02 Advanced Patient Assessment

The assessment cycle

Patient assessment is a continuous cycle: gather information, identify threats, form and test a working impression, act, and evaluate the response. Findings become meaningful in context and over time, not in isolation. Clinical judgment includes recognizing and analyzing cues, defining a hypothesis, generating solutions, taking action, and evaluating the result.

Use current local protocols, medical direction, and scope of practice. A systematic sequence supports sound judgment, but it must not delay an immediately necessary intervention or transport.

Scene size-up

Before patient contact, quickly determine whether the scene is safe and what resources may be needed. Consider traffic, violence, weapons, fire, electricity, hazardous materials, animals, infectious risks, and environmental exposure. Use appropriate personal protective equipment, and stage or withdraw if the scene is unsafe. Reassess scene safety as conditions change.

Compare dispatch information with what is present. Medications, medical equipment, vehicle damage, and the patient's position may provide clues about the illness or injury. Determine the number of patients and whether additional units, specialized rescue, law enforcement, advanced life support support, or triage are needed. Consider whether access or extrication will delay care.

Identify an appropriate approach, destination considerations, and transport priority. The scene plan should account for changing conditions and the resources required.

Primary assessment and immediate threats

The Primary assessment identifies and treats immediate threats to life. Form an initial general impression while approaching: consider whether the patient appears critically ill or injured, is alert and interacting, and is breathing normally. Then assess systematically.

1. General impression and responsiveness: Assess mental status and ability to speak or respond. Note appearance, posture, work of breathing, skin signs, and obvious distress.

2. Airway: Determine whether the airway is open and maintainable. Identify obstruction, secretions, vomit, or a need for airway support.

3. Breathing: Assess rate, depth, effort, chest movement, and breath sounds as indicated. Recognize inadequate ventilation or oxygenation and intervene according to protocol.

4. Circulation and major bleeding: Assess pulses, skin perfusion, and catastrophic hemorrhage. Control life-threatening bleeding promptly, and consider shock even before hypotension develops.

5. Disability and exposure: Make a rapid neurologic assessment, including level of consciousness and relevant pupil or motor findings. Expose only as needed to find threats, then prevent heat loss and preserve dignity.

Treat critical problems as they are found, coordinate team roles, and prepare for prompt transport when indicated. A detailed history or complete examination must not postpone care for an unstable patient.

History-taking

Obtain the patient's account when possible, then clarify or supplement it with information from family, caregivers, witnesses, medical-alert information, or records. Identify the source of each important detail, and distinguish what the patient reports from what you observe. Ask clear, respectful questions, allow time for answers, and adapt to age, language, hearing, cognition, distress, or communication disability.

Use OPQRST to structure questions about a symptom:

• Onset: When and how did it begin? Was it sudden or gradual?

• Provocation or palliation: What worsens or relieves it?

• Quality: How does it feel?

• Region or radiation: Where is it, and does it spread?

• Severity: How severe is it, using an appropriate scale?

• Time: How has it changed? Is it constant or intermittent?

Use SAMPLE to organize relevant background:

• Signs and symptoms

• Allergies, including the reaction when known

• Medications, including recent changes or missed doses

• Pertinent past medical history and relevant procedures

• Last oral intake, when relevant

• Events leading to the illness or injury

Ask focused follow-up questions and seek pertinent negatives: important symptoms that are absent. A checklist does not replace clinical reasoning. Consider baseline function and age-related differences, including those relevant to pediatric and older adult patients.

Secondary assessment and focused exams

After immediate threats are addressed, choose the breadth of examination according to stability, complaint, mechanism, and findings.

• Unstable or high-risk patient: Continue resuscitation and monitoring. Perform only the additional examination that informs urgent care or transport. For significant trauma, use an appropriate rapid head-to-toe assessment while protecting the spine when indicated by findings and protocol.

• Stable patient with a clear, localized complaint: Focus the examination on the relevant system or body region while remaining alert for unexpected findings.

• Unclear complaint, altered mental status, or concerning mechanism: Broaden the examination because the patient may not be able to localize or report injury reliably.

Use inspection, palpation, and auscultation as appropriate, and compare sides when useful. Assess relevant findings such as deformity, tenderness, wounds, swelling, abnormal movement, differences in breath sounds, pulses, skin temperature, and neurologic deficit. Explain the examination and preserve privacy. Do not interpret an unexamined area as normal.

Obtain and interpret vital signs in context. Depending on the presentation and local protocol, these may include heart rate and rhythm, blood pressure, respiratory rate and effort, oxygen saturation, temperature, pain, blood glucose, cardiac monitoring, or waveform capnography. Record the method and important abnormal findings; trends often matter more than a single value.

Reassessment and response to care

Assessment continues during treatment, movement, and transport. Reassess after an intervention, after a change in condition, and at intervals appropriate to acuity and protocol. A common operational convention is to reassess about every 5 minutes for unstable patients and every 15 minutes for stable patients, but local requirements govern.

Repeat the primary assessment, vital signs, and focused findings relevant to the patient's problem. Check whether the intervention worked, whether the patient improved or deteriorated, and whether the working impression or plan needs to change. Address and recheck abnormal findings, and document the patient's response and important changes.

The cited model guideline calls for at least two sets of vital signs for every patient, documentation of interventions and responses, and documentation of major changes.

Documentation and handoff

Create a clear, chronological record that allows another clinician to understand what happened and why. Include dispatch, scene, patient, and relevant timeline information; the chief complaint and its source; pertinent history and pertinent positives and negatives; initial impression and examination findings; and vital signs with times and significant trends.

Document clinical reasoning when relevant, including the basis for urgency, treatment, and destination decisions. Record interventions and their times, the patient's response, changes in condition, and reassessment findings. Include transport and transfer-of-care details, as well as any refusal or incomplete assessment in accordance with policy.

Use objective language. Quote important patient statements when helpful, and distinguish reported information from observed findings. Avoid unsupported conclusions, vague phrases such as “normal,” and undocumented assumptions. Correct errors through the approved process rather than obscuring the original record.

Give a concise verbal handoff that highlights the chief concern, important findings and trends, care given, response, and outstanding risks.