Assessment Card

 

*************Scene Sizeup*****************

Is the Scene Safe?

Number of Patients?

Nature of illness/Mechanism of injury

Additional resources? (Advanced Life Support needed?, lifting, extrication, police assistance,)

Consider c-spine

************Initial Assessment*************

Any unusual sights/smells/sounds

General Impression of the patient

AVPU (Alert/Verbal/Pain/Unresponsive)

Airway (Head tilt/Jaw Thrust)

Breathing (Quality/Auscultation)

Circulation (Rate/check for bleeding/grips/capillary refill/skin conditions)

Determine transport priority (stay and play/load and go)

*********Continued Assessment***********

Vitals (HR/Respirations/BP/SpO2/Pain/Pupils)

SAMPLE history (symptoms/allergies/medications/pertinent past medical history/last oral intake/event onset)

OPQRST

    O - Onset

    P - Provokes (anything make it better or worse)

    Q - Quality (how does the pain feel?  stabbing, burning, crushing, pulsing)

    R - Radiates (does the pain start somewhere and move?)

    S - Severity (pain scale 1 to 10)

    T - Time (when it started)

Rapid Assessment 

    D-deformity

    C-contousions

    A-abrasions

    P- Punctures

    B-burns

    T-tenderness

    L-Lacerations

    S-swelling

    DCAP-BTLS head (pupils, ears, nose, mouth)

    DCAP-BTLS neck (jugular vein distention, tracheal deviation, C-collar?)

    "           "      Arms, Chest, Abs, Pelvis, Legs, back

Detailed Physical Exam

    everything in rapid, but with palpations

******************Reassess**********************

Reassess ABC's (Initial Assessment)

Reassess Vitals (every 5 minutes for critical, every 15 for stable)

Reassess Interventions (Are the procedures you performed still on correctly?  O2 levels, cannula placement, bandaging, etc etc)

Radio Report Hospital (Age, Gender, Chief Complaint, Current Vitals, Pertinent Medical History, Treatment already performed noting any changes in vitals because of treatment, GCS, ETA)

Transfer Care