National Registry Paramedic – EMT Training
Once a candidate completes their paramedic education at a program accredited by CAAHEP (Commission on Accreditation of Allied Health Educations), they become eligible for the NREMT exam. A National Registry Paramedic candidate must successfully complete both the Cognitive and Psychomotor exams to become eligible for the NREMT’s National EMS Certification at the paramedic level.
If you don’t know whether you want to become a paramedic or an EMT, check out EMT vs. Paramedic for more information on each career.
This page will focus primarily on the National Registry of EMT Paramedic exams, however there have been some significant changes to Paramedic schooling programs and Psychomotor testing in August 2016 which will also be discussed.
All candidates that begin a Paramedic program after August 1 2016 are required to complete a paramedic portfolio that will become a part of their permanent education file.
You may be asking:
What is a paramedic portfolio?
Basically a paramedic portfolio is documented evidenced of how a student performed throughout their paramedic school program. It can be physical – with papers in a binder (Paramedic skill sheets, clinical sheets, etc) or it can be an electronic online paramedic portfolio.
The portfolio is a collection of evidence that shows the progress a student made throughout their training and it can be presented if the National Registry audits the EMS professional.
Some vital things that will be included in the paramedic portfolio are records of successful completion of the 33 required Paramedic skill sheets, Scenario Lab Forms, Clinical Evaluation Forms, and Capstone Field Shift Evaluation Worksheets.
The paramedic portfolio shows competency in emergency medical skills which means the National Registry paramedic psychomotor exam no longer needs to test candidates on 12 basic skills like in the past. Here is some information about the required paramedic portfolio forms.
The Scenario Lab forms document 20 successful performances in both the team member and team leader roles. (These patient contacts must involve any of the 15 Scenario Topic Areas.)
Ten of these will be successful team member evaluations and ten will be team leader evaluations.
In the team leader role the candidate will be required to complete:
→ Four successful adult patient leads.
→ Three successful pediatric patient leads.
→ Three successful geriatric patient leads.
Once a student demonstrates acceptable performance in any Scenario Lab topic area, the student is permitted to move on to the related clinical area. At this point a Clinical Shift Evaluation Worksheet must be completed by the Clinical Preceptor for each of the candidate’s clinical rotations.
Once these skills are completed in a clinical setting the candidate can move on to the Team Leader position at the Capstone Field Internship.
At this point Field Shift Evaluation Worksheets will be completed by the Field Preceptor for each of the candidate’s field rotation.
To clarify, during the Capstone field internship the candidate is a team leader in field and supervised by a clinician that is at least at a paramedic skill level.
The Candidate acts as team leader running all the calls and the preceptor only steps in to avoid patient safety issues, etc.
The patient contacts during this field internship will take place on an Advanced Life Support (ALS) Unit responding to critical and emergent patients (911 calls).
In order to successfully complete the field internship, the candidate will need to succeed in 18 of the last 20 patient contact evaluations.
The calls getting evaluated can be BLS (Basic Life Support) or ALS, because it can be difficult to get 20 ALS calls in a row. (“Successful” will be defined as a score of “2” in the Team Leadership category of the Capstone Field Internship Evaluation Worksheet).
National Registry Paramedic – Cognitive
The National Registry of EMT exam for the Paramedic level is a written Paramedic test that will have from 80 to 150 questions. There are 20 pilot questions in the paramedic exam that are being tested for future exams and do not count towards your final score.
The NREMT Paramedic (NRP) cognitive exam will cost $125 per testing attempt and the candidate will have up to 2 hours and 30 minutes to complete the paramedic test.
The NREMT Paramedic test is a written exam, but it is administered via computer using computer adaptive testing (CAT), which is discussed in detail below.
The cognitive portion of the NREMT exam for the Paramedic is constructed to administer test questions from 5 areas of content. The content categories are Trauma, EMS Operations, Airway; Respiration and Ventilation, Cardiology an Resuscitation, and Medical; Obstetrics and Gynecology.
Within these content areas, any questions related to patient care will pertain to 85% adult and elderly and 15% pediatric patients.
The goal of the National Registry Paramedic exam is to determine whether candidates possess the complex knowledge and skills needed provide patient care at a competent level. The paramedic tests need to assess whether candidates can successfully apply book learning and course knowledge to field experience while they provide safe patient care.
The paramedic test is designed to create situations and tasks an advanced EMS professional will need to respond to once on duty.
Wrong answers on the paramedic exam may reflect wrong decisions in the field that can lead to incorrect assessment or treatment of patients in the field.
The paramedic cognitive exam is organized using a test plan approved by the National Registry of EMT Board. The test plan is a blue-print that communicates with the computer testing software and instructs it on how to build each candidate’s exam.
According to the test plan each Paramedic exam will focus on:
• 13% – 17% Trauma
• 10% – 14% EMS Operations
• 18% – 22% Airway; Respirations and Ventilations
• 22% – 26% Cardiology and Resuscitation
• 25% – 29% Medical; Obstetrics and Gynecology
These 5 areas of content cover Emergency Medical Services (EMS) care and the standard for passing each is providing safe and effective entry-level emergency medical care.(This is also true for the for EMT-B and AEMT when taking the NREMT Exam )
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COMPUTER ADAPTIVE TESTING
Computer adaptive testing is a specific type of testing and being familiar with it can give you an advantage when taking the Paramedic test. The directions for the National Registry Paramedic exam are simple and you don’t need to be familiar with computers to do well on this test.
However, understanding computer adaptive testing (CAT) and getting comfortable with it can help a candidate pass the National Registry Paramedic exam and further your goal towards becoming a paramedic.
Computer adaptive testing (CAT) is different from the computer based linear tests that candidates may be used to. These linear tests are similar to taking a test with pencil and paper.
Linear tests have a fixed number of questions and the computer allows candidates to go back and change answers, mark questions for review, and skip questions. There is also no penalty for guessing with a linear test.
Computer adaptive testing however doesn’t have a set number of questions, there is no skipping questions or going back to change answers, and there will be a penalty for guessing. Now that you know the differences between these two types of tests, lets talk about how CAT works on the National Registry Paramedic test.
The computer adaptive test algorithm used for the NREMT Paramedic exam is a variable length (80-150 questions) test during which questions are delivered in a specific logical manner.
The paramedic test algorithm begins by presenting a medium or medium-easy item as the first question. The next paramedic test question is chosen based on whether the candidate gets the first question right or wrong.
Question Answered Correctly – If the candidate answers the National Registry Paramedic test question correctly, they will be given a question on the same topic that is of a higher difficulty level. This higher difficulty level question may not be asked immediately because the algorithm may test on other medium and medium-easy topics before moving to medium hard difficulty topics.
If the candidate continues to get answers correct on a topic, the difficulty level will increase until they either reach maximum ability level and begin to get the questions wrong or they reach the level of competency needed to pass that topic.
Question Answered Wrong – If the candidate answers the first National Registry paramedic test question incorrectly, the algorithm will at some point offer an easier question on that topic. If they answer wrong again they will be given an even easier question.
If they answer this question correctly, the algorithm will increase the difficulty level again and give the candidate another chance to get a question correct at that level of difficulty.
If the candidate gets it right, the difficulty gets harder until they reach their maximum ability level and consistently answer wrong on the same measured difficulty level, or they show the required level of competency needed to pass a content topic area.
Reasons Paramedic Test Will End – The algorithm continues to assess the test takers knowledge with each question and the National Registry paramedic exam will end when:
– It’s 95% confident the candidate is competent in each area of content.
– It’s 95% confident the candidate can’t reach the level of competency needed to pass the exam.
– The 2 hour 30 minute time limit is up.
– Candidate has answered the maximum allowed 150 questions.
ADVANTAGES OF COMPUTER ADAPTIVE TESTING
1. The National Registry Paramedic test can be shortened by around fifty percent while remaining more precise than a linear test. The adaptive algorithm won’t waste time presenting questions that are too hard or too easy for the test-taker. This shortens the amount of time required to take the paramedic exam and the number of question that the test-taker has to answer.
2. Can show results quickly after testing is completed. Technically the CAT makes results available as soon as the test is complete. In the case of the NREMT paramedic exam, test results will be posted within two business days on the candidate’s National Registry of EMT account. This requires the candidate to log in with their password at the National Registry of EMT website.
DISADVANTAGES OF COMPUTER ADAPTIVE TESTING
1. Candidate can’t go back and change answers, mark a question to review later, review their answers, or skip a question. Each question administered on the National Registry Paramedic test needs to be taken seriously, thought over, and answered well at the time it is given.
2. Candidates aren’t able to accurately judge or budget time allowed for each and every question. Since the paramedic exam is adaptive and the number of questions will vary based on a candidate’s performance, the candidate can not judge whether their test will have closer to 80 or 150 questions.
This means the candidate needs to remain flexible and focus on answering the paramedic questions correctly rather than rapidly.
Don’t Panic – If you begin the NREMT Paramedic exam and the questions seem to become difficult very quickly, it may be a good thing. Some individuals begin to panic because the National Registry Paramedic exam starts out ok and suddenly seems very hard after answering a few questions.
A candidate may feel like the paramedic test is hard questions with a few easier questions sprinkled in here or there. (This was my experience when I took the NCLEX for Nursing, which is also CAT.) If this happens to you during the test – don’t panic, it could be a sign you are doing well on the test.
After all, if you answer a question correctly, the National Registry Paramedic test administers more difficult questions until you show competency. This means if you are answering the lower level questions correctly, the test may begin administering harder and harder questions on each area of content. More correct answers means more hard questions.
Obviously, a candidate can be getting questions that seem very hard while doing poorly on the paramedic exam. In a situation where a candidate isn’t familiar with the material or is unprepared for the NREMT Paramedic Cognitive Exam, the questions may seem very difficult even though they are being administered easier and easier questions.
Another reason test-takers panic is because their test ends at 80 questions (60 test and 20 pilot questions). Once again this can be very good or very bad.
It means that within 60 questions the paramedic exam was able to determine with 95% confidence that the candidate is competent in ALL content areas, or the candidate will not be able to reach the minimum level of competency under any test circumstances.
Twenty questions in each NREMT Paramedic exam are “Pilot Questions” being tested for future candidates and do not count toward your test score.
When the National Registry Paramedic test stops after administering the minimum required items it usually means the candidate did very well or very poorly.
If a candidate studied well through Paramedic school and performed well, they should have an idea which group they fall into. Candidates who fail may have done well on most of the National Registry Paramedic exam, but did very poorly on a specific area or areas of content.
If the algorithm determines early that a candidate can not pass a required area of content it may end the test around 80 questions. The good news is if a candidate fails, the National Registry of EMTs will indicate how well they did on the content areas of the paramedic exam.
This will give the candidate a good idea of what content needs to be studied before attempting to retake the NREMT Paramedic exam.
National Registry Paramedic – Psychomotor Exam
Any candidate planning on taking the National Registry Paramedic Psychomotor Exam should be aware that significant changes were made to the test starting August 1 2016.
The previous paramedic test was a straightforward hands on exam which tested 12 basic skills. Information for that test is outdated because the new psychomotor paramedic exam is focused on reality based experiences which are tested for using 6 scenarios.
Studies indicated that students had trouble taking skills learned out of context, and transferring them to real life experiences on patients. Paramedic school now focuses more on taking skill testing from mannequins to real life scenarios as soon as the student is competent.
There is also a bigger focus on the role of a paramedic and the entire team dynamic. In the field, good team dynamics is very important not only for paramedics but to all emergency medical services (EMS).
The paramedic portfolio reflects this focus on team dynamics with it’s focus on both being a team member and team leader as a paramedic in training.
The new paramedic psychomotor exam consists only of 6 scenarios held at six stations instead of the previous twelve tests. All of these scenarios must be successfully passed. These six scenario stations are:
• Patient Assessment: Trauma
• Dynamic Cardiology
• Static Cardiology
• Oral Station Case A
• Oral Station Case B
• Integrated Out-Of-Hospital Scenario (OOHS)
The first station, Patient Assessment: Trauma
This is the most similar to EMT school testing. It will require studying the skill sheet and successfully transferring the knowledge into hands on skills. The candidate is required to perform a head-to-toe, physical assessment and voice treatments on a simulated patient after being given a scenario.
This hands on patient care will include Scene Size-up, Primary Survey/Resuscitation, History Taking, and the Secondary Assessment skills.
Here are the basic requirements of the Patient Assessment: Trauma, but it will be up to the candidate to determine at what point in the scenario to initiate the assessment.
Also, the candidate may need to change the order of or repeat certain parts of the assessment based on the live scenario. (Check the actual skill sheet for the critical criteria to avoid fatal mistakes.)
Patient Assessment: Trauma
A. Take or verbalizes appropriate PPE precautions
B. Determine the scene and situation is safe
C. Determine the Mechanism of injury/ Nature of illness
D. Determine number of patients
E. Request additional help if needed
F. Consider stabilization of the spine
G. Verbalize general impression of the patient
H. Determine responsiveness/level of consciousness
I. Determine chief complaint/apparent life-threats
a. Open and assess airway
b. Insert adjunct as needed
a. Assess breathing
b. Assure adequate ventilation
c. Initiate appropriate oxygen therapy
d. Manage any injury which may compromise breathing/ventilation
a. Check pulse
b. Assess skin color, temperature, or condition
c. Assess for and control any major bleeding
d. Initiate shock management
M. Identify priority patients/make transport decision based upon calculated GCS
N. Obtain, or direct assistant to obtain, baseline vital signs
O. Attempt to obtain SAMPLE history
a. Inspect mouth, nose, and assess facial area
b. Inspect and palpate scalp and ears
c. Assess eyes for PERRL
a. Check position of trachea
b. Check jugular veins
c. Palpate cervical spine
R. Chest: Inspect, palpate, and auscultate chest
a. Inspect and palpate abdomen
b. Assess pelvis
c. Verbalize assessment of genitalia/perineum as needed
T. Lower extremities: Inspect, palpate, and assess motor, sensory, and distal circulatory functions
U. Upper extremities: Inspect, palpate, and assess motor, sensory, and distal circulatory functions
V. Posterior thorax, lumbar, and buttocks:
a. Inspect and palpate posterior thorax
b. Inspect and palpate lumbar and buttocks area
W. Manage secondary injuries and wounds appropriately
X. Reassess patient
The dynamic cardiology station will present a scenario similar to the ACLS “megacode.” The candidate will be evaluated on their ability to manage a cardiac arrest situation. This will include delivery of electrical therapy and verbalizing all interpretations and treatments after being given a scenario.
The candidate should expect to use an actual functioning cardiac monitor defibrillator, or a realistic simulator cardiac monitor defibrillator simulator device.
Expect to spend up to eight minutes responding with the appropriate verbal treatments (algorithms) to four types of rhythms. There is no rational order to the cardiac rhythm changes: they are random and don’t have to make sense in a real life patient, so be ready to respond to any rhythm at any time. It’s high speed ACLS algorithms.
The dynamic cardiology scenario is testing your ability to electronically intervene with the monitor – using cardioversion, defibrillation, or pacing. You will need to verbalize medication interventions given along with other treatments like intubations, chest compressions, etc (which can be delegated to a partner). Some rhythms you might run into during testing are V-tach, V-fib, PEA, and third degree heart block.
According to the skill sheet the candidate will need to take PPE precautions, check patient responsiveness and check ABC’s. This includes checking if patient is responsive, breathing and checking for a pulse if the patient is unresponsive. Next the candidate will need to verbalize initiating CPR if appropriate, and attach the ECG monitor or paddles for a “quick look.”
The next steps on the NREMT paramedic skill sheet repeat with the candidate correctly interpreting rhythms, managing rhythms, noting changes in rhythms, and checking the patient condition – including pulse and blood pressure when appropriate.
The last step on the paramedic skill sheet indicates that the candidate should order high percentages of supplemental oxygen at the proper times throughout the scenario.
CRITICAL CRITERIA – Dynamic Cardiology
_____ Failure to deliver first shock in a timely manner
_____ Failure to verify rhythm before delivering each shock
_____ Failure to ensure the safety of self and others [verbalize “All clear” and observe]
_____ Inability to deliver DC shock [does not use machine properly]
_____ Failure to demonstrate acceptable shock sequence
_____ Failure to order initiation or resumption of CPR when appropriate
_____ Failure to order correct management of airway [ET when appropriate]
_____ Failure to order administration of appropriate oxygen at proper time
_____ Failure to diagnose or treat 2 or more rhythms correctly
_____ Order administration of an inappropriate drug or lethal dosage
_____ Failure to correctly diagnose or adequately treat v-fib, v-tach, or asystole
_____ Failure to manage the patient as a competent EMT
_____ Exhibits unacceptable affect with patient or other personnel
_____ Uses or orders a dangerous or inappropriate intervention
The Critical Criteria are significant for this station and failing one of these will lead to a fail for the Dynamic Cardiology Scenario test.
A candidate should be familiar with the Critical Criteria so they can avoid making a fatal error during the paramedic test.
At the static cardiology station there will be 4 cardiac rhythms that need to be completed in 6 minutes. Each rhythm will stay the same once it is handed to the candidate. The candidate will be given four prepared ECG tracings with brief patient description information attached. The candidate has to verbalize the interpretation of the rhythm and vocalize all associated treatments.
There are a total of 12 points available at this station, with 3 points available for each rhythm. One point is available for interpreting the rhythm correctly; however, if the candidate identifies the wrong cardiac rhythm from the ECG tracing they will get zero points for that rhythm scenario.
The other two points available for each rhythm tracing will be awarded based on how well the candidate verbalizes their handling of the scenario.
Quick Tip: Follow ACLS algorithms if they differ from local protocols.
Once you are given a cardiac rhythm strip and a brief description of the patient, read the description and identify the cardiac rhythm before continuing to your treatment plan algorithm.
An example of a possible patient description is:
48 y/o male complains of n/v. Blood Pressure 88/54 Resp 18 SaO2= 94% ETCO2=38
Remember to start with verbalizing scene safety and personal protection equipment for each ECG tracing. Being able to communicate effectively is also important in this station because all of your interventions will be verbal, not physical.
Here is an example of a possible scenario and candidate response from the Static Cardiology paramedic test:
65 y/o Male – Unresponsive – no respirations – no pulse –
Candidate Response: Cardiac Rhythm is Ventricular Fibrillation. “First I determine scene is safe and apply personal protection equipment. I request additional resources. I check airway, breathing, apply oxygen and suction if needed. Have partner begin CPR while defibrillator pads are applied. Defibrillate at 360 joules as soon as possible, followed by high quality CPR. Obtain IV or IO access and administer normal saline solution at a wide open rate. Give 1mg of Epinephrine (1:10,000) every 3-5 minutes. Continue high quality CPR, alternating compressions with a rhythm check every few minutes. Give 300 mg of amiodarone in a 20cc syringe. Have partner establish an advanced airway and attach waveform capnography. Ventilate patient with one breath every 6 seconds and at ten minutes we will consider reversible causes. We can also give a second dose of 150 mg of Amiodarone. At this time we will contact medical command for orders. Next.”
This is a fairly long example of what the candidate may need to verbalize during the Static Cardiology Paramedic Scenario. Time is an issue so speak quickly and clearly and when you are done with a rhythm, turn it upside down on the table and say “next.”
A candidate should keep in mind the following as a guideline for success while at this paramedic testing station.
Safety –> BSI -> PPE -> ABC’s -> VOMIT mnemonic (Vitals, Oxygen, Monitor, IV, Transport)
Oral Station A & B
The National Registry paramedic exam requires candidates to pass two Oral Station tests. These paramedic Oral Stations test the candidate’s ability to manage a call from top to bottom, beginning to end.
The candidate will usually be sitting at a table or desk and will be allowed to take notes while the instructor informs you about the medical call information.
If for some reason, you find yourself at an Oral Station without anything to take notes, ask for a pen and paper. They should provide it, and taking notes greatly increases the chances of passing each station.
The National Registry paramedic candidate will be given two separate cases and will be evaluated on their ability to verbally manage all aspects of an out-of-hospital call.
The paramedic candidate has 15 minutes to verbally complete each case (Oral A and Oral B) and will be evaluated in the following categories:
• Scene Management
• Patient Assessment
• Patient Management
• Interpersonal Relations
• Integrations (verbal report, field impression, and transport decision)
Just to clarify both of the Oral Stations only require oral skills and do not require any hands on or physical patient treatments. However, this doesn’t mean the candidate will sit down and be interrogated by the instructor and prompted to give correct answers.
The Oral Stations are more of a verbal back and forth between the instructor and candidate. If the candidate can get an understanding of how the Oral stations work before testing, they may be more comfortable with the process and be able to ask better questions during the test.
Before getting into how to talk your way through a call, lets talk about what kind of medical situations to expect. National Registry paramedic candidates need to be ready for any kind of call at both Oral Station A and B.
Often the scenarios will be pediatric, toxicology, elderly, environmental or illness related. Keep in mind, you may need to do some assessing to figure out the true cause of a patients signs and symptoms.
Just like in real life, patients may have an underlying issue that triggers other more obvious problems.