1. Importance of a Standardized Approach
PATIENT ASSESSMENT
Importance of a Standardized Approach

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

3. Is The Environment Safe?

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

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

6. 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

7. 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.

8. 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

9. 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)

10. 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)

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

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

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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.