PATIENT ASSESSMENT/MANAGEMENT – MEDICAL PATIENT
Student: ______________________________ Examiner: _______________________
Date: ________________________________ Initials: __________________________
SCENE SIZE UP
Yes
No
Takes body substance isolation precautions ;
Determines the scene is safe ;
Determines the mechanism of injury / nature of injury
Determines the number of patients
Requests additional help if necessary
Considers stabilization of the spine ;
INITIAL ASSESSMENT
Verbalizes general impression of the patient (sex, estimated weight, age, distress
level)
Determines responsiveness / level of consciousness ;
Determines chief complaint / apparent life threats
Assesses Airway ;
Assures airway is patent and will remain so
Assesses general rate, rhythm and tidal volume †
Consider oxygen therapy †
Assesses Breathing ;
Assures that ventilation is adequate †
Injury management †
Assesses for and controls major bleeding †
Assesses general pulse rate (normal, slow or fast) †
Assesses Circulation ; Assesses basic rhythm (regular or irregular) †
Assesses basic quality (full or weak) †
Assesses general skin (color, temp. and moisture) †
Identifies priority level of patient / transport decision ;
FOCUSED HISTORY/PHYSICAL EXAM
Signs and Symptoms (assesses history of present illness)
Respiratory
Cardiac
Onset
Provokes
Quality
Radiation
Severity
Time
Interventions
Onset
Provokes
Quality
Radiation
Severity
Time
Interventions
Continue on reverse
Altered
Mental
Status
Described
Onset
Duration
Associated
symptoms
Any trauma
Interventions
Seizures
Fever
Allergic Reaction
Poisoning /
Overdose
Environmental
Emergency
Obstetrics
Behavioral
Hx of Allergies
What exposed to
Exposure length
Effects
Progression
Interventions
Substance
When
How much
Time period
Interventions
Pt weight
Effects
Source
Environment
Duration
Conscious
Effects –
general or
local
Pregnant?
How long?
Contractions?
Bleeding or
discharge
Need to push?
LMP
Crowning
How do you
feel
Suicidal?
Treat to self
or others
Medical
problem?
Interventions
PATIENT ASSESSMENT/MANAGEMENT – MEDICAL PATIENT
Continued
SAMPLE HISTORY CONTINUED
Yes
No
Allergies ;
Medication ;
Past pertinent history ;
Last oral intake ;
Events leading to present illness (rule out trauma) ;
Performs focused physical examination
Assesses affected body part / system or, if indicated, completes rapid assessment
Baseline vital signs (BP, pulse, respiration’s, pupils) ;
Interventions (oxygen, med assistance, shock mgt, etc)
Transport ;
Detailed physical examination – verbalizes the consideration of:
ONGOING ASSESSMENT (VERBALIZED)
Repeats initial assessment
Repeats vital signs
Repeats focused assessment regarding patient complaint or injuries
Checks interventions
Must complete patient assessment within 10 minutes ;
ATTEMPTS
1
2
3
INSTRUCTOR COMMENTS:
; = CRITICAL CRITERIA. NOTE:
PASS _____ FAIL _____
Denote whether:
MidTerm
or
ASST. INSTRUCTORS, PLEASE MAKE SKILL LOG ENTRY.
Final