Assessment

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bdoss2006

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Should you do a full head to toe on every patient including medical patients? If you do not, should you mark "not assessed" or "no abnormalities" since you can visualize without touching and removing clothing?
 
This is probably a question you should address by re-reading the initial assessment (or primary assessment) chapter in your textbook.

Short answer - if a patient can cogently express their concern and you see no life threats or apparent other problems, a focused assessment is appropriate. There’s not really a need to fully expose and head-to-toe assess a patient who is A&Ox4 and clinically stable complaining of isolated tooth pain or pharyngitis.
 
This is probably a question you should address by re-reading the initial assessment (or primary assessment) chapter in your textbook.

Short answer - if a patient can cogently express their concern and you see no life threats or apparent other problems, a focused assessment is appropriate. There’s not really a need to fully expose and head-to-toe assess a patient who is A&Ox4 and clinically stable complaining of isolated tooth pain or pharyngitis.
Would you put not assessed, or would you put no abnormalities since you didn’t visualize any?
 
Would you put not assessed, or would you put no abnormalities since you didn’t visualize any?
How do you know there are “no abnormalities “ if you didn’t assess? You’ve just lied on a medical document.
 
This is a great question and one that requires the EMT to perform some critical thinking.

Imagine you have a patient with a simple medical complaint; for this example, let's say "abdominal pain."

When documenting your assessment, would you follow all the steps for a full physical exam, including inspection, palpation, and auscultation of every element? Or, would you focus your assessment by asking questions? I know I'd focus my exam on the areas that are integral to the complaint and ask questions about peripheral elements like arms, legs, and back. If the patient tells me they have no pain in their arm and it's not related to their complaint, it is documented as "no abnormalities." I may add that "the patient expressed no complaints or concerns" in the assessment comment tab. However, an answer to questions is also an assessment.

I know we miss more things by not looking than not knowing, but at some point, we have to be realists in the assessment. Of course, you have to use your powers of observation to make determinations of when a full head-to-toe assessment is necessary.
 
Would you put not assessed, or would you put no abnormalities since you didn’t visualize any?
Unless I had some reasonable suspicion to check, my narrative would state the patient had no complaints related to those other areas. Depending on the charting system, you might mark not assessed or just not note anything at all.
 
Should you do a full head to toe on every patient including medical patients? If you do not, should you mark "not assessed" or "no abnormalities" since you can visualize without touching and removing clothing?
This is where you have to start thinking about your patient, their complaint, and what's relevant to their situation. If you're going to mark something as "not assessed" you should have something in your narrative that explains why you didn't assess that. If you're marking "no abnormalities" then you've assessed that and you'd better have done so otherwise you've just lied on a legal document.
 
This is where you have to start thinking about your patient, their complaint, and what's relevant to their situation. If you're going to mark something as "not assessed" you should have something in your narrative that explains why you didn't assess that. If you're marking "no abnormalities" then you've assessed that and you'd better have done so otherwise you've just lied on a legal document.
I know this is old, but I am just looking back over things. I know what you’re saying, but by “not assessed”, do you mean didn’t ask questions related to it, or didn’t actually expose and touch, or what? Or vice versa, if you mark “no abnormalities” would you have to have actually exposed and touched/examined said area, or does just asking about the area suffice if they have no complaints with it? I guess what I’m asking is what do you really define as “assessed”? Just asking, or actually exposing and touching.
 
I know this is old, but I am just looking back over things. I know what you’re saying, but by “not assessed”, do you mean didn’t ask questions related to it, or didn’t actually expose and touch, or what? Or vice versa, if you mark “no abnormalities” would you have to have actually exposed and touched/examined said area, or does just asking about the area suffice if they have no complaints with it? I guess what I’m asking is what do you really define as “assessed”? Just asking, or actually exposing and touching.
When I state "not assessed" I literally mean that I did not do any kind of assessment whatsoever of whatever I marked as "not assessed." If I indicate that there were "no abnormalities" that means I performed an assessment and determined that no abnormalities were present. The depth/level of assessment is determined by my education, the situation, and my experience. It very well could be simply asking questions or could be doing palpation and/or any special tests or anything in-between.

I'm going to provide a simple demo. You roll your ankle. It hurts and is swollen. You managed to not fall. I'm going to do a focused exam. I'll expose the ankle as much as necessary to do the exam. I might palpate the area, note specifically what's tender and what isn't. I'm going to ask you about your legs and your hands/wrists to determine if I need to do any further evaluation of those. I'm going to ask more generalized questions of other systems/regions and some areas I'm going to defer or simply decline to evaluate.

So, when I do the patient assessment, some areas will have a high level of detail, some areas will simply be marked "no abnormalities", some areas will be marked "normal", and some areas will be marked as "not assessed." My narrative will compliment, not duplicate, the assessment and as such it would be quite obvious what was done or not done.

Also, I am purposefully NOT providing MORE detail than what I have already done precisely because going into that level of detail will not be instructive for you at the level you're at. You're just not ready for that detail because you're not equipped yet to learn that level of detail and make sense of it.
 
When I state "not assessed" I literally mean that I did not do any kind of assessment whatsoever of whatever I marked as "not assessed." If I indicate that there were "no abnormalities" that means I performed an assessment and determined that no abnormalities were present. The depth/level of assessment is determined by my education, the situation, and my experience. It very well could be simply asking questions or could be doing palpation and/or any special tests or anything in-between.

I'm going to provide a simple demo. You roll your ankle. It hurts and is swollen. You managed to not fall. I'm going to do a focused exam. I'll expose the ankle as much as necessary to do the exam. I might palpate the area, note specifically what's tender and what isn't. I'm going to ask you about your legs and your hands/wrists to determine if I need to do any further evaluation of those. I'm going to ask more generalized questions of other systems/regions and some areas I'm going to defer or simply decline to evaluate.

So, when I do the patient assessment, some areas will have a high level of detail, some areas will simply be marked "no abnormalities", some areas will be marked "normal", and some areas will be marked as "not assessed." My narrative will compliment, not duplicate, the assessment and as such it would be quite obvious what was done or not done.

Also, I am purposefully NOT providing MORE detail than what I have already done precisely because going into that level of detail will not be instructive for you at the level you're at. You're just not ready for that detail because you're not equipped yet to learn that level of detail and make sense of it.
If you ask the questions, and “decline to evaluate”, would that be “no abnormalities” since you asked about it, or “not assessed”?
 
If you ask the questions, and “decline to evaluate”, would that be “no abnormalities” since you asked about it, or “not assessed”?
You're thinking too much about what I just said above. If I'm asking questions, then I'm assessing and something will be charted about it being assessed. If I'm not going to assess something, (declining to evaluate) then it's not going to be assessed/evaluated and therefore will be charted as "not done" because it wasn't done. However, charting something as "not done" isn't the same as not charting about that something. If I chart that something isn't done, it means (and also inference for others is) I have considered the circumstances and have decided NOT to assess that something. If, instead, I simply do not chart anything, then the adage "if it wasn't charted, it wasn't done" is true. The patient could have been missing a foot and because I made no mention of it, I could be held liable for the missing foot whether the foot be a natural one that is no longer present OR it could be an artificial one that is not present with the patient. On the other hand, if I mark that foot as "not assessed" it means I did not assess that foot and my narrative will explain that there is no foot present to assess because, perhaps, there is a BKA and no artificial limb is present.

Does this start to make sense as to the difference?
 
I don’t think OP can’t differentiate. The same question and the endless loops of answer-question answer-question etc.
 
You're thinking too much about what I just said above. If I'm asking questions, then I'm assessing and something will be charted about it being assessed. If I'm not going to assess something, (declining to evaluate) then it's not going to be assessed/evaluated and therefore will be charted as "not done" because it wasn't done. However, charting something as "not done" isn't the same as not charting about that something. If I chart that something isn't done, it means (and also inference for others is) I have considered the circumstances and have decided NOT to assess that something. If, instead, I simply do not chart anything, then the adage "if it wasn't charted, it wasn't done" is true. The patient could have been missing a foot and because I made no mention of it, I could be held liable for the missing foot whether the foot be a natural one that is no longer present OR it could be an artificial one that is not present with the patient. On the other hand, if I mark that foot as "not assessed" it means I did not assess that foot and my narrative will explain that there is no foot present to assess because, perhaps, there is a BKA and no artificial limb is present.

Does this start to make sense as to the difference?
So let me ask this. If you have a patient with an isolated complaint, and you ask them “are you having any pain anywhere else?” Or “ is anything else bothering you” and they say no it’s just the one isolated complaint, is that sufficient to say you’ve assessed all the areas aside from ones related to the complaint, and you can mark “no abnormalities” in the ones not related to the complaint?
 
So let me ask this. If you have a patient with an isolated complaint, and you ask them “are you having any pain anywhere else?” Or “ is anything else bothering you” and they say no it’s just the one isolated complaint, is that sufficient to say you’ve assessed all the areas aside from ones related to the complaint, and you can mark “no abnormalities” in the ones not related to the complaint?
No. How are you not understanding this?
 
So let me ask this. If you have a patient with an isolated complaint, and you ask them “are you having any pain anywhere else?” Or “ is anything else bothering you” and they say no it’s just the one isolated complaint, is that sufficient to say you’ve assessed all the areas aside from ones related to the complaint, and you can mark “no abnormalities” in the ones not related to the complaint?
Some of your questions make sense to me. This one doesn't. It's not even about EMS as much as communication, ethics, and common sense. Is someone telling you it's ok to do what you're asking?

I saw a suggestion that you're overthinking some EMS basics. Perhaps that's the problem.
 
Some of your questions make sense to me. This one doesn't. It's not even about EMS as much as communication, ethics, and common sense. Is someone telling you it's ok to do what you're asking?

I saw a suggestion that you're overthinking some EMS basics. Perhaps that's the problem.
Honestly you’re probably right on the overthinking part. But to ease my overthinking, what is the answer to the question?
 
While a patient’s negative response to general questions about other pains or concerns provides some reassurance, it does not replace the need for a more detailed assessment.

To ethically and accurately document that other systems have “no abnormalities,” you should perform specific inquiries and examinations of those systems.

This approach not only ensures compliance with medical standards but also enhances patient care by identifying issues that may require attention.

(ChatGPT)
 
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