Assessment

[bdoss2006]

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?

 

[EpiEMS]

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.

 

[bdoss2006]

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?

 

[CCCSD]

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.

 

[NomadicMedic]

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.

 

[EpiEMS]

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.

 

[Akulahawk]

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.