Skills Evaluation Form

MUSCULOSKELETAL INJURIES

Name _____________________________________ Date _____________________ Group : _________

POINT REMARK
DISLOCATION OF THE SHOULDER √/x
S S
1. Proper use of PPE, survey the scene, introduce and ask permission. 3
2. Do manual stabilization. 2
3. Check PMS (pulse, motor, sensation) 3
4. Support the arm with a sling. 3
5. Place a pad between the arm and the chest. 3
6. Immobilize the arm with a swathe. 3
7. Secure the end of the cravat. 3
8. Reassess pulse, motor and sensation. 3
9. Indicate if patient is ready for transport. 2
TOTAL 25
POINT
FRACTURE or DISLOCATION OF THE ELBOW (BENT)
S
1. Proper use of PPE, survey the scene, introduce and ask permission. 3
2. Do manual stabilization. 2
3. Check PMS (pulse, motor, sensation) 2
4. Measure splints on the good side. 2
5. Stabilize the arm between two rigid splints. 3
6. Secure the splints in place. Secure the ends of the cravat. 3
7. Support the arm and splints with a sling. 2
8. Immobilize with a swathe. 2
9. Secure the end of the cravat. 2
10. Reassess pulse, motor and sensation. 2
11. Indicate if patient is ready for transport. 2
TOTAL 25
POINT
FRACTURE OF THE LEG
S
1. Proper use of PPE, survey the scene, introduce and ask permission. 3
2. Do manual stabilization. 2
3. Check PMS (pulse, motor, sensation) 2
4. Measure splints on the good side. 2
5. Insert cravat first on the void space. 2
6. Pad the ends of the splints. 2
7. Place the rigid splint on inside of patient’s leg, from groin to foot and on the
3
outside from waist to foot.
8. Place pads on body prominence and void spaces. 2
9. Secure the splints in place and secure the ends of the cravat. 3
10. Reassess pulse, motor and sensation. 2
11. Indicate if patient is ready for transport. 2
TOTAL 25
POINT
DISLOCATION OF THE KNEE (BENT)
S
1. Proper use of PPE, survey the scene, introduce and ask permission. 3
2. Do manual stabilization. 2
3. Check PMS (pulse, motor, sensation) 3
4. Measure splints on the good side. 3
5. Pad the splints. 2
6. Stabilize the knee between two rigid splints. 3
7. Secure the splints in place. Secure the ends of the cravat. 3
8. Support the leg with a pillow or other bulky material. 2
9. Reassess pulse, motor and sensation. 2
11. Indicate if patient is ready for transport. 2
TOTAL 25

Minimum passing score: 80 points Score: _____________

Instructor’s Name: ______________________

Instructor’s Signature: ___________________
COMMENTS: __________________________