Clinical Simulation Lab Request Form - University of Nevada, Reno

Clinical Simulation Lab Request Form
Instructions:
Fill in the form as completely as possible for each simulation you wish to run. If you wish to run multiple
simulations on the same day, a separate patient scenario form is required for each simulation. If we
already have your patient scenario form on file, only the first page is necessary. This is to ensure the lab
is properly set up, manikins are configured properly and the proper schedule is set in the B‐Line system.
When complete, press the submit button in the upper right corner and the form will be emailed to the
simulation coordinator. You will receive a confirmation email back for the dates and times requested. If
you are unable to email the form, you may print and send to the Simulation Coordinator at mail stop
0134.
Requestor Information:
Class title and number:
Requestor name (must be UNR faculty):
Requestor email:
Requestor phone:
Lab and Equipment Requested:
How Many Sim Labs Requested:(Up to 3)
Date: Beginning Time: Ending Time:
Will you be using: SimMan3G Y N SimBaby Y N
Debrief and Live Streaming:
Will you need a separate room to debrief? Y N If yes, how many people will be debriefed?
Are you planning on live streaming the scenario to the multipurpose room? Y N
If so, how many will be viewing?
For B‐Line viewing and recording, we have two options. Please choose one of the following:
A) All four cameras recording with audio
B) Three cameras with audio and the patient monitor
Scenario Information:
Number of students involved in scenario:
Number of instructors:
Number of confederates if any:
Number of non‐student observers if any:
Do we have your scenario(s) on file? Y N If YES, please list patient name(s):
If NO, continue to the next page.
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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
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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
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