Patient Assessment and Documentation

 

Patient Assessment:

 

Patient Assessments should be consistent for every patient you encounter.  This does not mean all patients and conditions are the same.  But your approach to assessment should be the same.  The National Standard for patient assessment, to which all EMTs are responsible, can be summarized in both the medical and trauma form in the following manner, we’ll call the Universal Patient Assessment:

 

1) Scene Size-up

2) Initial Assessment

3) Focused/Rapid Assessment

4) Detailed Assessment

5) Ongoing Assessment

 

Since many EMTs have never viewed the patient assessment quite this way, here is an explanation of the parts of patient assessment.  First a few facts:

  - The national standard, as well as the National Registry of EMTs, define 2 distinct assessments – 1 for medical patients, 1 for trauma patients

- Both of these assessments have all of the components of the Universal Patient Assessment as described above

- The BTLS assessment fits into the Universal Patient Assessment as well

- The AHA patient assessment, published in 2000 and still in use under ECC guidelines fits into the Universal Patient Assessment

- The key is that this assessment combines all of the assessments EMTs must learn, but it IS the National Standard Assessment, just like is taught in EMT classes all over the country.  This is just an advanced way of approaching it.

  1) Scene Size-up:

 

The AHA does not include this component in their assessment per se, but all of the others clearly define Scene Size-up as the first step of any assessment.  The components:

 

- Scene Safety

- Body Substance Isolation

- Number of Patients

- Assess need for additional resources (ALS backup, fire, police, dog catcher, haz-mat etc.)

- Consider need for essential equipment (Spinal Immobilization, ventilator, etc.)

- Consider Mechanism of injury

 

More may be added, but this is the basic list.

 

2) Initial Assessment:

 

- General Impression of Patient (on Approach)

- AVPU and C-spine control – SIMULTANEOUSLY

- Consent (actual/informed or implied)

- Airway

- Breathing

    -  Apply O2

- Circulation

    - Pulse

    - Hemorrhage

    - Skin Condition

- Decide:

  - Stay and play OR load and go

  - Rapid vs. Focused (Does not matter if trauma or medical patients)

 

*** Here is HOW to make that decision:

Rapid – If there is a dangerous mechanism

           - Altered Mental Status

           - Significant Life Threat from trauma or Multi-trauma is suspected upon general impression or

             completion of initial assessment

 

Focused – Isolated injury

              - Medical patients that are obviously not injured, even if serious (such as bed-confined patients

                with chest pain)

              - No significant life threat

 

Remember, you don’t interrupt the Initial Assessment unless:

 

- the patient is in cardiac arrest

- the patient has an airway obstruction

 

Other care can be taken over by a partner while the assessment continues, such as providing ventilations to a patient that has compromised ventilations.

 

3) Focused/Rapid Assessment:

  - So, which assessment did you decide to do?  Do it now, either Rapid or Focused

 

  A - Rapid) If you’re doing Rapid, then perform a head-to-toe assessment:

  •Identify Life Threats

•Brief assessment of head, neck, chest, abdomen, pelvis, upper and lower extremities, and back.  This head-to-toe procedure should end with a PMS check of every extremity.

•SAMPLE History

TRUCK – Unless rescue is necessary, the patient is loaded into the truck before vitals*

•Baseline Vitals, as well as other monitoring (EKG, SaO2, BGL, etc.)

•Neuro Exam if altered LOC

- Treatments – any that are known to be necessary at this point.

  * The reason the patient should be loaded into the ambulance BEFORE the first set of vitals is to decrease time on scene, and faster time getting to a physician.  Think about it – if you know the patient has a low blood pressure BEFORE you load, what are you going to do on scene to correct that?  There is no quick fix for vitals that is not already taken care of by the initial assessment. 

 

B – Focused)

If you decided to perform a focused instead, then perform it:

- Assessment of affected area or chief complaint

- SAMPLE History

- Baseline Vital Signs

- Prophylactic treatments, such as Oxygen or IV (if EMT-I or EMT-P)

- Load

- Other treatments, known to be necessary

 

4) Detailed Assessment:

  - Head to Toe Exam – this is a detailed exam of the patient.  If you performed a rapid assessment already on this patient, then the detailed exam will be the second time you perform a head-to-toe exam.  If you have only done a focused exam thus far, then this will be the first head-to-toe exam for this patient.  In other words, EVERY PATIENT GETS AT LEAST ONE HEAD-TO-TOE EXAM.  The detailed exam IS a more in-depth assessment that the rapid head-to-toe.  Remember, you pause the detailed exam to bandage minor wounds, you assess pupils, all lung fields, etc.  The head-to-toe detailed assessment ends with a PMS check of all extremities.

- Vitals – this should be your second set of vitals. If you perform a rapid assessment, you got your first set when you loaded the patient.  If you did a focused exam, you did the first set during the exam.

- Treatments – any that are not only done.

 

  5) Ongoing Assessment:

 

•Ask the patient about changes he/she feels

•AVPU

•ABCs

•Vital Signs – should be the third set, if there is time

•Reassess Identified injuries

•Reassess Interventions

•Check all monitors

•Reassess Abdomen (often the site of occult bleeding)    

Documentation:

  Some basic rules:

  The patient care report should be completed for every patient transported, one for each transport.  In other words, if a patient is transported from home to a doctor’s office, then from the doctor’s office back home, 2 separate run reports MUST be written.

  All information within the report must be covered as it applies to the patient, including all demographic information (name, address, insurance information, etc.), check boxes, signatures, times, etc.  Check boxes within non-narrative sections of the report should be carefully selected if they apply to the patient you are reporting about.  However, this does NOT mean that the same items don’t need to be included within the narrative.  Similarly, even if something is described in the narrative, it should still be selected as applicable within the various non-narrative sections of the report.  Therefore, conditions that are applicable will be stated TWICE in every report:  once within the non-narrative sections, and once during the narrative.  It is not necessary to include items not applicable to the patient. 

       Example:  If the patient is being transported to a follow-up appointment for evaluation of a stroke, and you are completing the history field of the report;  if the patient has hypertension, then check “hypertension”, and note it in your narrative.  But, if they do not have a history of diabetes, then you obviously wouldn’t check that they did, nor is it necessary to mention that they don’t in your narrative.

  From your patient assessment, all patients transported must have:

  - 2 sets of vital signs documented

- Head-to-toe assessment

-------------------------------------------------------------------------------------------------------------------------------------

Billing specific requirements:

  - The following are items that must be included in your NARRATIVE as they apply.  Following some items may be an underlined example or specific instruction.

-          How did you find the patient? Bed, chair, wheelchair, boat dock, etc.

-          What was the position of the patient (supine, sitting, fetal)?

-          The method by which you transferred the patient to the stretcher.  Pt. walked to stretcher, sheet drag, etc.

-          Current, observable, signs/symptoms or conditions, which prevents the patient from being transported by another means. Pt. is a Below-knee amputee, pt. is paraplegic, etc.

-          If the patient is “bed confined” document the reason why they are bed confined. Pt. history of ALS, numerous strokes, etc.

-          Bed confined is defined as unable to get up without assistance; and unable to ambulate; and unable to sit in a wheel chair. 

-          A specific description of any initiated or continued interventions, and results achieved by the intervention and the reason for the intervention.  IV established by sending facility, IV established enroute, traction splint, etc.

For Hospital-to-Hospital transfers only: Services or treatment not available at the hospital of origin. Patient was discharged from hosp. (name sending hospital) and admitted to hosp. (name receiving hospital) for treatment of _______ which was unavailable at sending hosp. (name sending hospital).  This is extremely important and must be worded very similar to this wording if it applies.

-          Treatment and/or services to be received at the destination facility or treatment and/or services received prior to the return point of origin. Coronary artery bypass graft (CABG), MRI, renal hemodialysis, etc.

-          Any medications administered prior to transport. By the sending facility, or by the patient’s family, or even the patients themselves.

-          Chief Complaint and the history of the Chief Complaint.

-          Level of Consciousness (Mental Status)

-          Signs or Symptoms

-          Focused Assessment (ABC’s)

-          SAMPLE (S/S, Allergies, Medications, Past History, Last Meal Events leading to)

-          Vital Signs (Two sets)

-          Patient status on arrival. Pt. resting, pt condition improved (and how), etc.

-          Receiving party (Who took charge of the patient? Who received report?) – Name and position.

If patient is unable to sign, then explain why. Pt is blind, pt hands are bandaged, pt. is disoriented to person,  place, and time and unable to follow instructions, etc.

 

-          Obtain Certificate of Medical Necessity (CMN FORM) – When in doubt, get one.

-          Any local forms required to go with the patient. Face sheets, DNR forms, X-ray films, orders, etc.

Notes for Carolina MedCare Documentation:

- If transporting to a Doctor’s Office, note in narrative “Patient transported to _____”  Fill in the blank with the Physician’s name AND full address. 

- Remember that this document is a MINIMUM of items that need to be included in your patient care reports.  You may still document other conditions you were trained to report or are bound by duty to report, such as scene conditions.

     Return to Documentation and Patient Assessment Page

Return to Risk Management Home Page