Patient Assessment

To ensure a comprehensive understanding of the patient assessment process, this flash card assignment breaks down every section and its core components. You'll translate key concepts into organized, accessible learning tools.

operations

Functional Equipment

Sufficient Inventory

Proper Documentation

Wellbeing of Self & Others

Functional Equipment

Is it whole?

Is it ready?

Sufficient Inventory

Do i have what i should?

Proper Documentation

Does this need to be time stamped

Am i writing legibly

Am i writing somewhere appropriate

Is my chart complete

Has it been reviewed

Is it objective? Honest? Thorough?

Wellbeing of Self & Others

Does my Partner need to be checked?

Do i need to be checked?

Is this decision healthy?

Should this be debriefed?

Scene Size-up & Safety

Evaluate Dispatch

Scene Safety

PPE

# of patients

Triage

Need for additional resources

Evaluate Dispatch

MOI or NOI?

Is there anything unique about the location?

Could I need special resources?

Are thre flags on the address?

does this make sense?

GUT CHECK!

Scene Safety

Physical hazards

weather hazards

Violence or crowds

Unstable structures

Live wires or fire

Exposed roadway

PPE

Gloves

Mask

Eye protection

Gown

Vest

Hair net & booties

Number of Patients

How many patients are there?

How many people are present?

Do I have the full picture?

Triage

Sort your patients

Sort your priorities

Additional Resources

Additional ambulances

ALS

Fire fighters

Rescue operations

Police

Bariatric ambulance

MD1

Supervisor / Incident management

Social services

Primary Assessment

Introduction

General impression

Level of consciousness

Airway

Breathing

Circulation

Disability

Exposure

Chief complaint

Baseline vitals

Transport decisions

Introductions

To the patient

To the family

To the other providers on scene

Set the tone

General Impression

Big sick

Little sick

Level of Consciousness

AVPU

Alert: acknowledges you as you approach them

Verbal: acknowledges or reacts after you apply verbal stimulation

Painful: reacts to painfull stimulation

Unresponsive: does not respond to any stimulation

Airway

Is it patent?

if not, what can i do to open it?

If it is, can it remain open?

Breathing

Are they?

Is it adequate or inadequate?

if inadequate, why?

Does it need to be assisted?

How should i assist it?

Circulation

Do they have a pulse?

What is the quality?

Is it too fast, or too slow?

Are they bleeding?

Are there signs of poor perfusion?

Disability

Is there an obvious cause for what i can see?

Is there something disabling my assessment?

Exposure

Can i get to my patient?

Can i perform my assessment?

Can i perform my treatment?

Is it safe to be here?

Is it SMART to be here?

Chief Complaint

What’s going on?

What happened?

Why am I here?

Why did you call 911 today?

Baseline Vitals

Pulse

RR

BP

Lung sounds

Pupils

Skin condition

SPO2

Pain

Transport Decision

Stay and play

Load and go

Secondary Assessment

History gathering

Focused physical assessment

Primary assessment

Differential diagnosis

Onset

Did it start suddenly?

Did this come over time?

Acute v chronic

Provocation / Palliation

Does anything make it feel better?

Does anything make it worse?

Have you taken anything for it?

Quality

What does it feel like?

Can you describe it to me?

If “shortness of breath”

Does it feel like you’re not getting enough air? or is it hard to breathe?

Region & Radiation

Can you point to where it hurts?

Does it travel anywhere else?

Does it hurt anywhere else?

Does it feel like it’s moving?

Saverity

On a scale of 0-10, 0 being no (complaint) at all, and 10 being the worst (complaint) you have ever experienced, what does it feel like?

Time

What time did all of this start?

If it was a while ago…

What caused you to wait, or prevent you you from seeking help sooner?

Associated Symptoms

Ask about symptoms that would confirm you differential diagnoses, or rule out another problem

Pertinent Negatives

symptoms that would rule out another problem

Signs / Symptoms

What do you see?

Signs

What are they complaining of?

Symptoms

Allergies

Are you allergic to anything?

Medications

Are you prescribed any medications?

Do you take your medications the way they are prescribed?

Do you take over the counter medication?

Are there medications that you are prescribed, that you’re not taking?

Have you had any recent changes on medications?

What do you take this medication for?

Pertinent Past Medical history

Have you ever had this problem before?

If so, what happened? What did they do for you? What did they diagnose you with? Did they tell you what to do if it happened again?

What kind of medical problems do you have?

Do you see a doctor for any medical problems?

Have you been diagnosed with any medical problems?

Last In / Last Out

Have you been eating regularly? If not, what is different, and for how long has it been different?

Have you been going to the bathroom regularly?

When is the last time you ate / went to the bathroom?

Events Leading Up

What were you doing when this started?

What were you doing earlier?

Did this start during that, or after?

Have you done this task before?

Focused Physical assessment

Perform a hands on assessment based on the patient’s area of complaint.

Primary Reassessment

General impression - reassess for changes, are they still what i initially thought?

Level of consciousness - has it improved , or worsened?

Airway - is it still patent? Did i fix it?

Breathing - are they still breathing adequately, do I need to try something else?

Circulation - has there been any positive improvement?

Disability - have i worked past it?

Exposure - do I need to expose more?

Chief complaint - has it changed, lessened, or increased?

Baseline vitals - trend vitals every 5/10 minutes

Transport decision - is my destination still appropriate

Differential Diagnosis

Based on the information you have gathered, what is going on with this patient?

Rule

Out

Worst case

Scenario

Patient Treatment & Transport

ABCS

Cardiovascular & Circulatory Management

Motion Restriction

Medications

Interventions

Transport

Transfer of Care

ABCs

Airway, Breathing, & Circulation should take priority when making treatment and transport decisions

They require constant reevaluation

There is no room for compromise

Cardiovascular / Circulatory Management

You won't always have the time or capacity to treat every single problem, clean every wound, or ask every question.

Trending Vitals:

Stable patients: every 10-15 minutes

Unstable patients: every 5 minutes

After any intervention or significant movement

Minimum of 2 sets on all patients

Gold standard = 3 sets on all patients

Motion Restriction

Modern EMS equipment has made lifting and moving patients significantly safer

Patients with serious conditions should not exert themselves further

Medications

Is there a medication I can give to help with this condition?

9 Rights of Medication Administration

Reassessment of efficacy

Interventions

Did the patient improve? Did they decline? Did my intervention work? Do I need to do more? Do I need to change my plan?

Transport

Do they need a specialty hospital?

Primary v Comprehensive Stroke

PCI Center

Trauma Center

Burn Center

Pediatric Center

Dialysis Capable

L&D w/ NICU

Do they need lights & sirens?

Do I know the safest route?

Is everyone, and everything secured?

Am I prepared to be on the road?

Transfer of care

LISBAR

SOAP

To someone of equal or higher medical authority capable of providing necessary care