SOUTHERN ILLINOIS UNIVERSITY RADIOLOGIC SCIENCES PROGRAM DIAGNOSTIC MEDICAL SONOGRAPHY SPECIALIZATION ULTRASOUND DEPARTMENTAL PROCEDURE AND PROTOCOL FORM I,, have read and understand the Ultrasound Department s Procedure and Protocol Manual and am sufficiently informed to perform according to stated procedures. I have been shown the location of supplies and equipment necessary for performance of ultrasound guidance procedures. Student Signature Clinical Supervisor s Signature
SIU RADIOLOGIC SCIENCES DIAGNOSTIC MEDICAL SONOGRAPHY PROGRAM HOSPITAL POLICY MANUAL AND DEPARTMENT ORIENTATION FORM I,, have read and understand the Hospital Policy Manual at _ and agree to acknowledge and abide by the policies in the manual. If I do not abide by the policies as stated, I understand that I will be subject to expulsion from the clinical site. I also have been given a hospital orientation as well as a radiology/ultrasound department orientation to familiarize myself with the following: locations of various departments throughout the hospital the hierarchy of the radiology department the patient flow procedure the processing of films from the beginning paperwork through the filing system routine imaging protocol of this department. Student Signature Clinical Supervisor s Signature
SIU RADIOLOGIC SCIENCES DIAGNOSTIC MEDICAL SONOGRAPHY PROGRAM STUDENT-HOSPITAL EMPLOYMENT AGREEMENT We, the undersigned, agree that any present or future employment of shall only occur during hours not scheduled for clinical education. If the above-named student shows evidence of working for employment during assigned clinic hours or forging time, he/she will be expelled from that affiliate as a clinic assignment. This may ultimately result in expulsion from the program. Student Clinical Instructor Chief/Administrative Technologist SIUC Faculty
SIU RADIOLOGIC SCIENCES DIAGNOSTIC MEDICAL SONOGRAPHY PROGRAM FILM BADGE POLICY Since ultrasound does not involve ionizing radiation, SIU does not require ultrasound interns to wear film badges. Because clinical experience must be accomplished, no ultrasound student is to be involved with diagnostic radiography during clinical internship hours. If the intern has arranged employment at the clinical site on hours other than clinical internship, arrangement for the film badge is the responsibility of the employer. Should pregnancy occur during the internship, the student has the option of completing the internship after the pregnancy or signing a waiver of responsibility and completing the internship. The waiver may be obtained from the Sonography Program Director. I have read and understand the above policy. Intern s Signature Clinical Supervisor s Signature
SOUTHERN ILLINOIS UNIVERSITY RADIOLOGIC SCIENCES PROGRAM DIAGNOSTIC MEDICAL SONOGRAPHY SPECIALIZATION UNDERSTANDING OF CLINICAL RESPONSIBILITIES I,, hereby acknowledge that I have read and understand the contents of this student handbook and agree to abide by these policies as stated or be subject to University recourse. 1. List the departmental or hospital intercom/phone code for: a. A patient experiencing cardiac or respiratory arrest. b. Assistance with a violent patient, family member, or visitor. c. A fire noticed within the department or hospital. d. A weather emergency or natural disaster (tornado, earthquake, mine explosion, massive auto accident, bomb explosion). 2. List the name(s) of your Clinical Instructor(s). Student Signature Clinical Instructor s Signature *To be kept in the student s file at the program office.
ULTRASOUND CLINIC II COMPETENCY EVALUATION - CATEGORY I & III Student: Exam: Clinic Site: : Please assess the student s professional and clinical performance at this stage of his/her internship by placing the number which best describes each category in the space provided. 3 = Meets performance expectations of an entry-level sonographer 2 = Performs exam with minimal assistance 1 = Not yet competent - requires direct supervision I. Patient Care: Assists patient to and from the exam room Explains procedure to patient, and verifies patient preparation Answers patient s questions in a professional manner Demonstrates empathy for patient/ patient s family Observes patient confidentiality II. Obtains a thorough and accurate patient history: Identifies pertinent clinical questions and the goal of the examination Recognizes significant clinical information and historical facts from the patient and the medical records, which may impact the diagnostic examination Tailors exam accordingly III. Scanning Skills Follows imaging protocol Selects correct transducer and frequencies for the examination Positions patient for optimal anatomical visualization Demonstrates ability to optimize images (proper knobology) Identifies pertinent anatomical structures, artifacts, abnormal findings Performs related measurements Labels images correctly Utilizes appropriate examination recording devices Practices universal precautions IV. Exam follow-through Completes patient examination and paper work in timely fashion Effectively communicates patient history, clinical, and sonographic findings to physician Demonstrates initiative in following-up on interesting cases Evaluator s comments: Total Points Clinical Supervisor s signature: Intern s comments: Intern s signature
ABDOMINAL DOPPLER LOG NAME Demonstrate and evaluate abdominal vessels with spectral/color Doppler. Log all Abd Dop (observed, assisted or performed) both on this form and on your daily logsheet. Five documented performances of each vessel are required before competency is attempted. DATE EXAM (O-A-P) SUPV TECH HA HV PV AO IVC SMA SMV RA RV O=Observed (strictly observed, little patient interaction, no hands-on) A=Assisted (assisted with patient care, some hands-on, with supervision) P=Performed (provided patient care, performed most of exam with minimal supervision) HA = Hepatic Artery, HV = Hepatic Vein, PV = Portal Vein, AO = Aorta, IVC = Inferior Vena Cava SMA = Superior Mesenteric Artery, SMV = Superior Mesenteric Vein, RA = Renal Artery, RV = Renal Vein
ABDOMINAL DOPPLER LOG NAME *Photocopy as needed.
ULTRASOUND CLINIC II COMPETENCY EVALUATION - CATEGORY II (Hepatic Artery, Hepatic Vein, Portal Vein, Inferior Vena Cava, Superior Mesenteric Artery, Superior Mesenteric Vein, Aorta, Renal Artery, and Renal Vein) Student: Exam: Clinic Site: : Competency must be demonstrated and a form completed for each of the above listed vessels.* A minimum of 5 spectral/color Doppler exams must be logged before a competency can be attempted for that vessel. Please evaluate the student s performance by placing the number which best describes each category in the space provided. 3 = Meets performance expectations of an entry-level sonographer 2 = Performs exam with minimal assistance 1 = Not yet competent - requires direct supervision I. Identifies vascular structure correctly II. III. IV. Employs optimization skills to demonstrate color flow Demonstrates good judgment in obtaining spectral analysis (correct Doppler angle, etc.) Recognizes normal vs. abnormal flow and proceeds accordingly Evaluator s comments: Total Points Clinical Supervisor s signature Intern s comments: Intern s signature * A total of 9 evaluation forms must be completed one for each of the above listed vessels. *
ULTRASOUND CLINIC II COMPETENCY EVALUATION - US GUIDANCE Student: Exam: Clinic Site: : Due to the unpredictability of ultrasound guidance exams, it is expected that the student will be involved in all guidance exams until competency can be documented. Please evaluate the student s performance by placing the number which best describes each category in the space provided. 3 = Meets performance expectations of an entry-level sonographer 2 = Performs exam with minimal assistance 1 = Not yet competent - requires direct supervision I. Sets up for the exam maintaining sterile field/transducer as required II. III. IV. Explains procedure to patient and obtains signed consent Performs pre-scan and localizes region of interest Sonographically visualizes needle and documents procedure according to protocol V. Utilizes critical thinking while assisting in performance of procedure VI. VII. VIII. Monitors the patient during and after the procedure Labels and transports specimen according to protocol Cleans area following OSHA guidelines post procedure Evaluator s comments: Total Points Clinical Supervisor s signature Intern s comments: Intern s signature
SIU RADIOLOGIC SCIENCES DIAGNOSTIC MEDICAL SONOGRAPHY PROGRAM CLINICAL ATTENDANCE TIME SHEET NAME: CLINICAL SITE *Time sheet is to be kept current at all times and turned in at end of semester. *Indicate: P = Present A = Absent T = Tardy H = Holiday PD = Personal Day *One Personal Day each semester may be taken upon prior approval of your Clinical Supervisor. *Failure to comply with the hours assigned by your clinical site will affect your clinical internship grade. MONTH 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Hours Present January February March April May June July August Hours Absent Hours Made Up Total Days (Clinical Instructor's Signature) () (Student's Signature) ()
ULTRASOUND EXAMINATION DAILY LOG SHEET NAME Complete one line for each exam: ; Exam; Level of participation (O-Observed (minimal patient care, no scanning), % = Percentile of exam performed (assisted with patient care, scanned with supervision); P=Performed (provided patient care, performed most of exam); Level of Supervision (D-Direct Guidance; L-Limited (Assisted as needed); I-Indirect (Available as needed); Initials of supervising sonographer; and Preliminary exam findings. DATE EXAM O/%/P D/L/I SUPV EXAM FINDINGS Daily Log Sheet *Photocopy as needed
WEEKLY LOGSHEET (To be mailed to instructor at end of day each Friday) Student s Name: One column per Patient Indicate organ(s) & % performed for each exam Abdominal Doppler Adrenals Appendix Breast GB/Biliary System Aorta/IVC Liver Pancreas Spleen Urinary Tract Retroper/Peritoneum Scrotum Soft Tissue Thyroid/Parathyroid Prostate Phys-Guided Procedure Gyn. / Transabdominal Gyn. / Endovaginal OB 1 st Trimester OB 2 nd /3 rd Trimester Biophysical Profile Vascular Other Weekly Logsheet
CLINIC LOGBOOK MONTHLY TOTALS Name: Month/ Year Total Exams Daily Totals: One column per Abdominal Doppler Adrenals Appendix Breast GB/Biliary System Aorta/IVC Liver Pancreas Spleen Urinary Tract Retroper/Peritoneum Scrotum Soft Tissue Thyroid/Parathyroid Prostate Physician Guided Proc. Gyn. / Transabdominal Gyn. / Endovaginal OB 1 st Trim. OB 2 nd / 3 rd Trim. Biophysical Profile Vascular Other Total Exams / Day
PERSONAL / PROFESSIONAL GROWTH ASSESSMENT Student: Clinic Site: Please assess each statement by placing the number which best describes the student s professional and clinical performance at this stage of his/her internship in the space provided. 3 = Consistently meets performance expectations 2 = Meets performance expectations most of the time 1 = Lacks consistency in performance 0 = Unacceptable I. Demonstrates good rapport / communication skills with patient; clinical supervisor; department personnel; and radiologist(s)/physicians II. III. IV. Demonstrates continual improvement of scanning skills Demonstrates desire to learn Demonstrates ability to accept positive criticism V. Demonstrates flexibility VI. VII. VIII. IX. Demonstrates initiative to assist in or perform all clinical duties Demonstrates professional appearance and good hygiene Demonstrates good attendance and punctuality Demonstrates responsible work ethics X. Exercises good judgment Evaluator s Comments: Total Points Clinical Instructor s Signature Intern s Comments: Intern s Signature
SIU RADIOLOGIC SCIENCES DIAGNOSTIC MEDICAL SONOGRAPHY PROGRAM EVALUATION OF CLINICAL SITE Clinical site Please rate the following categories. 5=excellent, 1=poor, 0=not applicable This evaluation must be submitted along with all competency forms prior to your last day at the facility. This evaluation will be held in confidence and is performed to insure that the facility is meeting the needs of the student sonographer. Should any difficulties arise prior to the end of the semester, it is the responsibility of the student to notify the sonography program director immediately. The facility provided adequate opportunity for completion of the required competencies. 5 4 3 2 1 0 The ultrasound staff was courteous, informative and helpful. 5 4 3 2 1 0 The clinical instruction and support facilitated my learning experience. 5 4 3 2 1 0 The overall clinical experience was a positive contribution toward my clinical education. 5 4 3 2 1 0 My pre-clinical preparation was adequate to enable me to accomplish clinical competency. 5 4 3 2 1 0 Medical (Physician) input was informative and helpful. 5 4 3 2 1 0 STUDENT COMMENTS STUDENT SIGNATURE
DMS Student Clinical Experience Record DMS Accreditation Requirement Statement: I certify that the examination numbers below are accurate and may be verified by review of Clinical Log records. I have observed, assisted or performed the following number of examinations between the period of (month), (year) and (month), (year). Student Signature: # Clinical Site(s) # Abdomen # OB/GYN # Vascular Total # Exams Total # Clinical Hours Fall Semester Spring Semester Summer Semester Total exams & hours DMS Student Permanent Clinical Record