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Skills and Procedures Form - Emergency Medicine
Please check your clinical capabilities, and where indicated, list the approximate number of procedures performed within the last 24 months.
Management and treatment of medical emergencies including: cardiac arrest, acute CHF, respiratory failure, acute GI bleeding, DKA
Management and treatment of OB emergencies including: precipitous delivery, hemorrhage, ectopic pregnancy, spontaneous incomplete abortion
Management and treatment of psychiatric emergencies including: acute psychosis and overdose
Management and treatment of injuries including: poisoning, anaphylaxis, shock, overdose, drowning, burns, and electrocution
Management and stabilization/treatment of single or multiple trauma including: perforation of thoracic or abdominal viscus, pneumothorax, blunt or penetrating injuries, head trauma, spinal cord injuries, hemorrhage, soft tissue injuries including the eye, fractures, dislocations, soft tissue injuries of the extremities
Do you feel comfortable covering a Level III, usually rural, setting?
Yes
No
Do you feel comfortable covering a Level I trauma setting?
Yes
No
How many Emergency Medicine hours per month would you like for us to provide you?
Board standing in Emergency Medicine
ABEM or AOBEM Certified
Yes
No
Date First Certified:
Date Most Recently Re-certified:
ABEM or AOBEM Qualified
Yes
No
Date First Became Qualified:
Expected Date of Completion
Oral Exam:
Written Exam:
Emergency Medicine Work History
Note: Do not put “See CV.” Only include information for work completed within the past 24 months.
Hospital Name - 1
Dates of Affiliation
(mm/yy)
Trauma Level Rating
Average Annual Patient Volume
Total Hours Logged
(estimated)
Single or Double Coverage?
Hospital Name - 2
Dates of Affiliation
(mm/yy)
Trauma Level Rating
Average Annual Patient Volume
Total Hours Logged
(estimated)
Single or Double Coverage?
Hospital Name - 3
Dates of Affiliation
(mm/yy)
Trauma Level Rating
Average Annual Patient Volume
Total Hours Logged
(estimated)
Single or Double Coverage?
Hospital Name - 4
Dates of Affiliation
(mm/yy)
Trauma Level Rating
Average Annual Patient Volume
Total Hours Logged
(estimated)
Single or Double Coverage?
Hospital Name - 5
Dates of Affiliation
(mm/yy)
Trauma Level Rating
Average Annual Patient Volume
Total Hours Logged
(estimated)
Single or Double Coverage?
Please list any limitations or comments on information provided above:
I affirm that all information provided on this page is true and accurate.
*
Print Name
Date
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