Clinical Simulation Lab Request Form - University of Nevada, Reno

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Learning Objectives: (Optional) Clinical Simulation Lab Request Form Scenario Information: Setting(ER, Hospital Room, etc): Length of Scenario: Minutes Brief Description: Patient Information: Please submit one completed form for each patient scenario. Patient name: Last Middle (optional) First DOB: Sex: M F Weight: MM/DD/YYYY Allergies: Initial Vitals at Start of Scenario: HR SPO2 BP RR Drugs to be Administered: Please do not leave blank. Enter None if no drugs are to be used Drug1: Dose: Delivery Method: Change in vitals after drug (enter NA if none): HR SPO2 BP RR Over Minutes Drug2: Dose: Delivery Method: Change in vitals after drug (enter NA if none): HR SPO2 BP RR Over Minutes Drug3: Dose: Delivery Method: Change in vitals after drug (enter NA if none): HR SPO2 BP RR Over Minutes Page 2 of 3
Clinical Simulation Lab Request Form Patient Monitor Display: Please tell us what you would like displayed on the patient monitor. Enter NONE if you want it off. Special Instructions: Please enter a DETAILED description of how the lab space should be arranged and any props or equipment needed for the scenario. Examples: SimMan3g in ER with pitting edema on both ankles and several tissues containing greenish sputum. IV connected and running with NS, ETC. Supply Request: Please list all expendable items requested. Example: 2x2 sterile gauze. Lab Roles and Responsibilities: Simulation technical staff roles and responsibilities: • Prepare the simulation room and technology based on assigned cases for the day and faculty’s prep list. • Set‐up the debrief room. • Review the programming with the clinical instructor. • Operate the manikin and cameras during the scenarios. Instructor roles and responsibilities: • Provide students a brief orientation on their roles and responsibilities and the simulation area at the start of each day. • Manage the live scenario from the simulation control room and respond appropriately to students’ actions. This may require altering the scenario. • Provide the voice of the patient. I agree to adhere to the Policies and Procedures of the University of Nevada Clinical Simulation Lab. The policies and procedures may be found at: www.unr.edu/simulation/about the lab/proceduresandscheduling Revised 12/12 Page 3 of 3
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Clinical Simulation Lab Request Form - University of Nevada, Reno

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