CLINICAL SITE INFORMATION FORM

Transcription

1 CLINICAL SITE INFORMATION FORM Other: Proof Current First98058 Aid of Please (2 student and years) CPR listhealth Washington Bloodborne Ext. clearance (425) 400 Melinda Renton Norman, PT t I: IntiIrmation For tile Academic PrOflTllm Angie South State Pathogen Medical Glass, Norman@Vallevmed.org 43rd Melinda Angie (425) X ocriminal Child Street Director Center Training Norman, Norman@Valleymed.org _Glass@valleymed.org clearance background of Rehabilitation PT check Services he Person son ormatio o HIPAA ID CCCE Name (List Director name / Contact of Clinical and Physical credentials) Person Center I Zip Therapy Phone State I WA lmail Clinical ox Proof badge OSHA Drug of education with immunization Other IndicateCredentialed Center screening education firsttbandtest last name and school which of Web the Cis following are Initial Date Revision Date

2 Valley Medical Center will require a Student Program Checklist to be signed by the ACCE and returned to Valley Medical Center prior to initiation of the internship. The Checklist attests that the educational program has the above information on file. It will be provided by Valley Medical Center to the ACCE in a timely manner. Valley Medical Center will not require copies of individual certifications. 5

3 Information About Multi-Center Facilities If your health care system or practice has multiple sites or clinical centers, complete the following table(s) for each of the sites. Where information is the same as the primary clinical site, indicate "SAME." Ifmore than three sites, copy this table before entering the requested information. Note that you must complete an abbreviated resume for each CCCE. Name oflauren Melinda_ Clinical WA Site 3600 (425) Renton Valley Lauren Melinda Lind Medical Adams Glass, Ave Ext. SW, OTRIL Center SteChildren's 160 Therapy I Zip I CCCE State I Facility Name of Clinical Site CCCE I City Street Address I Zip Ext. I Facility State Name of Clinical Site City CCCE Street Address I I Zip Ext. I Facility I State 6

4 Clinical Site Accreditation/Ownership Yes Is D No your JCAHO CARF Government Other clinical site Agency certified/ (eg, accredited? CORP, PTIP, If no, rehab go agencyștate to #3. Also Total Joint Center, DateStroke of Last ccred itatio DCertified Center for I:8J Nonprofit Government Hospital/Medical Physician/Physician PT/PTA Other your n/certifica Owned and clinical (please Bariatric Owned Agency site? tio specify) n Center center (check Group Public allowned that Hospital apply) Which If yes, of the hasfollowing your clinical bestsite describes been certified/accredited the ownership category D Corporate/Privately Owned by: Clinical Site Primary Classification To complete this section, please: A. Place the number 1 (1) beside the category that best describes how your facility functions the majority (:::50%) of the time. B. Next, if appropriate, check (.J) up to four additional categories that describe the other clinical centers associated with your facility. I ECF/Nursing Federal/State/County Other: Acute School/Preschool Ambulatory Multiple Private Rehabi Ind We ustrial/occupational Ilness/Prevention/F Care/Inpatient Specify Iitation/S Practice Level Care/Outpatient Home/SNF Medical ub-acute Program Health HospitalX itness X D D Program Health Facility Rehabilitation Clinical Site Location Which of the following best describes your clinical site's location? DRural X Suburban Durban 7

5 Information About the Clinical Teaching Faculty fy ABBREVIATED RESUME FOR CENTER COORDINATORS OF CLINICAL EDUCATION Please uvdate as each new CCCE assumes this vasil NAME: NoD NoxD Angie DX Norman YesD practice: clinical Length time Yes in Y2 years XOther of YesD 14 CI APT Yes Credentialing A X Credentialed CI apply: Length Mark (X) of all time that as atheci: CCCE: 13 years 3 years I Certified Clinical Specialist: Other credentials: SUMMARY OF COLLEGE AND UNIVERSITY EDUCATION (Start with most current): FROM Zoology Physical TO DEGREE Therapy BS MAJOR PERIOD OF INSTITUTION SUMMARY OF PRIMARY EMPLOYMENT (For current and previous four positions since graduation from college; start with most current): Present TO EMPLOYER PERIOD 1997 OF POSITION PT EMPLOYMENT FROM Providence St. Peter Hospital (acute care, inpatient rehab, PT III 8

6 CONTINUING PROFESSIONAL PREPARATION RELATED DIRECTLY TO CLINICAL TEACHING RESPONSIBILITIES (for example, academic for credit courses [dates and titles], continuing education [courses and instructors], research, clinical practice/expertise, etc. in the last three (3) years): Course Date Provider/Location 9

7 CLINICAL INSTRUCTOR INFORMATION Provide the following infonnation on all PTs or PT As employed at your clinical site who are CIs. For clinical sites with multiple locations, use one form for each location and identify the location here. No. Years Clinical A of Teaching No. KEY: List of = Clinical Highest Earned APT of Years Certifications Graduation AYear credentialed. of APTA T= L/EIT State Practice of Member Yes/N 0 Physical PT/PT CI Graduated from Number 3027Lymphedema 7]9]0Outpatient 14]2Vestibular ]915Outpatient ]6? 1413Inpatient LWA 17]5Outpatient 13]2Outpatient Licensure 6Temporary MSPT MPT Occupational ] ]992 Acute 200] PT ]99] ]978 ]995 Rehab OrthoYes Neuro B Health = Care Other Washington CI C credentialing L= E= A= Which Cert. Program Licensed, Eligible clinical CI Number specialist Outpatient Inpatient Supervisor Neuro D'Youville Hand Back Rehab Cheepman Duke Eastern Therapy L Services University PTOOOO 7254 of Name followed by credentials PTOOOO

8 Jon Takagi WA N/A 14<1Oupatient 1917Inpatient lh 82 87Inpatient 1< 51/ Outpatient Acute MSPT PTA Ortho No Care Green University Western N/A LPT River of College OCS LevellIl certified NAIOMT 8260 PTOOOO 11

9 Clinical Instructors What criteria do you use to select clinical instructors? (Mark (X) all that apply): D X APT Demonstrated Career Clinical Therapist Certification/training Years No Delegated Other Acriteria of Clinical ladder (please (not competence experience: initiative/volunteer APT opportunity job strength specify): Instructor A) description clinical Number: course clinical Credentialing instructor > 1X credentialing teaching How are clinical instructors trained? (Mark (X) all that apply) X APT Clinical Professional 1: No Continuing Other 1 individual Atraining Clinical (not (please center APTA) education continuing training inservices specify): Instructor clinical (CCCE:CI) by education Education academicd consortiad instructor D(eg, X and credentialing chapter, program CEU course) Information About the Physical Therapy Service Number of Inpatient Beds For clinical sites with inpatient care, please provide the number of beds available in each of the subcategories, r / Rehabilitation Psychiatric Total Other Number specialty center center centers: of Beds Specify listed Number of Patients/Clients E. h ber of oatient/cl. d Total Individual Student patient/client (depends PTA service therapist's float PTA - - up end and upon end tovisits of schedule. individual inpatient of area internship per ofday pm.) Will OUTPATIENT Total Student Individual PT/PTApatient/client PTA Team PTA visits per day 12

10 Patient/Client Lifespan and Continuum of Care Indicate the frequency of time typically spent with patients/clients in each of the categories using the key below: 1=(0%) 2=(1-25%) 3=(26-50%) 4=(51-75%) 5=(76-100%) Rating 0-12 Over Patient Critical Am Continuum bulatory 65 years Lifespan care, years (this /outpatient of ICU, population Careacute covered Rating 3by SNF Rehabilitation /ECF /su b-acute Wellness/fitness/industry Home health/hosoice I -5) Patient/Client Diagnoses 1. Indicate the frequency of time typically spent with patients/clients in the primary diagnostic groups (bolded) using the key below: 1=(0%) 2=(1-25%) 3=(26-50%) 4=(51-75%) 5=(76-100%) 2. Check (--1) those patient/client diagnostic sub-categories available to the student. (1-5) Congen Burns Scar Fitness Organ Neuromuscular Arthritis Chronic Oncologic Open Amputation Cognitive Well Musculoskeletal Bone Vestibular Cerebral Lymphedema Pulmonary Muscle Connective Brain Acute Cardiac General Orthopedic Spinal Peripheral Other: Neuro-muscular Cardiovascular-pulmonary Integumentary formation ness/prevention disease/dysfunction wounds injury transolant cord (Soecifv) italldevelopmental (SpecifY) (May (Specify) medical pain surgery impairment conditions nerve disorder dysfunction/disease tissue surgery iniury cross degenerative conditions -iniury accident disease/dysfunction adysfunction/disease number a comorbidity of diagnostic only groups) Other: (Specify) 13

11 Hours of Operatioll Facilities with multiple sites with different hours must complete this section for each clinical center. Days of the Week 5:00 To: Outpatient Therapist are covered From: (p.m.) 8:00 8:30 have service (a.m.) by Comments rotating varied hourschedules. therapists. are 7:00-6:30 Weekends M-F Studellt Schedule Indicate which of the following best describes the typical student work schedule: o Standard 8 hour day X Varied schedules Describe the schedule(s) the student is expected to follow during the clinical experience: The average is an eight hour day 8:30-5:00 Monday through Friday. Individual therapist work varied schedules. A student may be asked to match their CI schedule. They may be asked to work a confirmed 32 hour per week schedule with additional opportunities set up to achieve a 40 work week, as available. This will be determined on an individual basis. Staffillg Indicate the number of full-time and part-time budgeted and filled positions: II 7 2 Full-time Part-time Inpatient 2Current 0total budgeted Staffing budgeted 3II 1 Full-time 416 IPart-time Outpatient 70 Current 1 total budgeted Staffing budgeted 14

12 Information About the Clinical Education Experience Special Programs/Activities/Learning Opportunities Please mark (X) all special programs/activities/learning opportunities available to students. 0 Aquatic Critical Group Sports Surgery Team Vestibular Wound Other Neonatal Administration Athletic Cardiac Com Industrial/ergonomic Inservice Back Biomechanics Departmental Qual Radiology Research Screening/prevention Nursing Orthotic/Prosthetic Pain Pediatric-general: Classroom mun ity management school meetings/rounds physical care/intensive therapy (observation) rehabilitation venue home/ecf/snf ityire-entry training/lectures experience (very administration0 lab coverage therapy limited) fabrication Children's PT care0 access 0 Women's Work Early consultation Employee Home Prevention/wellness Pulmonary Neurological Musculoskeletal Developmental Cognitive (specify intervention programs/classes health Health/OB-GYN intervention rehabilitation impairment below) program 0 X X X Therapy only (outpatient) Lymphedema/hand Assurance/CQ Hardening/conditioning I/TQ Mclinic Specialty Clinics Please mark (X) all specialty clinics available as student learning experiences. Seating/mobility Orthopedic Pain Developmental Prosthetic/orthotic Preparticipation Other Screening Scoliosis Sports Wellness Women's Hand Neurology Balance Feeding Hemophilia Industry clinic (specify clinic medicine health clinics clinic below) sports clinic clinic (limited)0 0X 0 0 Arthritis 0 15

13 Health and Educational Providers at the Clinical Site Please mark (X) all health care and educational providers at your clinical site students typically observe and/or with whom they interact. X Massage Administrators 0 Nurses Occupational Speech/language Social Alternative Athletic workers trainers therapies: Prosthetists Respiratory Physicians Podiatrists Psychologists Students Therapeutic Others Special Vocational Dietitians Audiologists Exercise Health Fitness Enterostomal (specify education information professionals from assistants physiologists (list /orthotists therapists rehabilitation recreation other /wound specialties) below) teachers physical X 0 X therapists counselors disciplines therapv pathologists education programs Affiliated PT and PT A Educational Programs List all PT and PTA education programs with which you currently affiliate. Program Name XPTA 0 XPT 0 Cheney, Tacoma, TX City Seattle, MO Auburn, CA ID and WA State 0 16

14 A vailability of the Clinical Education Experience Indicate educational levels at which you accept PT and PTA students for clinical experiences (Mark (X) all that apply). D Specialty Physical Therapist Physical First DIntermediate X Full Final Half Other: Therapist experience: days days experience (Specify) experiences: Assistant Check allcheck that apply. all that apply. experience 2FromTo PTA 41 schedules impact hours/week) Indicate the range of weeks you will accept students for anyone part- PT I adult outpatient PTA pediatric inpatient PT Yes DNo Is your clinical site willing to offer reasonable Comments accommodations for students under ADA? What is the procedure for managing students whose performance is below expectations or unsafe? ACCE advises CCCE. CCCE meets with CI to discuss management. Frequent feed back and goal setting times set between student and CI. Feedback loop then frequently between CI, CCCE, ACCE and student. Answer if the clinical center employs only one PT or PT A. Explain what provisions are made for students if the clinical instructor is ill or away from the clinical site. Multiple team members are willing and available to work with interns if there instructor is away. There are also multiple additional observational experiences. 17

15 X Clinical Site's Learning Objectives and Assessment Yes The Students D 3. I. No student's academic Does Are with prepared all your professional objectives? disabilities? program's clinical at different site objectives staff (on provide levels an members asfor needed written within specific who the basis) clinical provide academic learning education physical experiences? curriculum? objectives therapy services to students? acquainted with the clinical Ifno, go site's to # learning 3. objectives? 2. Do these objectives accommodate: When do the CCCE and/or CI typically discuss the clinical site's learning objectives with students? (Mark that apply) (X) all X Beginning Weekly At Other Daily mid-clinical end PRN of clinical of the clinical experience experience X Indicate which of the following methods are typically utilized to inform students about their clinical performance? (Mark (X) all that apply) X Student Written Ongoing As Weekly per student self-assessment and written feedback oral request goals mid-evaluation summative and inthroughout addition feedback, final theevaluationx clinical tothe formal prnclinical only X and ongoing written & oral feedback OPTIONAL: Please feel free to use the space provided below to share additional information about your clinical site (eg, strengths, special learning opportunities, clinical supervision, organizational structure, clinical philosophies of treatment, pacing expectations ofstudents [early, final]). Surgery observation available (for total hip or knee only) Participation in community events available throughout the year. (bike helmet fittings, backpack awareness, Senior Fair, Career Fair, Bring Your Kids to Work Day, etc... ) Exposure to Team Rounds Aquatic Therapy 18

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17 Part II. Information for Students Use the check (~) boxes provided for Yes/No responses. For all other responses or to provide additional detail, please use the Comment box. Arranging the Experience Yes Are Is two one How a D6. D Rubella any step X3. X10. X12. X13. No I. is current this Does other Is Are a) Is a students information emergency other Is Titer Mantoux 7. any II. are your health X student Is other Test non-emergency student clinical (1/ receive need tests/immunizations c..j TB or student required health communicated physical check) to responsible site the contact care (PPO) required to same to exam provide medical attest have or be available the required? immunizations official CPR for a to records required? clinical proof to student emergency the proof provide care an certified? for holidays clinic? of understanding available required site of students? interview? health prior proof any HIPAA for required Provide health as other insurance? specific tof staff? the training?provided OSHA students? care of on-site? current individual provided Td, prior Hep Measles, Student the work costs? To Bloodborne Recommended Tetanus, Btobeinternship Program by Mumps, determined basis VMC Oiptheria, on pathogens site Checklist needs two Comments onweeks an to be If b) yes, If certifications signed yes, within prior benefits a) If (Please yes, please bytowhat ACCE. please orientation note and list. time risks if required. specify: Individual aframe? specific of athepatitis-b yourcourse facility? is immunization? required). 4. Indicate the time the student should report to the clinical site on 20

18 and YesIs the Da X19. X21. X23. X24. No 20. child student a) Is Is abuse the Can medical a 22. criminal responsible student the clearance student testing required background for required? available receive the to cost submit be CPR First check on-site certified or Aid required to afor certification drug instudents? First clearances? (eg, test? while Aid? Criminal on-site? Human past internship two Washington Only Resources site years orientation instances prior State will tocomments of -occur with within work statements, the and related first will If yes, exposure day include etc please of... the privacy describe internshipparameters. Housing Yes No X Is housing provided State: for female students? (If (If no, no, go go to to #32) #32) Comments I Zip: Person What Description Name: istothe contact average of thetotype cost obtain/confirm of of housing? provided: housing: City: Address: 30. How far is the housing from the facility? 21

19 If housing X a) b) is Isnot there 32. provided a contact list available forperson either concerning for gender: information housing on housing the Please Center areainreference Website of for Valley linksmedical Please the area list contact of the clinic? person and phone #. on Transportation Yes What Subway Airport? Bus Dstation? 35. No is the station? Will Is public parking cost a student for transportation available parking? need aatcar the available? toclinical complete center? the clinical free ] experience? block 5will Valley internship. miles miles Or limited Map be public Medical mailed andplease parking transportation prior Center reference tocomments directions each website to access internship issuesthis regarding confirmation. information whereprior the clinical center is located. No unusual safety issues 36. How a) Train closestation? is the nearest transportation (in miles) to your site? Meals Yes D 40. No Are 39. facilities Are meals available available for $ the for storage students and on-site? preparation (I f no, of go Microwave Cafeteria food? to #40) available and refrigerator Comments Lunch Dinner (if yes, indicate 22

20 Stipend/Sell olars Itip Yes X41. X42. No Is athis stipend/salaryprovided in lieu of formeals students? or housing? If no, go to #43. Comments the clinical experience to be eligible for a stipend/salary? 43. a) What Howis much the minimum is the stipend/salary? length of time($ the / week) student needs to be on e. Special Information D Yes Specify No X Do Will Is there you dress 47. the require adoes code facility/student your for any have case women: site additional access study have dress or ato written inservice code? the Internet Ifno, or policy from verbal at gofor all the to work pants and missed students # clinical 45. heel from okay. Casual educational Additional basis. institution days site? Very Lab Based the Will Determined all No due professional. jacket shoes. support limited scrub on requirements. to assignments institution circumstances -loaners tops. educational Comments Scrub individual policy. may available and No be progression given skirts prn or of shorts. tointernship. facilitate Closed toe X Otlter Student Information D Yes Other Tour Review Student Supplemental 49. Quality Reimbursement Required Documentation/billing Policies Learning Patient Facility-wide Noof (specify facility/department of expectations you information/assignments assurance and goals/objectives style assignments a) provide readings procedures Please below inventory volunteer issues indicate -the eg, (eg, student (specificallyx bloodborne of orientation case the clinical with typical study, X experience an pathogens, orientation on-site hazardous and quality orientation content materials, issues) to byyour marking etc.) clinical HIPan AA, Xsite? by Healthstream all items that (safety are included. diary/log, inservice) 23

21 In appreciation... Many thanks for your time and cooperation in completing the CSIF and continuing to serve the physical therapy profession as clinical mentors and role models. Your contributions to learners' professional growth and development ensure that patients/clients today and tomorrow receive high-quality patient/client care services. 24