PATIENT ASSESSMENT/MANAGEMENT

MEDICAL

 

Takes or verbalizes body substance isolation

SCENE SIZE-UP

Determines the scene is safe

Determines the mechanism of injury/nature of illness

Determines the number of patients

Requests additional help if necessary

Considers stabilization of spine

INITIAL ASSESSMENT

Verbalizes general impression of patient

Determines responsiveness/level of consciousness

Determines chief complaint/apparent life threats

Assesses airway and breathing

            Assessment

            Initiates appropriate oxygen therapy

            Assures adequate ventilation

Assesses circulation

            Assesses for and controls major bleeding

            Assesses pulse

            Assesses skin color, temperature and condition

Identifies priority patients/makes transport decision

FOCUSED HISTORY AND PHYSICAL EXAM / RAPID ASSESSMENT

Signs and Symptoms (Assess history of present illness)

 

Respiratory

Cardiac

Altered Mental Status

Allergic Reaction

Onset

Provokes

Qualtiy

Radiates

Severity

Time

Interventions

Onset

Provokes

Qualtiy

Radiates

Severity

Time

Interventions

Description of episode

Onset

Duration

Associated symptoms

Evidence of trauma

Interventions

Seizures

Fever

History of allergies

Exposed to what

Exposed how

Effects

Progression

Interventions


 


Poisoning or Overdose

Environmental Emergency

Obstetrics

Behavioral

Substance

When exposed

How much

How long was exposure

Interventions

Estimated weight

Source

Environment

Duration

Loss of consciousness

Effects

General or loca

Are you pregnant

How long have you been pregnant

Pain or contractions

Bleeding or discharge

Do you feel the need to push

Last menstrual period

Crowning

How do you feel

Determine suicidal tendencies

Is the patient a threat to self or others

Is there a medical problem

Interventions

Allergies

Medications

Past medical history

Last meal

Events leading to present illness (rule out trauma)

Performs focused pysical examination

            Assesses affected body parts and systems or, if indicated, completes rapid assessment

VITALS (Obtains baseline vital signs)

INTERVENTIONS (Re-evaluates transport decision)

Verbalizes the consideration for completing a detailed physical examination

ONGOING ASSESSMENT (verbalized)

Repeats initial assessment

Repeats vital signs

Repeats focused assessment regarding patient complaint or injuries

Checks interventions

 

CRITICAL CRITERIA

            Did not take or verbalize body substance isolation technique

            Did not determine scene safety

            Did not obtain medical direction or verbalize standing orders for medication interventions

            Did not provide high concentration oxygen

            Did not evaluate and find conditions of airway, breathing, hemorrhage or shock, hypoperfusion

            Did not differentiate patientŐs needing transportation versus continued assessment at scene

            Does detailed or focused history and physical examination before assessing airway, breathing, circulation

            Did not ask questions about the present illness

            Administered a dangerous or inappropriate intervention