Importance of a Standardized Approach PATIENT ASSESSMENT Importance of a Standardized Approach

Four key factors should be considered: 1.Environment 2. Severity 3. Medical versus trauma 4. Level of care available

Is The Environment Safe?

What’s the Patient’s Severity? Stable or Unstable

Medical or Trauma? NOI MOI Responsive Significant Not responsive Non-significant

Initial Assessment Orderly exam with correction of life-threats General impression Chief complaint (MOI/NOI) Assess mental status Assess airway, breathing, and circulation Determine priority and need for ALS

Purpose of an initial exam is to rapidly identify and manage the life-threats. Every patient should receive an initial assessment. Treat any life-threats immediately. Most patients do not have life-threatening problems.

What is your General Impression? The environment (ie: bottom of stairs, out in the cold, tripod position, pool of blood) Patient’s MOI/NOI Patient’s age and sex Patient’s degree of distress Listen for the chief complaint Keep the priority of care in focus

Mental Status Are they conscious or unconscious? (if unconscious do CPR quick-check) Introduce yourself What’s your name? (oriented to person) Do you know where you are? (oriented to place) What day of the week is it? (oriented to day) How can I help you today? (chief complaint)

Focused History & PhysicalExam: Medical Responsive History of present event (OPQRST) SAMPLE History Baseline Vital Signs Focused physical exam Transport Not Responsive Rapid Physical Exam Baseline Vital Signs SAMPLE History Transport (if not already doing so)

OPQRST Elaborate on the Chief Complaint O – onset P – provocation Q – quality R – radiation, region, referral S – severity T - time

Detailed Physical Exam of your Trauma Patient Assess the: head, face, eyes, nose, mouth, neck, chest, abdomen, pelvis, extremities, back and buttocks

Focused History & Physical Exam: Trauma Significant MOI Rapid Trauma Exam Baseline Vital Signs SAMPLE History Transport (if not already doing so) Non-significant MOI Focused Exam Baseline Vital Signs SAMPLE History Transport as needed

Listening to our Patients Establishing a rapport with patient and family is important

Factors that can Facilitate Effective Communication Is the patient comfortable? Consider your method of approach Professional, respectful introductions Addressing the patient: name and formality Establishing trust Consider the environment, modesty, emotional, and biological needs Confidentiality

Communicating with Children Your interview must be age appropriate Kneel down to get to the child’s level Involve the parent or caregiver in the interview

Communicating with the Elderly Aging rate differs with the person so do not assume all elderly are visually or hearing impaired Give the patient time to discuss the chief complaint Verify information with a family member or caregiver as necessary

Things to Keep in Mind Practice your listening skills Do not judge Demonstrate kindness, compassion, and empathy Understanding basic communications skills is essential to EMS providers

Be A Patient Advocate It is your responsibility to advocate for the patient and the patient’s needs Advocating for your patient means making sure the next caregiver understands what has been seen and learned about the patient so far.

Putting it All Together A standardized approach helps to assure the patient receives an appropriate assessment based on the following key factors: The environment MOI or NOI Severity of injury or illness Level of care available

Conclusion Patient Assessment- procedures performed to find out what is wrong with a patient on which decisions about emergency medical care and transport will be based. • Performed on every patient-the key to all medical care • Use a Systematic, constant approach to Patient Assessment • The first step in caring for any patient is a good Initial Assessment.