EMR Medical Patient Assessment

Card Set Information

Author:
Scott57
ID:
273390
Filename:
EMR Medical Patient Assessment
Updated:
2014-05-16 00:51:09
Tags:
Patient Assessment
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Description:
EMR Medical Patient Assessment
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  1. FIRST STEP
    BSI!!
  2. Scene Size up
    • 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
  3. Primary assessment
    • 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.
  4. Assessing airway and breathing
    • Assessment
    • Assures adequate ventilation
    • Initiates appropriate oxygen therapy.
  5. Assesses circulation
    • Assesses/controls major bleeding
    • check pulse
    • assesses skin color (color, temperature and condition)
  6. History Taking
    • Signs and symptoms (assess history of present illness)
    • Allergies
    • Medications
    • Pertinent history
    • Last oral intake
    • Event leading to present condition
  7. Signs and Symptoms
    • Onset
    • Provacation
    • Quality
    • Radiation
    • Severity
    • Time
  8. Onset
    When did the problem start or get worse?
  9. Provacation
    • Is there anything that makes it better?
    • Is there anything that makes it worse?
  10. Quality
    Can you describe the pain? Is it sharp, dull, achey, or pressured?
  11. Radiation
    Does the pain radiate or move to any other location?
  12. Severity
    On a scale of 0-10 (0 being no pain and 10 being the worst imaginable) where do you rate your pain?
  13. Time
    How long has the condition been going on?
  14. Secondary Assessment
    Assess the affected body part or system

    • Cardiovascular
    • Pulmonary
    • Neurological
    • Musculoskeletal
    • Integumentary
    • GI/GU
    • Reproductive
    • Psychological/ Social
  15. Vitals Signs
    • Blood Pressure
    • Pulse
    • Respiratory rate and quality

    • State Field impression
    • Interventions [verbalize proper interventions/treatment]
  16. Reassessment
    Demonstrate how and when to reassess the patient to determine changes in condition.

    Provide accurate verbal report to arriving EMS unit.

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