NREMT Patient Assessment / Management Medical Skill Sheet

Start Time:

Stop Time:

Date:

Candidate's Name:

Evaluator's Name:

Move your mouse over the different steps to see more info. Respiratory only at this time.

These are EXAMPLES of questions and verbalizations. This is NOT a script.

Points
Possible

Points
Awarded

Takes, or verbalizes, body substance isolation precautions I am wearing my gloves and other proper BSI

SCENE SIZE-UP

Determines the scene is safe Is my scene safe? No dogs or threatening people?

Determines the mechanism of injury/nature of illness Why was the ambulance called? What is wrong?

Determines the number of patients Is there just 1 person sick or are there others?

Requests additional help if necessary If we need additional resources, personnel, law enforcement I would call for it now.

Considers stabilization of the spine I would consider stabilizing the spine, but do not see an immediate need.

INITIAL ASSESSMENT

Verbalizes general impression of the patient The patient appears stable/unstable.

Determines responsiveness/level of consciousness The patient is conscious / unconscious. On the AVPU scale they are ______

Determines chief complaint/apparent life threats The patient's chief complaint is chest pain and this could be a life threat

Assessment of airway and breathing There is no visible bleeding, the patient's pulse is ______ and their skin is warm, moist and pink.

Assessment
Indicates appropriate oxygen therapy
Assures adequate ventilations

Assessment of circulation The patient's airway is open because they are talking to me. They appear to have adequate respirations and I will put them on high flow O2 via non-rebreather mask.

Assesses and controls major bleeding
Assesses pulse
Assesses skin (color, temperature, and condition)

Idenitifies priority patients/makes transport decision If this is a priority patient we will load and go. If not we will continue assessing at the scene or in the ambulance.

FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID ASSESSMENT If I have something to FOCUS on (the patient is conscious and and can tell me what is wrong) I will perform an exam FOCUSED on that complaint. If the patient is unconscious I will do a rapid head to toe assessment.

Signs and symptoms (Assess history of present illness) I will begin the interview process with the conscious patient. Maybe get some history from bystanders of an unconscious patient.

Respiratory	Cardiac	Altered Mental Status	Allergic Reaction	Poisoning/ Overdose	Environmental Emergency	Obstetrics	Behavioral
Onset? When did you begin having trouble breathing? What were you doing?	Onset?	Description of the episode	History of allergies?	Substance?	Source?	Are you pregnant?	How do you feel?
Provokes? Does anything make it feel better or worse?	Provokes?	Onset?	What were you exposed to?	When did you ingest/ become exposed?	Environment?	How long have you been pregnant?	Determine suicidal tendancies
Quality? Can you describe how your breathing feels right now?	Quality?	Duration?	How were you exposed?	How much did you ingest?	Duration?	Pain or contractions?	Is the patient a threat to self or others?
Radiates? Is the breathing difficulty stationary in your chest or does it move?	Radiates?	Associated symptons?	Effects	Over what time period?	Loss of Consciousness	Bleeding or discharge?	Is there a medical problem?
Severity? Where are you at on a scale of 1 to 10 if 1 is very easy to breath and 10 is very hard to breath?	Severity?	Evidence of trauma?	Progression?	Interventions	Effects-general or local	Do you feel the need to push?	Interventions?
Time? Has the problem been constant since it started or does it come and go?	Time?	Interventions?	Interventions?	Estimated weight?		Last menstrual period?
Interventions? Have you tried anything to make it feel better?	Interventions?	Seizures?
		Fever?

Allergies Are you allergic to anything?

Medications Are you taking any medications? Are you using any herbal supplements or other drugs?

Past Pertinent History Have you ever had problems like this before? Have other people in your family had any similar problems?

Last oral intake When was the last time you had anything to eat or drink? What did you have?

Events leading to present illness (rule out trauma) Have you fallen or been hurt recently? Other than this problem has today been a fairly normal day?

Performs focused physical examination ( assesses affected body part/system or, if indicated completes a rapid assessment) I am going to do a focused exam of the affected body part or system. I will auscultate the lungs for breathing problems, BP for chest pain etc. If I do not have a chief complaint to focus on I will finish a rapid assessment.

Vitals (obtains baseline vital signs) I am going to gather baseline vitals with the help of my assistant.

Interventions (obtains medical direction or verbalizes standing order for medication inverventions and verbalizes proper additional intervention/treatment) After utilizing online medical control and/or standing orders I will administer/assist with proper interventions. Metered dose inhalers, nitroglycerin, etc.

Transport (re-evaluates the transport decision) If the patient's condition is getting worse I might consider a helicopter rendezvous or transport to a closer hospital.

Verbalizes the consideration for completing a detailed physical examination If time is available AND there is a necessity I would do a detailed physical exam.

ONGOING ASSESSMENT (verbalized)

1Interactivity stops here

Repeats initial assessment

Repeats vital signs

Repeats focused assessment regarding patient complaint or injury

Total

Critical Criteria

____Did not take, or verbalize, body substance isolation precautions as necessary

____ Did not determine scene safety

____ Did not obtain medical direction or verbalize standing orders for medical interventions

____ Did not provide high concentration of oxygen

____ Did not find or manage problems associated with the airway, breathing, hemorrhage or shock (hypoperfusion)

____ Did not differentiate patient's need for transportation versus continued assessment at the scene

____ Did detailed or focused history/physical examination before assessing the airway, breathing and circulation

____ Did not ask questions about the present illness

____ Administered a dangerous or inappropriate intervention