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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]
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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
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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
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Attendance and Leave Policies
..........................................................................................11
Clinical Attendance Policy
.............................................................................................11
Sick Time Policy
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Medical Leave Policy
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Clinical Assessment and Grading
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13 Clinical Training Grading Process
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MPTC Respiratory Therapist Program Inter-Rater Variability
Reduction Plan ...............13 Clinical Training Complaint
Resolution
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Probation
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Dismissal from the Clinical Site
..........................................................................................14
Moraine Park Respiratory Therapy Program Clinical Manual Review
Acknowledgement
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14 Appendices
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1 Revised 8/22/2019
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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10 Revised 8/22/2019
• 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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13 Revised 8/22/2019
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_____________________________________________________
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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
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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
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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:
Address: City: State: Zip Code:
Name: Contact Phone:
Address: City: State: Zip Code:
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
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Incident Report Moraine Park Technical College 235 North
National Avenue P.O. Box 1940 Fond du Lac, WI 54936-1940
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:
__________
Updated 4.2018 Page 2 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
mailto:[email protected]?subject=Incident%20Reportmailto:[email protected];%[email protected]?subject=Incident%20Report
-
Incident Report Moraine Park Technical College 235 North
National Avenue P.O. Box 1940 Fond du Lac, WI 54936-1940
Witness Statement
Name: Contact Number:
Please describe what you witnessed.
Witness Signature: Date:
Updated 4.2018 Page 3 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
-
Appendix 3 (rev 8/22/19)
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 _____
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 _____
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 _____
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 _____
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 _____
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:
____________
Appendix 4 (rev 8/22/19)
-
Appendix 5 (rev 8/22/19)
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:
__________________________________________
-
Appendix 6 (rev 8/22/19)
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:
-
Appendix 6 (rev 8/22/19)
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
-
Appendix 7 (rev 8/22/19)
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): _____________
_______________________________________________________________________________
Appendix 7 (rev 8/22/19)
-
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.
Appendix 8 (rev 8/22/19)
-
Significant Exposure Description Form Moraine Park Technical
College 235 North National Avenue P.O. Box 1940 Fond du Lac, WI
54936-1940
Updated 4.2018 Page 1 of 1 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.
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
Address: City: State: Zip Code:
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
Address: City: State: Zip Code:
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: