# Trouble with assessments



## ironguy321 (Nov 17, 2007)

Wow! It seemed so easy in class but once I tried to apply my skills to it I had the hardest time. I did my best to fill them out at my 12hr clinical but I feel like they aren't very good. I'm a little nervous because I don't know if my instructor will fail me for writing such poor assessments haha. Has anyone else had trouble at first with assessments? It was my first time to do them on my own and I found it rough since I was trying them on OD's and chest pains. How did you guys improve assessment/documentation skills?


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## Chimpie (Nov 17, 2007)

Practice, practice, practice.

Let's see if we can break it down for you.  Why do you consider your assessments poor?


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## skyemt (Nov 17, 2007)

i'm with chimpie... a little difficult without particulars...

i can tell you, the more you can have a standardized approach, the better...

also, really understanding why you are asking each question and doing each step... if you approach it from the perspective of 'memorizing' steps, you may get by, but when you get out in the field you will be totally lost.

lets get some more particulars...


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## ironguy321 (Nov 17, 2007)

I just feel like I'm not getting enough information. Some of the information I had to get from the triage report. Maybe its because the pt. was asked the same questions by the triage nurse, another nurse, and then a "student" (pt. didn't really like the word student coming out I guess). I would only get one or two S/S. It was like I went completly blank when I would start asking questions. I did copy this from the triage report as I didn't really understand this pt. at all.

CC: ETOH OD
Consent: Actual
Vitals: 106/66 BP, 76p, 18 resp, warm/dry/pink  temp. 97.2
AVPU: A
GCS:13
was this pt. really having an OD? He was on anti-depressants and when I tried talking to him it seemed like all he wanted was someone to talk too.

Back on topic, maybe it's because it was my first pt. assessment. Whenever we do them in class, we get tons of information but in the clinical setting I felt like I wasn't getting enough.


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## Chimpie (Nov 17, 2007)

Are you asking open ended questions?  If you ask yes/no questions, that's all you're going to get.

Now I'll be completely honest.  Being a MFR in an industrial setting I've never really had to worry about hospital setting narratives.  Recording vitals, SAMPLE, what we did on scene, etc prior to transport is all we had to worry about.  

Let me ask this:  In class, when you ask a question to your 'pt', do you always get specific answers?  Or are your 'pts' vague at all?

This is a common problem with training classes.  You get taught the basics (vitals, SAMPLE) but are not taught how to dig deeper for more information.


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## ironguy321 (Nov 17, 2007)

Wow, now that I look at what you said and my assessments, I have been asking yes/no questions. Its amazing looking back on them now the little things I missed like not checking the pelvis, listening to breath sounds, etc. I think its because since I was in the ER everyone pretty much knew what was wrong, had been done, etc. which would explain why my sheets look so empty. We've trained to ask pt.s at the scene to gather as much information as possible but when I was looking on the triage report everything seemed to be slimed down and maybe thats why my questions were so vague (already knew the answers). Like you said already, practice, practice but its hard to do assessments in the ER since the everyone already knows the problem and the details. I'm sure I will do better with the FD in this area. Could you still explain to me the PT who said he had an ETOH OD? His vitals were stable and frankly, he seemed fine (just a little drunk). I wrote that down as one of my assessments and I'm nervous my instructor will ask me a lot of questions about it while its unclear to me as well. Any other tips or pointers for me to improve my assessments? I do believe open ended questions will improve things greatly.


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## Chimpie (Nov 17, 2007)

Who said the pt was ETOH OD?  The pt? Triage? Ambulance Crew?

When it comes to cases of ETOH OD, it's usually not the pt who makes that determination.  The pt is usually putting up a fight, doesn't think there's a problem, wants everyone to go away, etc.

If it's the pt that says he's ETOH OD, then there's usually a bigger, underlying problem there.  Like you said, it seemed that he just wanted to talk.  Maybe he was having a bad day.  Maybe he's having a bad year.  Maybe he did need to talk to someone.  Maybe he caused this situation trying to find an outlet.


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## skyemt (Nov 17, 2007)

i have to admit, i am confused by your posts...

where are you doing these assessments? for what purpose?

class assignment during clinical time?

are you out in the field?


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## BossyCow (Nov 17, 2007)

When someone tells you the pt has .... you should go over in your mind everything you know associated with that particular illness, trauma or condition and start asking those questions. 

Also those mnemonics are great.. OPQRST, SAMPLE, DCAP-BTLS, use them enough and it becomes second nature..


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## So. IL Medic (Nov 20, 2007)

Ironguy - here's a tip that sounds silly at first. When you're alone at home, make up a patient. For example, you're called to the residence of a 64 y/o female c/o difficulty breathing. On a pad of paper, spell out your SAMPLE and OPQRST then remember head to toe for your exam. Then ask out loud open ended questions and answer them out loud. 
Signs and symptoms - what seems to be the problem today? When I woke up, I couldn't catch my breath. *O*When did this start. Early this morning, it woke me up and it's getting worse so I called 911. *P* Anything make it easier or harder to breathe? No, I just can't breathe. Can you usually sleep on your back? Yes why? *Q and R* Feeling any pain anywhere? Harder to breathe in or out? No, I can't tell. *S* Answers itself. *T* How long has this been going on? I've had trouble for a couple days but nothing like the last hour.
Allergies - Are you allergic to any meds? Penicillin and sulfa
Medications - What meds do you take? I've got an inhaler and blood pressure meds Have you tried your inhaler? It's not working today What bp meds? I don't know. The bottle is over there.
Past medical history - What medical conditions do you have? High blood pressure and a chronic lung condition. Like Asthma? No, something worse. COPD? Maybe, what's that?
Last intake - when is the last time you ate or drank anything? Last night. Couldn't eat breakfast.
Events - So what were you doing before this happened? I was sleeping.

Exam - pt is caox3, pale, warm, dry, perrla, chest has bilateral wheezing all lobes with some accessory muscle use, abd norm, extremities normal and no edema noted

There's your basic assessment. Flesh it out according to your class and protocols. Make up as many practice pts as needed until it starts becoming smooth and more natural feeling. The great thing about the mnemonics is that they provide a standard form to cover the necessary assessment.


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## ironguy321 (Nov 20, 2007)

I got them done but let me tell ya, lots of negative feedback from my pt's. I didn't do anything wrong but when I asked if it would be ok if I asked them a few questions to pass my rotation (I had a big "STUDENT" badge across my chest) they would roll their eyes, moan, etc. but still agreed to do it. I guess asking the pt's the same questions they just answered was a little rough but you gotta do what you gotta do :glare:


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## TKO (Nov 28, 2007)

First off, don't apologize to your patients for being a student.  That's life and how the system works.  If you felt more confident you wouldn't feel the need to apologize.

There may be nothing wrong with you or your ability to do your job; you may only need more experience.  That's pretty common for EVERYONE when we started.  And we all admit freely that we are always learning.

Here are my tips.

don't try to be House MD.  You are looking to fill in your run sheet with the basics first.  If you think of pertinent questions after that, good for you and the rest will come.  But don't get focused on one thing.  If I were to narrow it down for all pts, I would suggest that you nail the following each and every time.... *assume scene-safety and all the rest*


*1) Introduction and opening 2 questions: "Where does it hurt/what seems to be the problem?" and "What happened/caused this?" (this is done during your Initial Assessment and answers S of SAMPLE and CC).  

- These 2 questions can save you a lot of time and help to determine a rapid body survey vs. focused exam (you don't need to be listening to the chest if they broke their wrist arm-wrestling).
- If it was a fall or collision, did they hit their head and lose Cx?

2) In your Hx (while your partner is getting vitals) you will want to ask P of SAMPLE.  It is the Big 7: Cardiac Hx? Breathing difficulties? Stroke? Recent syncope? Hi/low blood-pressure? Epilepsy? Diabetes?

3) Ask about person, event, time, place PRN.  If they have pain, ask OPQRST.

4) after transport, during Head-to-Toe exam, ask the M-P-L-E.
*


That's the minimum interview.  When you master that and get it everytime, the rest will come to you more naturally.  But you really need to get that everytime, cause if you're not getting that, then you're not doing your job.

The hands on assessment has been written out ad-nauseum.  I'm sure you are just getting blank spots d/t insufficient experience and confidence.  Learn the basics with your eyes closed and close them when you have to or don't look directly at your pt.

Good luck!


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## TKO (Nov 28, 2007)

well, that partially answer S of SAMPLE and P also includes previous Hx of the current medical condition.


Like I said above, that's the basic interview.  Good investigative skills will develop with your understanding of those basic questions.  You'll eventually want to start asking your pt in the Hx about WHYs.  Like "Why did you fall down the stairs?" or "Why can't you sleep at night?".  But this all comes with mastery of the basics.

I know I am re-iterating this point over and over, but I see so many paramedics skipping over the basics to get to the meat because they assume on scene they know what is going on already.  That's poor a poor Hx interview and can really lead the Hospital staff down the wrong road if they get tunnel-vision from what you tell them.

I've worked calls where we got tunnelled with Hx of Epilepsy and when things weren't adding up we'd check our source and it was a bystander that didn't really know the pt.  But they saw what looked like a seizure and therefore that must have been epilepsy.  I learned not to listen too closely to a bystander.


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## TKO (Nov 28, 2007)

whoa!  I am tired.  4 AM with my pager on my hip and I was missing stuff.  Anyway, I'll shortform it for you again so I don't look so stupid.  

1) ASK those opening 2 questions to get your CC.
2) ASK neuro/orient x4 PRN.
3) ASK the big 7 and pertinent PHx.
4) ASK your SAMPLE (in the order that is relevant to your situation.  SMP are usually important in the Hx.  ALE are usually best answered in back of the bus.  USUALLY.)
5) ASK your OPQRST if there is pain.

again, get through those without thinking and the Hx of MOI questions will be easier to ask.  That should make more sense.


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## haneyk (Dec 18, 2007)

Ok, I know I am new here but can someone tell us what the abbriaviations mean, such as SMP or ALE?.  I have most of the other ones just could not remember SMP & ALE.


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## emtangie850 (Dec 18, 2007)

haneyk said:


> Ok, I know I am new here but can someone tell us what the abbriaviations mean, such as SMP or ALE?.  I have most of the other ones just could not remember SMP & ALE.




I do believe that they are referring to SAMPLE. Are you firmiliar? Reffer back to the first page of this post- it is explained. 

(Asking them all esentially; just not at once- getting the most important information first IE SMP, Then ALE later. But still makes up SAMPLE)

-Angie


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## haneyk (Dec 18, 2007)

Yes, Just never saw it stated that way before. I know SAMPLE well but never broke it up in different parts. Thanks.


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## emtangie850 (Dec 18, 2007)

haneyk said:


> Yes, Just never saw it stated that way before. I know SAMPLE well but never broke it up in different parts. Thanks.


I guess it just depends on the type of situation. If it is a "load and go" you are going to ask more specific HELPFUL questions first. 
Hope this helps.
-Angie


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## certguy (Dec 20, 2007)

*Assessments*

You're getting some good feedback . Everybody feels shaky when they get started . The more you practice , the better you get . Once you get used to the system , your assessments style will take on a rythm . Hang in there . It's a step by step process . One suggestion ; If you can catch a crew when they're not busy , see if you can practice an assessment with them so they can give you some pointers and feedback .


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## emtwacker710 (Dec 20, 2007)

Here is something that may help, If you know the acronyms SAMPLE, OPQRST, DECAPBTLS, AVPU, they will help a lot. Learn those and practice, practice, practice! We were all at the stage you are right now at sometime in our lives and we got better (well most of us) so just keep going!


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