# Your patter for assessing orientation



## Brandon O (Oct 4, 2009)

When assessing a patient's degree of orientation, what questions do you like to ask? Everyone seems to do this differently and I think there's a lot to be learned from hearing different ideas. (For what it's worth I feel that this can vary some depending on emergency vs. transfer runs, and perhaps also depending on the type and severity of call... but it's all worth hearing.)

Additionally, what's the actual LOC assessment in your agency? I was originally taught A&Ox4, where the 4 are Person, Place, Time, and Event (PPTE), but I've also seen a lot of x3 (Person, Place, Time only) and even some x3 that are the other way (Place, Time, Event). This can cause some problems -- i.e. if you're told a patient's A&Ox3 that can either mean they're fully oriented or altered, depending. I've actually got two different run sheets in use at my company and each uses a different system. What's common in your area?


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## surname_levi (Oct 4, 2009)

i've known some to ask a pt if they know who the current president is


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## DV_EMT (Oct 4, 2009)

I do AOx4... with the 4th being "what happened"... but here in the hospital I work at... its x3 beacuse they don't need to recall the prior events.


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## bunkie (Oct 4, 2009)

We're taught A&Ox4. Self, Place, Time (date), Events.


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## MrBrown (Oct 4, 2009)

We use GCS and AVPU


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## Brandon O (Oct 4, 2009)

surname_levi said:


> i've known some to ask a pt if they know who the current president is



Seen this too, but was always a little leery of it -- I guess it's meant to assess Time, but it really seems like more of an assessment of awareness of current events... which I guess is important, but if you know what "time" it is relative to the things that affect you, but don't know who's in Washington, I'd be less concerned than if the reverse was true...


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## Epi-do (Oct 4, 2009)

We use A&Ox3 (person, place, time).  Our medical director has went on several "rants" about how "ridiculous" x4 is.  He thinks that saying someone is oriented to the event is a bit redundant because in order to accurately tell you what happened the patient would have to be oriented to the other three.  In fact, at our last audit & review, he started making jokes about how patients that were described as A&Ox4 must be clairvoyant or something similar.

Personally, I will just start talking to the patient about why the called, how they are feeling, what is going on with them to see how appropriate they appear.  If they seem to be a little bit "off," then I will start asking the who, what, when, where type questions to assess their orientation.


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## Brandon O (Oct 4, 2009)

My personal method is probably more suited to IFT than emergencies. Like Epi I pretty much just chat, and involved in that is a number of questions that I sincerely want to know the answer to -- things like how long they've been in the facility I'm taking them from, where they're headed now and why they're going there, whether they were born "around here," how to pronounce that funny last name of theirs, and what the current date is for the paperwork because my darned watch never seems to work. Yeah, I already know the answer to most of those, but it's always nice to confirm, and if they have a different understanding of something (like what procedure they're going in for) it can be cleared up, and if we discuss all of the above then I've assessed their LOC without harassing them with the silly sort of questions they probably get all the time.

But to be honest, I probably wouldn't know the date or what the doc's doing to me today if I were some of these people, so context is pretty important. They don't usually know the weather either but that doesn't mean they're altered, just that their room doesn't have an oceanside view.


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## Shishkabob (Oct 4, 2009)

Do you know your name?

Do you know where you're at?

Do you know what day it is?

Do you know why we were called here/what were doing?


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## MMiz (Oct 4, 2009)

I always said:

I know this is going to sound funny, but I ask all of my patients these questions:
1.  Do you know who is the United States President?  If not, I ask if they know their name.
2.  Do you know where we are right now?
3.  Do you know what day it is today?


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## Epi-do (Oct 4, 2009)

MMiz said:


> 3.  Do you know what day it is today?



I always feel like that one is a trick question, because half the time I have to look at my watch to make sure they are correct if I opt to ask them.  I know I am oriented, but my world doesn't revolve around days of the week so much any more as it does A, B, or C shift.


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## Brandon O (Oct 4, 2009)

And if you're en route, "where are you?" is even more tricky. I often have *no* idea where we are, and "in an ambulance" seems a little cute


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## MMiz (Oct 4, 2009)

Epi-do said:


> I always feel like that one is a trick question, because half the time I have to look at my watch to make sure they are correct if I opt to ask them.  I know I am oriented, but my world doesn't revolve around days of the week so much any more as it does A, B, or C shift.


I agree with you completely on that one.  I'm not asking it for the patient's sake... I really want to know what day it is.  They all seem to blend together when you work the midnight shift


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## el Murpharino (Oct 4, 2009)

I've heard people ask how many quarters there are in a dollar...doesn't work well with everyone, obviously.  I've also had people mention two or three random things (i.e. peanut butter, giraffe) and have the patient recall it back to them a minute or two later.  

This in addition to the usual suspects:  "whats your name, what dy of the week is it< where are you right now?" - although I may ask them their address or what type of vehicle they are in.  

Usually one can get a good idea of mental status while asking them questions about their present medical condition/injuries without having to ask them the above mentioned questions.


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## Brandon O (Oct 4, 2009)

el Murpharino said:


> I've heard people ask how many quarters there are in a dollar...doesn't work well with everyone, obviously.



Yeah, I don't think I make that much without overtime


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## Melclin (Oct 4, 2009)

There's a bit of debate at uni about questions to establish the confused/oriented part of the GCS. 

I used to use "Who's the prime minister". But one sessional tutor told me once that some people may not actually know. I reckon that's BS. Honestly...who doesn't know who leads the nation. Maybe it takes you a moment to think past a mental block because you're tired, maybe you accidentally say the wrong name and quickly correct yourself...but to just straight up not know? 

I reckon if the pt didn't know the explanation as to why that would follow would be enough to gauge the conscious state anyway.


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## wyoskibum (Oct 4, 2009)

surname_levi said:


> i've known some to ask a pt if they know who the current president is



LOL! Not all patients can answer that question even if they aren't altered.   I was confused during the last administration on who was the president.  Was it George or ****?  ;-D

You should only ask questions that the patient is expected to know.  Person, Place, Time, and Events.


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## wyoskibum (Oct 4, 2009)

Melclin said:


> I used to use "Who's the prime minister". But one sessional tutor told me once that some people may not actually know. I reckon that's BS. Honestly...who doesn't know who leads the nation. Maybe it takes you a moment to think past a mental block because you're tired, maybe you accidentally say the wrong name and quickly correct yourself...but to just straight up not know? .



Don't you ever get stupid American Tourists?  Or do all visitors have to pass a Social Studies test before they can enter the Country? LOL!


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## Akulahawk (Oct 4, 2009)

My pattern for assessing orientation is determining person, place, time, (recent) event. This is modified for the situation, appropriate for the location. IOW: I won't ask the exact same question for someone on the street vs. someone in a SNF vs. someone in an acute care hospital, but I'm still looking for the same things.


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## Melclin (Oct 4, 2009)

wyoskibum said:


> Don't you ever get stupid American Tourists?  Or do all visitors have to pass a Social Studies test before they can enter the Country? LOL!



Lol. We don't let Americans into the country since 'dance your *** off'.

thats what i mean about the explanation, its one of those questions where if they didn't know, they'd want to explain why. 'whos the pm? Whats a pm? Oh priyminista? Oh yeah little gai who looks like a baby'. Gcs ? 15. Dx? American.


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## firecoins (Oct 4, 2009)

I ask name, birthdate, year and president.  

I never ask specific dates as people may not honestly know the date. People still may September despite it being October and be orientated.  I ask year.  If they tell me 1974, I know they may not be orientated.


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## firecoins (Oct 4, 2009)

Brandon Oto said:


> And if you're en route, "where are you?" is even more tricky. I often have *no* idea where we are, and "in an ambulance" seems a little cute



if they say in an ambulance, they are orientated.


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## firecoins (Oct 4, 2009)

wyoskibum said:


> LOL! Not all patients can answer that question even if they aren't altered.   I was confused during the last administration on who was the president.  Was it George or ****?  ;-D
> 
> You should only ask questions that the patient is expected to know.  Person, Place, Time, and Events.



so who's president?  Obama or Rahn Emanuel?


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## Jon (Oct 4, 2009)

firecoins said:


> if they say in an ambulance, they are orientated.


Yup. For example... on a transport the other day... I got... "In an ambulance...in New Jersey" It was accurate. Pt. described that they weren't from around the area. I've also had them tell me... "turning onto High Street".

I always ask who the president is, as well as inquiring about the present situation at other points in my assessment.

I once had a partner who would always ask "Where does Mickey Mouse live?". He got a large number of acceptable answers: "on the TV", "Disneyland" "Disney World" etc.


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## feral (Oct 5, 2009)

If they fell or MVA and couldn't tell you what happened do they know if they hit their head? 
If they could tell you their name, where there at, and time/month/yr, or even president, but couldn't tell you what happened...is there still concern? Of course there is, and that is why we want to get a&ox4.  
If they don't know what happened to them then the issue is severe enough to at least get checked out by the hospital whether it is trauma, diabetic emergency or whatever.


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## Kevin1990 (Oct 5, 2009)

In ohio, near canton, we ask the person, place and time (day), and sometimes if its a trauma or a severe loc, we ask 4. Our standard is A&OX3, but it all depends on the company.


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## mycrofft (Oct 6, 2009)

*Here's mine*

"Look at your pantsleg" (County Jail)
"Look at your wristband" (name DOB and cross reference number)
"It's Tuesday, sir. OK, he's oriented".


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## nomofica (Oct 6, 2009)

Here we're taught GCS, AVPU and A&Ox3.


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## Aidey (Oct 6, 2009)

I was taught GCS and AOx4/AVPU scale. 

What drives me bonkers more than anything is that AVPU and AOxwhatever are taught as separate assessments, and they aren't. You first determine if the pt is Alert, or responds to verbal stimuli, or painful or unresponsive. If you find them alert you then use the questions to determine how alert. Telling someone a patient is "Alert" doesn't tell me anything more than their eyes are open. 

/rant


In most cases I start with "Hello my name is xxxx I'm a paramedic with the ambulance, what is your name?" If they can tell me, then I ask "What is going on today?" or some version of. If they can't tell me, then I ask them if they know where they are. If they get that one, I ask if they know the date. 

I will also ask them to hold out one hand or the other so I can take a pulse. It's an easy way to assess if the pt can follow directions. 

I usually end up asking a lot more than 4 questions with patients who don't answer one right. For example, if they don't know the date, I'll ask them the day of the week, then the month, then the year and see if they know those. If they don't know what building they are in (home, work, the grocery store etc) I will ask them if they know what city they are in. 

A lot of times when we pick up homeless/transient patients they won't know the day of the week, but they will know the month and year. For them that may be totally normal. I also work nights, so at 1am a pt will answer Tuesday, when it's really Wednesday now. It doesn't mean they are altered, so you have to be able to assess the pt outside of the questions.


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## mycrofft (Oct 6, 2009)

*Asked a frequent flier what day it was (or night as it were).*

"FRIDAY".
(me) "Yeah?"
(him)"Yeah. You're here, aren't ya?!"


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## lightsandsirens5 (Oct 7, 2009)

For LOC we use AVPU. To determine the mental status of an alert pt, we use A&Ox4. Person, place, time, event. (Or four other closly related questions.) For those of you that say that mental status and LOC are the same, I was taught that a person can be alert, but not mentally oriented. (And it makes complete sense.) Thus we use AVPU and A&Ox4.

I will use A&Ox4 on pts who I suspect of having a decreased mental status. Or on less talkative pts. Normally though, you can tell by the type of conversation they can carry on. If they are capable of that, they are probably oriented. Works great for IFT pts. Usually you can work those questions into your other assment questions on scene, or small talk en-route to the hospital.

If they are A&Ox4, and they look at you funny when you ask, I just tell them that I have to ask those questions and everyone gets asked them.


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## HCEMS (Oct 7, 2009)

I usually ask the basic three questions....person, place, and time.  However, sometimes with geriatric pts I switch up the time with event or ask something that might be more likely for them to know because if they live in a nursing home or have assisted living where they maybe don't care about what day it is or it is not something that's relevant to their life.


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## BossyCow (Oct 9, 2009)

I can get most of that information in my general get acquainted conversation with the patient. Hi, my name is.... what's yours? (Knows self) When did this start? (Knows time) Where were you when this happened? (Knows Place) Then I usually toss in Do you know what day today is and Tell me about what happened. 

I had one frequent flyer I really, really, really wanted to leave at home. When I asked her 'what year is it?' because I knew she probably didn't remember the day.. she responded.... 1988 (it was 2009) I told her.. no, that's not right.. and she got really pissy and said.. "Fine... 1989... like that makes a big difference" We transported... sigh.. she was drunk... and stinky... was checked out at the ER, released to call us again and again and again and again.


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## Fox800 (Oct 14, 2009)

The most basic questions are those about person/place/time/event. What is your name? What city are we in? What month is it? What happened to you/why is EMS here?

Sometimes a patient may be able to answer those questions but may still be "altered". In instances where the patient's legal capacity is in question, we will perform a more thorough examination of their mental capabilities.

What is your birthdate?
Where do you live/what is your address?
Things as simple as remembering their medical history/medications/allergies.
How many dimes are in a dollar? How many quarters are in $1.75? Etc.
Who is the president of the United States?
Where is it safest for a child to play: in a city street, a playground, or a battlefield?
Start at 100 and count backwards, subtracting by 7 each time. 100, 93, etc...

We will state our concerns and possible consequences/reasoning for suggesting transport. If it is something that we are really worried about, we will make the patient repeat back "I understand that I may be having a heart attack and could die" or something to that effect, depending on the situation/differential diagnosis.


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