPTC Clinical Training Safety Agreement (Appendix 1) form must be completed and turned into the instructor each first time rotation.

Equipment Each clinical site should introduce the student to the equipment available in the respiratory therapy clinical setting. This should include basic maintenance, monitoring, troubleshooting, calibration, control, and proper documentation practices.

Communication The site preceptor and MPTC's RT director of clinical education are the contact people for their respective organization. Communication between them should on a regular basis and as situations exist that require attention.

Incident Reporting In the event of an incident involving a student during clinical training, the clinical preceptor must forward a legible copy of the incident form to MPTC program official.

An incident may be an occurrence that involves a student injury, student involvement during a patient/staff injury and/or failure to follow clinical site protocol.

An MPTC Incident Report form (Appendix 2) is included in the clinical training manual if needed.

Confidentiality All student records shall be maintained in accordance with the provisions of the Federal Family Educational Rights and Privacy Act of 1974.

All student records accumulated during the program are considered confidential and

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kept in a locked file. The contents of a student’s file are not revealed to any unauthorized person without the student’s knowledge and written consent. Students may review any records, which pertain to them in the program official’s office during regular office hours. Any records maintained by the clinical affiliates concerning individual students are subject to the same considerations regarding confidentiality, security and availability.

Students are also required to respect the privacy rights of others which are specified in HIPAA.

Clinical Site Preceptor Qualifications

• Personnel supervising students should have the appropriate qualifications listedbelow.

• Shall be credentialed in good standing by respective credentialing agencies(NBRC).

• Shall meet the criteria for the position as established by the sponsoring institutionand/or accrediting agencies.

• Shall demonstrate competence in instructional and evaluation procedures andtechniques, by reviewing the preceptor handbook and completing preceptortraining and posttest.

• Shall document a minimum of 2 years full-time professional experience, or asrequired by accreditation agencies, or as designated and approved bydepartment management.

Supervision of Respiratory Therapist Students Students must have adequate direct supervision during all clinical assignments. Students are not allowed to perform independently those clinical procedures they have not gained competency in. Students must perform all Respiratory Therapy procedures under the direct supervision of a qualified respiratory therapist.

A qualified respiratory therapist is to be readily available during the student's clinical experience. Students will have preceptor contact information on hand at all times.

Students shall not take the responsibility or place of the qualified staff.

Student Assessment Clinical preceptors overseeing the skills of the student will complete the assessments included in MPTC's Curriculum Modules. The student will be responsible for submitting their required completed documentation at the end of the rotation. The student is responsible for initiating the completion of the daily assessment and four week core ability documentation. The preceptors will complete these documents in the web based clinical tracking system (Trajecsys).

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MPTC Director of Clinical Education Responsibilities • Orientate site preceptors and designated staff to the RT program's academic and

clinical education mission, objectives and goals.• Ensure student orientation to department policy and procedures as well as safety

procedures within the first clinical training week.• Provide regular feedback to the student.• Demonstrate knowledge of program goals, clinical objectives, and clinical

evaluations.• Recognize and document student’s performance, incident reports and/or

counseling forms as required.• Exhibit a positive professional attitude and communication skills toward students

and the teaching process.• Participate in continuing education to improve and maintain competence in

evaluation and professional skills.• Perform problem resolution, if needed.• Maintain confidentiality in accordance with program policy.• Be responsible for reviewing, signing, and maintaining effective student records

which include:o Assessment forms for the department rotationo Safety and infection controlo Equipmento Documentation systemo Professionalism.

• Facilitate proper student rotations in the clinical setting to achieve MPTCProgram goals and objectives

• Serve as a liaison between MPTC and clinical training site as necessary.• Implement and promote diligent compliance with policies and procedures.

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Student Responsibilities General All students are required to respect and follow all dress codes and clinical standards and procedures while at the clinical training site. Student photo ID tags are to be worn at all times, outside of the clinical uniform, while at the clinical site.

Clinical Site Attendance Clinical Attendance is mandatory. The student is responsible for notifying MPTC RT director of clinical education and clinical site preceptor or representative, of any absences as soon as possible and preferably prior to the expected arrival time.

Absences will be considered justified and excusable only in extenuating circumstances such as emergencies, serious illness, or death in the immediate family. This will be left to the discretion of the MPTC RT program director or director of clinical education. It is the responsibility of the student to notify and provide documentation to MPTC’s program director or director of clinical education, concerning these extenuating circumstances.

Record-Keeping Students must maintain the Physician Interaction Log (Appendix 3). All physician communication and interaction must be recorded in this form found in Trajecsys.

Students must track clinical attendance on the Attendance Log (Appendix 4) of this module and accessible in Trajecsys.

Students will participate in a daily core ability review. It is the student’s responsibility to remind and ensure the preceptor completes the Daily Core Ability Review Assessment form (Appendix 5) in Trajecsys, at the end of each clinical day, as well as a core ability evaluation using the Core Ability Evaluation (Appendix 6) every 4 weeks.

Students will complete a site survey, accessible in Trajecsys, after each rotation and identify site or preceptor issues. If the issue needs immediate attention the student must report it to a MPTC instructor.

Procedural Competency Evaluation form (Appendix 7) will be completed in Trajecsys, by site preceptor. It is the student’s responsibility to complete PCE addendums after successfully completing the competency check-off, and to keep track of completed competencies.

Medical Treatment or Disability As a Result of Training When enrolling at MPTC, the student accepts full responsibility for all medical treatment and care and/or disability for any illness and/or injury incurred while on campus or at an affiliated clinical training site. Neither the college nor the affiliated clinical training site is required to carry medical insurance or worker’s compensation coverage on students. MPTC will not accept responsibility for medical or other costs incurred by sick or injured students while on campus or at the clinical training site.

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Transportation and Expenses The student is responsible for providing reliable transportation to class and clinical training site(s).

The student is responsible for his/her own lodging and board during clinical training.

The expenses for which the student is responsible include but are not limited to:

• Room and board• Meals• Uniforms• Health Insurance• Medical Bills• Learning materials

Allied Health Dress Code As students entering the Allied Health professions, it is imperative to present a professional appearance. Healthcare facilities’ regulations regarding personal appearance are based on both safety issues as well as the fact that the healthcare field is, overall, conservative in nature. Healthcare facilities have the right to refuse to accept any Allied Health students who do not adhere to site-specific dress-code rules. Though individual programs and sites may well enforce much more stringent rules, the minimum expectations for all Allied Health students are as follows:

• Clothing - Clothing must be clean and in good condition. Furthermore, to ensurethat clothing is professional in appearance, Allied Health students should notethe following regarding clinical attire:

o Uniforms are required at clinical sites.o Lab coats must be available at clinical sites (optional).

• If no lab coat is used, an MPTC patch must be displayed on uniformsleeve.

o Uniform must be clean, pressed, and free of pet hair or stains.• Hair - Hair must be clean. Long hair must be tied back. Extreme hairstyles must

be avoided. Facial hair must be kept clean and trimmed.• Jewelry/Body Piercings - Minimal jewelry should be worn. Body-piercing

jewelry must be removed.• Makeup - Excessive makeup should be avoided.• Nails - Nails must be kept clean and manicured. Allied Health students involved

in direct patient care must keep nail length at ¼ inch or less. No artificial nails arepermitted.

• Name Badge - Name badges from MPTC identifying Respiratory Therapiststudents must be worn at all times while at clinical sites.

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• Offensive Odors - Allied Health students are expected to:o Bathe frequentlyo Use deodoranto Brush their teetho Use mouthwash or breath freshener as necessaryo Avoid perfumes and cologneso Take any other steps deemed necessary to eliminate odors that others

may find offensiveo Cigarette odors on person or clothing must be avoided before and during

clinical hours• Tattoos - All tattoos must be covered while at clinical sites. Specific concerns

regarding this should be discussed with program instructors.

Social Media Policy It is unacceptable to post ANYTHING related to your education in the Respiratory Therapist Program including: information or comments regarding faculty, clinical preceptors, support staff, physical domain, or the educational environment of Moraine Park Technical College on FACEBOOK or any other SOCIAL MEDIA site.

It is equally unacceptable to post any pictures, comments or reference to any patients, clinical sites and/or affiliates, employees or situations related to your clinical education. This includes any case study you are required to turn in for a grade. This is irrespective of the nature of the comments.

Failure to comply with these guidelines will include suspension or termination from the Respiratory Therapist Program.

Miscellaneous Information • Personal phone calls—no personal phone calls should be received or made

while in the clinical area except for emergencies. Departmental telephones maynot be used for personal calls.

• Cell phones are to be left with personal belongings and not carried into patientcare areas.

• It is not permitted to complete school activities while employed.

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Attendance and Leave Policies Clinical Attendance Policy

• Attendance is mandatory.• Three tardies equal one absence (tardy is defined as arriving any time after your

assigned start time).• Less than 80% of clinical attended/day equal one absence.• One excused absence is allowed. You must contact both the site preceptor and

MPTC's RT program director or director of clinical education as soon as possibleto the absence. Failure to do so constitutes an "unexcused" absence.

• A second absence will be documented as "unexcused.”• Any absence must be made up.• Unexcused absences are not allowed. If an unexcused absence occurs, the

student will earn no credit for the Core Ability on the Clinical Core AbilitiesEvaluation. This may lead to immediate dismissal of the student from theprogram.

• Emergency situations will be addressed on an individual basis by the RTprogram director or director of clinical education.

• If a student elects not to take a lunch break, they cannot use this time to leaveclinical before the set time.

• If MPTC program officials are asked to remove a student or if the student isdismissed from a clinical site for a documented deficiency or deficiencies, thestudent may be dismissed from the RT program. It is NOT the responsibility ofthe college to obtain another clinical placement for the student when they did notsuccessfully perform in their original clinical placement.

• Appointments such as medical, dental, etc. should be scheduled on a non- clinical day in the late afternoon, if possible, so as not to conflict with clinicalcourse work.

• It is suggested that a student not work eight hours prior to clinical day.

Sick Time Policy Student absent from clinical training due to illness:

• Contact the clinical site preceptor or representative prior to the scheduled shift ifpossible or as soon as possible. Do not leave a voice mail on the clinicaldepartment telephone; page a staff member.

• Contact MPTC's RT Director of Clinical Education as soon as possible with anexplanation of missed clinical training time. A voice mail must be left with a returnnumber if unable to talk with the program official.

• Attendance is mandatory and any sick time greater than one missed clinical daymust have a written physician’s excuse.

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Medical Leave Policy Due to the possibility of a medical condition that affects one’s ability to complete the curriculum in the Respiratory Therapist program, a policy is hereby established:

• The student must notify the program director or director of clinical education as soon as possible.

• Any aspects of clinical education that are not attainable due to this circumstance, must be completed at a later date to meet competency levels. Extended medical leaves will be handled on an individual basis per faculty discretion.

• Student must complete the Clinical Absence Training form (Appendix 8) for every absence and turn into MPTC instructors.

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Clinical Assessment and Grading

Clinical Training Grading Process Grading for clinical training will be as reflected in the clinical course module.

MPTC Respiratory Therapist Program Inter-Rater Variability Reduction Plan • All clinical competency criteria will be evaluated as “MET, NOT MET or N/A” to

reduce inter rater variability.• No Likert scales will be utilized, to reduce inter-rater variability.• All preceptors will review preceptor training materials and test out on materials.• Preceptors are instructed that students must meet all applicable competency

criteria as “MET” or check off is aborted; student must then review competencyand remediate as needed, prior to any additional attempts.

• At the end of each clinical course, submitted clinical competency check off formswill be reviewed for inconsistency by the PD and DCE.

• If inconsistencies (i.e. blank areas, illegible entries, unsigned competencies) areidentified as a trend (more than two occurrences in a clinical course by onespecific preceptor) an action plan will be put in place and will include but not belimited to:

o Re-education of preceptors as indicatedo Re-evaluation of check off tools

• Preceptor training materials will be updated biennially and disseminated to newpreceptors as needed.

Clinical Training Complaint Resolution Any student complaints regarding non-compliance of the clinical training site with MPTC must put a specific complaint in writing to program officials. Program officials will immediately contact the clinical preceptor at the training site and determination will be made of the appropriateness of the complaint.

The program official must respond to the written complaint within 5 business days from the time the complaint was received. Possible resolution could include student reassignment and further evaluation of the site may be warranted.

Probation If a student is not performing satisfactorily during clinical training, this is to be reflected in the Core Ability Assessment and MPTC Daily Assessment, and verbal communication between clinical preceptor and program official.

If a problem/concern occurs, the clinical preceptor or student will communicate with MPTC's RT director of clinical education or program director, immediately.

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Action may be in the form of counseling the student via telephone, visiting the Clinical Training site to counsel the student, formal probation or dismissal from the program.

The student will be notified in writing of probation and the improvements required. The site preceptor and the student must sign this written notification. The length of the probation will be presented in writing.

MPTC remains in close contact with the student and the site preceptor and designees during the probation period. At the end of the agreed probationary period, the student must have made satisfactory improvement in the areas outlined by the probation notice. If this has not occurred, termination from the program will be immediate.

Dismissal from the Clinical Site In the event the clinical site dismisses a student, the student will leave the site immediately and contact the program official. STUDENT MAY NOT CONTACT THE SITE WITHOUT PERMISSION OF PROGRAM OFFICIALS. The clinical site must have proper documentation for such an action.

If the clinical site requests program officials to notify the student of dismissal, program officials will notify the student as soon as possible.

Program official will determine, through interviews of the clinical site and student, the appropriate actions necessary which may include but are not limited to:

• No Action Plan• Placement at a different clinical site, if one is available• Removal from the clinical site• Probation• Suspension• Dismissal

Moraine Park Respiratory Therapy ProgramClinical Manual Review Acknowledgment

I acknowledge that I have reviewed and understand all the content presented in the Respiratory Therapist Clinical Handbook.

Student Signature_____________________________________________________

Appendices

Appendix 1 - Clinical Training Safety

Appendix 2 – Incident Report

Appendix 3 – Physician Communication Log

Appendix 4 – Attendance Log

Appendix 5 – Daily Core Ability Review

Appendix 6 – Core Ability Evaluation

Appendix 7 – Procedural Competency Evaluation Treatment Procedures with Patients – Clinical Competencies

Appendix 8 – Clinical Training Absence Form

Significant Exposure Form

Appendix 1 (rev 8/22/19)

Clinical Training Safety Agreement

I ____________________________________________ agree to review and adhere to the safety, confidentiality, and health policies established at my Clinical Training site.

I have been informed of department policy & procedures for fire safety, location of all safety equipment and emergency procedures.

___________________________________________________ ____________________ Clinical Preceptor Instructor Date

___________________________________________________ ____________________ Student Signature Date

Clinical Training Safety Agreement

I ____________________________________________ agree to review and adhere to the safety, confidentiality, and health policies established at my Clinical Training site.

I have been informed of department policy & procedures for fire safety, location of all safety equipment and emergency procedures.

___________________________________________________ ____________________ Clinical Preceptor Instructor Date

___________________________________________________ ____________________ Student Signature Date

Incident Report Moraine Park Technical College 235 North National Avenue P.O. Box 1940 Fond du Lac, WI 54936-1940

This report is to be completed IMMEDIATELY after any incident involving employee injury, non-employee injury, property damage, or vehicle dama ge.

Student Employee Visitor Other (please specify): _ ________________ General Information

Name: First M.I. Last

ID Number: N

Address: City: State: Zip Code:

Contact Phone: Program Area (Students Only):

Incident Information Beaver Dam Fond du Lac West Bend Other (please specify): _____________________

Incident Date: Time: Month/Date/Year

Incident Location (be specific):

Describe the incident:

a.m. p.m. Date Incident Reported:Month/Date/Year

Incident Reported to:

Have any individuals been exposed to blood and/or body fluids due to this incident/injury?

Was first aid or medical treatment given? Yes

Name and address of treating practitioner/hospital:

Yes No If Yes, the Significant Exposure Description form must be completed and attached to this form. Form is available on myMPTC.

No

Witness Information * Request each witness complete a Witness Statement at the end of this form. Use additional sheets if necessary.

Name: Contact Phone:


Name: Contact Phone:


Updated 4.2018 Page 1 of 3 Moraine Park Technical College does not discriminate on the basis of race, color, national origin, sex, disability or age in employment, admissions

or its programs or activities. The following person has been designated to handle inquiries regarding the college's nondiscrimination policies: Equal Opportunity Officer, Moraine Park Technical College, 235 N. National Avenue, Fond du Lac, WI 54935-2884, 920-924-6459 or 920-924-3232.

Appendix 2


Employee Injury

Employee Position: Supervisor’s Name:

Nature of Incident: Slip/Fall Fracture/Sprain/Strain Laceration/Abrasion Other, please explain

Identify injured area: (be specific)

Did incident/injury occur on work time? Yes No

Property and/or Vehicle Damage

Specific description of damage:

MPTC Vehicle Information: Year: Make: Model:

Other Drivers Vehicle Information: Year: Make: Model:

Insurance Company: Agent: Policy #:

Additional Information (if applicable): Did the Police respond? Yes No

Police Report No.

Drawing

Significant Exposure Form Other, please explain:

Signature of Person Injured/Affected (required): Date:

Signature of Instructor (Student Reports Only): Date:

Signature of Dean or Associate Dean (Student Reports Only): Date:

Email Completed Report and Witness Statements

Employee Reports: Lori Schrage, Human Resources, District Office

All Other Reports: Carrie Kasubaski, Finance, District Office

Office Use Only HR/Finance: __________________ Date: __________



Appendix 2

mailto:[email protected]?subject=Incident%20Reportmailto:[email protected];%[email protected]?subject=Incident%20Report


Witness Statement

Name: Contact Number:

Please describe what you witnessed.

Witness Signature: Date:



Appendix 2


Moraine Park Respiratory Therapy Program Physician Interaction Log Document must be turned in at the end of each clinical course

Name of Student: Course#______ Site:_______________ Site:________________

Name of Physician Type of Interaction Date Time Spent Topic/summary of interaction Preceptor Verification A. Patient Focused _____ Type A 1 hour = 4 points _____

B. Tutorial _____ Type B 1 hour = 3 points _____ C. Small Group _____ Type C 1 hour = 2 points _____ D. Large Group _____ Type D 1 hour = 1 point _____











**You are expected to earn a minimum of 10 points per clinical course. Physician interaction for is worth 10% of your grade. If you earn less than 10 points it will affect your final grade for the clinical.

Attendance Log

Student Name: __________________________________

Date Time In

Time Out

Reason student left early, if any Preceptor Name/Site

Absences: Date: ____________ Date: ____________ Date: ____________

Missed clinical hours completed: # Hours: ____________ Facility: ____________ Date: ____________

# Hours: ____________ Facility: ____________ Date: ____________



Daily Core Ability Review Assessment Respiratory Therapist Student

(Please Print)

Name of Student: ____________________________ Site: _______________________

Date: _______________ Preceptor: __________________

Scoring Guidelines

MET = Demonstrates Behavioral Criteria

NOT MET = Does Not Demonstrate – Please explain in comment (be specific).

Core Abilities Met Not Met Cognitive (Critical Thinking) Consistently displays knowledge, comprehension, and command of essential concepts to optimize patient care Comment:

Psychomotor (Technical Skill) Selects, assembles and verifies proper function and cleanliness of equipment; Assures operation and corrects malfunctions; provides adequate care and maintenance Comment:

Performs procedures competently, in a reasonable time frame for clinical level Comment:

Affective (Professionalism/Ethics) Demonstrates effective communication (inter-personal and team) initiative, self-direction, responsibility and accountability Comment:

Exhibits courteous and pleasant demeanor; shows consideration and respect, honesty, integrity and functions in an ethical manner per AARC Guidelines Comment:

Preceptor Signature: __________________________________________


Core Ability Evaluation

Preceptor please: • Evaluate the student on each criterion below by placing a check mark in the

appropriate column.• Document reasoning for “not met” in comment box under criterion (or any

comment you have).• Complete evaluation after student’s four week rotation and place in the MPTC

mailbox located in your department.

Student please: • Present form to preceptors 1 week before due.

Key: Met = Student Demonstrates Criterion Not Met = Student does not Demonstrate Criterion

Clinical Core Abilities Met Not Met Student is punctual and stays until the assigned time. Comment: Student ensures patient confidentiality of records and diagnosis. Comment: Student adheres to AARC Guidelines involving ethical and legal issues. Comment: Student adheres to program dress code and personal hygiene: a) clean and pressed uniforms; b) clean shoes; c) name tag andfilm badge; d) clean hair.Comment: Student demonstrates communication skills appropriate to the clinical setting and patient Population. Comment: Student seeks assistance in any situation where the student is not competent. Comment: Student works as a team member in the clinical setting. Comment: Student checks 2 patient identifiers and explains procedures to the patient. Comment: Student complies with facility documentation policies. Comment: Student uses non-patient time to increase skills and knowledge. Comment:


Clinical Core Abilities Met Not Met Student takes into account pertinent safety issues when working with patients (guard rails, head of bed, NPO, VAI/VAE protocols). Comment: Student applies standard precautions, e.g., dealing with body fluids, performing medical asepsis or sterile technique. Comment: Student follows department protocol. Comment: Student seeks out optional clinical experiences. Comment: Total Possible Points: 14

Student Name: ___________________________________

Clinical Site: _____________________________________

Preceptor Name: __________________________________ (Please Print)

___________________________________________________ ____________________ Preceptor Signature Date


Treatment Procedures with Patients (Clinical Competencies)

Competencies may be completed after check-off in the laboratory setting has been done. In parentheses is the clinical course that the check off may be completed. The list of required competency is as follows:

No. Competencies Date Completed

Demonstrate competence in the following clinical competencies: 1 Apply standard precautions/transmission-based isolation. (515-175) 2 Assess vital signs: pulse and respiration, blood pressure. (515-175) 3 Provide education to the patient and family. (515-175) 4 Perform pulse oximetry. (515-175) 5 Perform chart review. (515-175) 6 Demonstrate cylinder safety. (515-175) 7 Administer oxygen therapy. (515-175) 8 Perform open suctioning. (515-175) 9 Perform closed suctioning. (515-175) 10 Perform extubation. (515-175). 11 Perform arterial puncture. (515-175) 12 Administer bronchial hygiene adjuncts, i.e. vibratory PEP, PEP, HFCWO. (515-175) 13 Manage artificial airways. (515-175) 14 Manage ventilator modes based on patient need. (515-179) 15 Manage non-invasive positive pressure ventilation. (515-179) 16 Administer aerosolized medications. (515-175) 17 Evaluate patient response to mechanical ventilation. (515-179) 18 Initiate mechanical ventilation. (515-179) 19 Evaluate patient readiness for liberation from mechanical ventilation. (515-179) 20 Administer hyperinflation adjuncts, i.e. incentive spirometry, IPPB, PAP. (515-175) 21 Demonstrate strategies to prevent ventilation associated events. (515-175) 22 Implement weaning protocols. (515-179) 23 Perform a pulmonary exam. (515-175) 24 Participate as a member of the inter-professional care management team. (515-175) 25 Perform manual ventilation according to patient needs. (515-175) May be simulated 26 Evaluate hemodynamic data. (515-179) May be simulated 27 Evaluate need for home O2 therapy i.e. O2 titration with exercise(515-179)May be simulated 28 Perform tracheostomy care. (515-175) May be simulated 29 Interpret capnography results. (515-179) May be simulated 30 Manage mechanical ventilation of the neonate/pediatric patient. (515-184)May be simulated 31 Administer chest physical therapy. (515-175) May be simulated 32 Set up large volume medication nebulizer. (515-175) May be simulated 33 Change ventilation circuit. (515-175) May be simulated 34 Assist with intubation. (515-175) May be simulated 35 Perform nasotracheal suctioning. (515-175) May be simulated 36 Perform screening spirometry. (515-179) May be simulated 37 Administer aerosol medication therapy. (515-175) 38 Demonstrate clinical core abilities. (515-175)

Optional Clinical Procedures Date Completed Perform trach change. Perform sputum induction. Assist with bronchoscopy. Assist with thoracentesis. Manage use of Heliox. Manage use of Nitric Oxide. Perform transcutaneous monitoring. Assist with sleep lab procedures. Perform complete pulmonary function test. Optional Perform an arterial line draw. Monitor pleural drainage systems. Optional Create respiratory care plan according to evidence-based practices. Optional Assist with apnea testing. Optional Assist with cardiopulmonary stress testing. Optional

All completed competencies must have an accompanying procedural competency addendum completed in Trajecsys to earn full points for the competency check-off. (see below):

Procedural Competency Evaluation (PCE) Addendum (Attach to PCE)

PCE# and Title: _________________________________

Name: _________________________________________

Date: ______________ Site: _______________________

Name of AARC Clinical Practice Guideline pertaining to this competency or identify Chapter/page number from Egan Fundamentals: ___________________________________________________

Indications for the competency (intervention): _________________________

Hazards and/or Contraindications for the competency (intervention): _________________________

List an evidence based or professional resource for this competency (intervention): _____________

_______________________________________________________________________________


Clinical Training Absence Form

Student Name: _________________________________________________________

Clinical Training Site: ____________________________________________________

Date of Missed Training: __________________________________________________

Reason For Time Missed: _________________________Absence ______ Late ______

Early Departure ______Total Time Missed: ______

Explanation of Time Missed: _______________________________________________

______________________________________________________________________

______________________________________________________________________

Student Signature: ______________________________________________________

Clinical Preceptor Comments: _____________________________________________

______________________________________________________________________

______________________________________________________________________

Clinical Preceptor Signature: ______________________________________________

The student completes the top part of this form including the signature. The Clinical Preceptor then signs the form and the student returns it to RT Director or Clinical Educator at MPTC. A separate form must be completed for each and every occurrence. It is required that ALL late arrivals, absences and early departures be reported.

Students who leave early are to report to the Clinical Training Preceptor and fill out a missed time form as indicated above before leaving. Students who leave the Clinical affiliate early without notifying the Clinical Preceptor may be subject to disciplinary action.


Significant Exposure Description Form Moraine Park Technical College 235 North National Avenue P.O. Box 1940 Fond du Lac, WI 54936-1940



This form is to be completed IMMEDIATELY after any significant exposure to blood and/or bodily fluids and must be included with the Incident Report.

SECTION I: Exposed Person Data Student Employee Visitor Other (please specify): _ ________________

Name: ID Number: N First M.I. Last


Contact Number:

Exposure Date: Time: a.m. p.m.Month/Date/Year

Incident Location:

Number of Hepatitis B vaccinations previously received: None 1 2 3

Previous Anti-HBs positive: Yes No Unknown

SECTION II: Source Person Data

Is the source person Known Unknown If unknown, skip to Section III

Name: ID Number: N First M.I. Last


Contact Number:

Does the source person have any known history of or risks for bloodborne pathogens: Yes (explain below) No

Please indicate history or risks:

Counseled prior to testing by: on First M.I. Last Month/Date/Year

Testing: Accepted Declined HIV Test Result: HBsAG Result:

Disclosure to the exposed person of the source person(s) HIB/HIV test results is requested.

SECTION III: Description of Exposure

Type of Exposure: (check all that apply) Blood/bodily fluid splash (e.g.: eye, nose, mouth)

Blood exchange from penetrating wound (e.g.: needle puncture)

Blood/bodily fluid exposure (e.g.: CPR)

Area of body exposed: Type and volume of fluid exchanged:

Specific description of exposure incident:

Signature of Exposed Person (required): Date:

Email Completed Report and Witness Statements

Employee Reports: Lori Schrage, Human Resources, District Office

All Other Reports: Carrie Kasubaski, Finance, District Office

Office Use Only HR/Finance: __________________ Date: __________

mailto:[email protected]?subject=Significant%20Exposuremailto:[email protected];%[email protected]?subject=Significant%20Exposure

IntroductionClinical SitesAssessmentRemediation ProcedureMoraine Park Technical College Vision StatementMoraine Park Technical College Mission StatementRespiratory Therapist Program Mission StatementProgram GoalsTechnical Skills Assessment ProgramAARC Statement of Ethics and Professional Conduct

Clinical Experience and TrainingClinical Training Assignment ProcessClinical Experience ObjectivesOrientation to Clinical SiteProfessional EthicsEquipment Operation and Safety

Clinical Site ResponsibilitiesSafety OrientationDepartment Policy and ProceduresEquipmentCommunicationIncident ReportingConfidentiality

Clinical Site PreceptorQualificationsSupervision of Respiratory Therapist StudentsStudent Assessment

MPTC Director of Clinical Education ResponsibilitiesStudent ResponsibilitiesGeneralClinical Site AttendanceRecord-KeepingMedical Treatment or Disability As a Result of TrainingTransportation and Expenses

Allied Health Dress CodeSocial Media PolicyMiscellaneous InformationAttendance and Leave PoliciesClinical Attendance PolicySick Time PolicyMedical Leave Policy

Clinical Assessment and GradingClinical Training Grading ProcessMPTC Respiratory Therapist Program Inter-Rater Variability Reduction Plan

Clinical Training Complaint ResolutionProbation

Dismissal from the Clinical Site

Moraine Park Respiratory Therapy Program Clinical Manual Review AcknowledgementAppendicesResp Therapist Clinical Handbook 2019 Final FORMS.pdfClinical Training Safety AgreementClinical Training Safety AgreementAttendance LogDaily Core Ability Review AssessmentRespiratory Therapist StudentPreceptor Signature: __________________________________________Core Ability EvaluationTreatment Procedures with Patients(Clinical Competencies)Clinical Training Absence Formincident-report-2019.pdfEmail Completed Report and Witness Statements Employee Reports: Lori Schrage, Human Resources, District OfficeOffice Use Only

Physician Interaction Log Accessible.pdfMoraine Park Respiratory Therapy Program Physician Interaction Log

Appendices.pdfAppendices

Core Ability Forms.pdfDaily Core Ability Review AssessmentRespiratory Therapist StudentPreceptor Signature: __________________________________________Core Ability Evaluation

Pg 8.pdfStudent ResponsibilitiesGeneralClinical Site AttendanceRecord-KeepingMedical Treatment or Disability As a Result of Training

Other: OffOther-please specify: Zip Code1: Contact Number: Exposure Date: Incident Location: None: Off1 check box: Off2 check box: Off3 check box: OffPrevious AntiHBs positive Yes: OffPrevious AntiHBs positive No: OffPrevious AntiHBs positive - Unknown: OffKnown: OffUnknown_2: OffID Number1: Contact Number_2: Yes explain below: OffNo_2: OffHistory or risks: Counseled prior to testing by: MonthDateYear: Accepted: OffDeclined: OffHIV Test Result: HBsAG Result: Bloodbodily fluid splash eg eye nose mouth: OffBlood exchange from penetrating wound eg needle puncture: OffBloodbodily fluid exposure eg CPR: OffArea of body exposed: Type and volume of fluid exchanged: Student: OffEmployee: OffVisitor: OffOther please specify: OffOther Specify: Name: ID Number: Address: City: State: Zip Code: Contact Phone: Program Area: Beaver Dam: OffFond du Lac: OffWest Bend: OffOther please specify_2: OffOther Location: Incident Date: Time: am: Offpm: OffDate Incident Reported: Incident Location be specific: Incident Reported to: Describe Incident: Body Fluids Yes: OffBody Fluids No: OffFirst Aid Yes: OffFirst Aid No: OffName Adder Treating: Name_2: Contact Phone1: Address_2: City_2: State_2: Zip2: Name_3: Contact Phone2: Address_3: City_3: State3: Zip3: Employee Position: Supervisor Name: Slip/Fall: OffFracture/Sprain/Strain: OffLaceration/Abrasion: OffOther Incident: OffSpecific area of injury: Injury on work time Yes: OffInjury on work time No: OffSpecific description of damage: MPTC Vehicle Year: MPTC Vehicle Make: MPTC Vehicl Model: Year: Make: Model: Insurance Company: Agent: Policy: Additional Info: Police Respond Yes: OffPolice Respond No: OffPolice Report: OffPolice Report Number: Drawing: OffSignificant Exposure: OffOther Check Box: OffOther please explain: Sig of Person Injured/Affected: Date: Signature of Instructor: Date_2: Date_3: HRFinance: Date_4: Name of Witness: Witness Contact Phone: Witness Description: Witness Signature Date:

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