Principles of Assessment

Assessment principles

Foundational guidelines for gathering and interpreting information to evaluate a patient's condition.

Scene size-up

The process of evaluating safety, identifying hazards, and determining the nature of the incident before approaching the patient.

Primary assessment

Focuses on identifying and managing immediate life threats such as airway, breathing, and circulation issues.

Secondary assessment

A detailed evaluation of a patient's condition after immediate life threats have been addressed, focusing on other injuries or medical issues.

Reassessment

The ongoing process of monitoring a patient's status and evaluating the effectiveness of interventions.

Clinical behavior and judgment

The decision-making process used to interpret assessment findings and determine appropriate interventions based on patient needs.

Effective communication and documentation

Ensures accurate transfer of information between providers and maintains a legal record of care.

OPQRST mnemonic

A tool for gathering information about a patient’s chief complaint: Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Time.

SAMPLE mnemonic

A checklist for patient assessment: Signs/Symptoms, Allergies, Medications, Past medical history, Last oral intake, Events.

Physical examination techniques

Include inspection, palpation, percussion, and auscultation to identify signs of illness or injury.

Mental status assessment

Evaluating a patient’s orientation to person, place, time, and purpose to gauge brain function.

Assessment protocols

Structured processes like OPQRST and SAMPLE that help ensure important details are not missed.

Pattern recognition

The ability to identify common symptoms and signs that help narrow down potential diagnoses.

Diagnostic process

The method of gathering information, considering possible diagnoses, and reaching a conclusion.

Critical thinking in EMS

The analytical and decisive process that helps EMTs think through problems and make effective care decisions.

Heuristics

Cognitive shortcuts or rules of thumb that help in making quick decisions but can lead to biases.

Anchoring bias

When the first impression or diagnosis overly influences subsequent thinking, making it hard to revise.

Confirmation bias

The tendency to focus on evidence that supports an initial diagnosis while ignoring contradictory data.

Illusory correlation

The mistaken belief that two events are causally related when they may just coincide.

Overconfidence bias

The tendency to overestimate one’s knowledge or abilities, which can lead to poor decision-making.

Pediatric assessment adjustments

Modifications made in assessment techniques based on the developmental stage and specific needs of children.

Auscultation

The technique of listening for internal sounds of the body, typically with a stethoscope.

Palpation

Examination technique involving the use of hands to feel for abnormalities or signs of illness.

Jugular vein distention (JVD)

A sign that can indicate heart failure or obstructive chest conditions.

Altered mental status

A change in a patient's cognitive functions, often indicating serious underlying conditions.

Blood glucose monitoring

A key tool for assessing diabetic emergencies and identifying hypoglycemia.

Gastrointestinal bleeding signs

Vomit that looks like coffee grounds or stool that is dark and tarry.

Anaphylaxis

A severe allergic reaction that requires immediate medical attention.

Musculoskeletal injury assessment

Focused physical examination in trauma situations involving inspection, palpation, and comparison.

EMT diagnosis

A label for a patient’s condition based on gathered information, guiding evaluation and treatment.

Emergency medicine approach

Focuses on ruling out life-threatening conditions and initiating urgent treatment in a time-constrained environment.

Systematic processes

Examinations involving a structured approach to history-taking, physical examination, and assessment of body systems.