Lemhi County Medical Supervision Plan Emergency Medical Service Patient Care Protocols



Download 398.53 Kb.
Page8/9
Date conversion20.11.2016
Size398.53 Kb.
1   2   3   4   5   6   7   8   9



65

Credentialing Process Form

Provider_____________________________________________Agency_____________________________________





Level of Credentialing EMR EMT-B AEMT-85 Paramedic



State EMS Licensure #______________________________ Exp.Date_____________________________

CPR # _____________________________ Exp. Date ____________________________

ACLS #______________________________Exp. Date_____________________________

PALS #______________________________Exp. Date _____________________________

Please Provide Copies of above certificates



Skills Verification aAttached Skill credentialing check list)

Training Officer Signature_____________________________________________Date:_______________________



The above provider has successfully completed all requirements for credentialing for the ____________________________________ EMS Agency and is fully credentialed at the level of________________



Provider understands and agrees to adhere to all requirements for continuous credentialing within the system. Failure to do so will result in loss of credentials and nee for recommendation of the process .





Provider Signature Date Medical Director Signature Date

_______________________________ ______ _______________________________ ________

66


Lemhi County Idaho Emergency Medical Service Credentialing Plan

ALL: Emergency Medical personnel that are affiliated with a State of Idaho Licensed EMS Service go through a credentialing every recertification cycle. Credentialing can be completed by Department/Agency Training Officer and/or President. All EMS Providers will supply needing documentation for this process.


Credentialing Check list

Name

ID

Date Completed

Annual skills

Semi-Annual






Airway/Ventilation/oxygenation



Observed
Adult Ped.

Training/Testing
Adult Ped

Date

Initials

Airway nasal













Airway- Oral













Bag Valve Mask (BVM)













Cricoid Pressure (Sellick)













Head tilt /Chin lift













Jaw- Trust













Modified Jaw Trust (trauma)













Modified chin lift













Mouth to barrier













Mouth to Mouth













Mouth to mask













Mouth to Nose













Mouth to stoma













Obstruction Manual













Oxygen Therapy Nasal Cannula













Oxygen Therapy Non- rebreather mask













Oxygen Therapy Simple face mask













Oxygen Therapy King airway













Oxygen Therapy Combitube













Pulse Oximetry













Suction Upper airway













Ventilators ATV for non-intubated patients



























67






























Cardiovascular/Circulation



Observed
Adult PED.

Training/Testing
Adult Ped.

Date

Initials

Cardiopulmonary Resuscitation (CPR)













Defibrillation Automated/Semi Automated













Hemorrhage control Direct Pressure













Hemorrhage control Dressing













Hemorrhage control Pressure dressing













Hemorrhage control Tourniquet












1   2   3   4   5   6   7   8   9


The database is protected by copyright ©dentisty.org 2016
send message

    Main page