EMR Medical Patient Assessment

BSI!!

• 1. Determines the scene is safe
• 2. Determines mechanism of injury/nature of illness
• 3. Requests additional EMS if necessary
• 4. Considers stabilization of spine

• 1. Determine responsiveness/ level of Consciousness.
• 2. Determine Chief complaint/ apparent life-threats.
• 3. Assess Airway and Breathing
• 4. Assess circulation
• 5. Identifies patient Priority and makes treatment/ transport decision.

• Assessment
• Assures adequate ventilation
• Initiates appropriate oxygen therapy.

• Assesses/controls major bleeding
• check pulse
• assesses skin color (color, temperature and condition)

• Signs and symptoms (assess history of present illness)
• Allergies
• Medications
• Pertinent history
• Last oral intake
• Event leading to present condition

• Onset
• Provacation
• Quality
• Radiation
• Severity
• Time

When did the problem start or get worse?

• Is there anything that makes it better?
• Is there anything that makes it worse?

Can you describe the pain? Is it sharp, dull, achey, or pressured?

Does the pain radiate or move to any other location?

On a scale of 0-10 (0 being no pain and 10 being the worst imaginable) where do you rate your pain?

How long has the condition been going on?

Assess the affected body part or system

• Cardiovascular
• Pulmonary
• Neurological
• Musculoskeletal
• Integumentary
• GI/GU
• Reproductive
• Psychological/ Social

• Blood Pressure
• Pulse
• Respiratory rate and quality

• State Field impression
• Interventions [verbalize proper interventions/treatment]

Demonstrate how and when to reassess the patient to determine changes in condition.

Provide accurate verbal report to arriving EMS unit.