Principles of Patient Assessment in EMS

The Ongoing Assessment

Introduction Ongoing assessment (OA) – the phase of care provided to the patient while enroute to the hospital. The steps of the OA include: Repeating the IA Re-evaluating the patient’s priority Reassessing and recording the VS Repeating the focused assessment Checking interventions

Settling In Once in the ambulance assure that: The patient is properly secured (belted) The compartment temperature is appropriate IV is secure/patent Equipment is fastened down Oxygen is switched to the onboard Monitors are secured and visible

Settling In (continued) Once you are “settled in” maintain a continuous concerned conversation with the patient. Explain or answer questions to keep the patient informed and alleviate anxiety. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. Repeat the IA Manage any potential life-threats. Re-evaluate patient priorities. Observe and note “trends.” Communicate with medical control or the receiving facility. Document assessment finding and care rendered. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. Trending The process of obtaining a baseline assessment, followed by serial assessments to determine if patient is getting better, worse, or has no change. An important tool in patient care. Examples of trending info are VS or noting MS changes. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Communicating Enroute In most EMS systems a radio report to Medical Control or the receiving hospital is done enroute. This is also done with other methods (cell phone, computer, or fax). Local protocols may have you consult or obtain permission for various treatments. Information obtained in the OA is a significant part of the radio report. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. Documentation Important to document assessment findings and patient management. Assessment cards are helpful for taking notes prior to writing a complete prehospital care report (PCR). Take notes on: Scene size-up IA and Vital signs FH and PE OA © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Documentation (continued) Some EMS providers utilize a PDA for taking notes or to quickly reference information. The PCR: NOT designed to be completed enroute Report needs to be neat, complete, accurate, and well thought out © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Documentation (continued) The PCR continued: Use objective language and avoid subjective judgments Be exact about what you see, hear, feel, or smell Avoid interpretations about patient behavior Include pre- and post- assessment findings around treatment modalities (i.e. splinting, med administration, etc) Document pertinent patient quotes such as “I drank 2 beers” Use only abbreviations that are standardized and commonly understood by other health care professionals © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Repeat the Focused Physical Exam In a medical patient focus on the specific complaint (i.e. respiratory, cardiac, etc). In a trauma patient with no significant MOI, focus on the isolated injury. Reassess distal PMS and splinting. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Checking Interventions Anything that the EMS provider does to a patient that is expected to change the patient’s condition should be reassessed. Determine if the intervention had an effect: Positive - desired improvement Negative - undesired deterioration No observed effect Reassess vital signs every 5 minutes for unstable patients and every 15 minutes for the stable patients. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Conclusion The OA is done on every call when the patient is transported to a receiving facility. The steps involve reassessment of the IA, obtaining serial VS and observing for trending in the patient’s condition. Make notes for trending, radio report and documentation.