Based off chapters 12 and 13 of Nancy Carolines Emergency Care in the Streets.
Appear to be a seamless process
Yield a definitive field diagnosis
Only focus on his or her complaint
Not deviate at all from a strict format
Let the patient guide the questions that you can ask in order to build a cohesive rapport on which you can build
Develop and cultivate your own style of assessment and an overall strategy for evaluating an providing care
Approach every patient care in the same fashion with the realization that patient assessment in the field is a static process
Strictly adhere to you departments standard operating procedures so that they become a rote series of actions.
Efficiently executing a patient care plan
Quickly identifying your patients problem
Definitely diagnosing the patients problem
Establishing your priorities of patient care
Can qualify that a patient is indeed sick
Determine how far away the hospital is
Perform a detailed physical examination
Are able to qualify how sick a patient is
Justify his or her treatment to the patient
Report his or her findings to the physician
Determine which treatment protocol to use
Decide on the appropriate receiving hospital
Patients name and chief complaint
Chief complaint and patients address
Patients name and family physician
Chief complaint and the patients sex
Rapidly formulate a working diagnosis and prepare a care plan
Determine if the patient is alert to person,place,time, and event
Quickly rule out a life-threatening cause of the patient's problem
Determine if the patients problem is medical or trauma in nature
The reason why the patient called EMS is the first place
A chronological account of the patients signs and symptoms
Your perception of the severity of the patients condition
A past medical problem that is causing the chief complain.
Do you ever experience dizziness and chest pain when exerting yourself
How long has it been since you were thoroughly examined by a physician
Do you feel any pain or discomfort when touch your abdomen or chest
Has your doctor ever told you that you have a heart, lung or brain problem
Make the patient feel comfortable in disclosing personal information to you
Leave no doubt in the patients mind that you are truly a professional caregiver
Establish positive patient rapport and encourage honest, open communication
Help you gain the trust of the patients family more than the trust of the patient
The patient is a male who was involved in an assault
Assessing geriatric patients who fear losing their independence
The patient is critically ill or injured and is semiconscious
Cultural differences exist between the patient and paramedic
Review the patients transfer paperwork
Document at least two sets of vital signs
Call a radio report to the extended care facility
Presume that the patient will not with to speak
Is the pain sharp or dull
Can you describe the pain
Do you have a cardiac history
Does the pain radiate to your arm
Tell the patient to be more specific
Document water pill using quotation marks
Ask the patient the dose of the medication
Attempt to clarify the name of the medication
Remain professional and nonjudgmental when asking the patient
Reassure the patient that you can be trusted and will not tell anyone
Question the patient in the presence of a trusted family member
Tell the patient that withholding such information from you is illegal
Determine his or her name
Properly introduce yourself
Establish a rapport with him or her
Perform a physical assessment
Severity
Quality
Region
Progression
Tell the patient that the pain will subside in time
Note how distressed the patient appears to be
Document your perception of the patients pain
Ask the patient if he or she would like an analgesic
The amount of alcohol consumed if often overstated
The patient often gives a reliable and accurate history
Alcohol can mask any number of signs and symptoms
Suspicions of alcohol intoxication must be documented
Multiple injuries that are various stages of healing
A patient who refuses to allow a family member to speak for him or herself
Injuries that are inconsistent with the history that you are given
A husband who towers over his wife and answers your questions for her
Must be assumed to have an altered mental status until proven otherwise
Should immediately be asked another question to facilitate gathering data
Should have the question repeated back to him or her using different terms
May be deciding if he or she can trust you enough to answer the question
Prioritize the patients complaints
Perform a complete head to toe exam
Address all complaints simultaneously
Assume that all complaints are linked
A lawsuit lodged against you by the patient or his or her family
The patients choice not to share as much information with you
Causing the patients family members severe emotional distress
Emotional distress when the physician tells the patient otherwise
Immediately depart the scene and notify law enforcement personnel
Ignore the family members departure and continue to assess your patient
Have your partner follow the person, while working to defuse the situation
Ask the patient to follow the person in an attempt to reason with him or her
Place your hand of his or her shoulder ( if appropriate) and reassure him or her that you are in control of the situation
Tactfully advise the patient that you cannot effectively help him or her if he or she continues to cry
Have one family member calm the patient as you gather the medical history from another family member
Administer a sedative medication, which will calm the patient and facilitate your gathering of th medical history