What does the nursing or doctor assessment like?

[patzyboi]

in a hospital? I know this is an EMS forum, but it'll be some nice knowledge. So does anyone here know?

For example in EMS, our patient assessment is composed of Scene size up, primary assessment, history taking, secondary and reassessment, and everything has their subcategories.

 

[medichopeful]

in a hospital? I know this is an EMS forum, but it'll be some nice knowledge. So does anyone here know?

For example in EMS, our patient assessment is composed of Scene size up, primary assessment, history taking, secondary and reassessment, and everything has their subcategories.

What does it look like? It honestly depends on the specialty or area of nursing and (though some of the other posters on here can talk more about it) medicine (now granted, I don't necessarily consider them to be completely separate fields, but that's a different discussion for a different day!).

Without a specialty in mind, the assessments are (at the most basic level) the same. ABCs are the first concern, what does the patient look like when the provider walks in the room, and neurological information upon discussion with the patient. Then, either the whole body is assessed or the specific area of concern is addressed (in "EMS terms," "focused" vs. "complete" assessment).

The real difference is in the depth of the assessment, specific assessment techniques/skills/"maneuvers"), and the level of understanding and knowledge that accompanies each technique.

A lot of the time, the in-hospital assessment is concerned with the larger picture, longer term care, and comparison to the admitting condition or the condition from the previous shift. Most of the time, an EMS assessment only looks at a small time period and the changes that take place within it. An in-hospital assessment is many times focused on longer-term changes (of course, there are some areas in-hospital where this isn't necessarily the case, like emergency departments).

Looking over this, it seems to be all over the place. But hopefully it helps a little?

 

[NYMedic828]

It looks like a person in scrubs or a lab coat.

 

[VFlutter]

It usually depends on the patient and their condition but I tend to follow a general outline for my daily assessments.

Past medical history and current medications are usually handled in the ER but we still go over them again once they are admitted to the floor.

There really isn't a scene size up like EMS but I take a quick look around the room for any safety issues, cleanliness, check equipment, and see what drips are running.

When I start out my shift I do a general head to toe assessment on each patient. This looks pretty similar to an EMS medical assessment. Once done with that I do a more focused assessment on the particular body system related to their chief complaint or problem. For my patient population it is usually cardiac so I auscultate heart tones, assess edema, check surgical incisions, etc. If they are a stroke patient then I would go into a detailed neuro assessment. This usually takes me around 15 mins a patient.

After assessing everyone I sit down and look up labs, test results, and then meds/procedures for the day.

The rest of my assessments for the day are usually quick focused assessments related to changes in condition or after administering meds. If they come back from a procedure I will spend more time reassessing them.

If it is an emergent situation such as new onset chest pain, dyspnea, or arrhythmias then I will go into a rapid medical assessment similar to what you would probably see in EMS.

 

[JPINFV]

For a brand new medical patient, it's fairly similar, just more in depth. History of present illness (OPQRST, other related symptoms, medical history/allergies, medications/etc), do a physical exam, write an assessment and plan.

If it's an OB patient, headaches, swelling, ABD pain, loss of fluid, vaginal bleeding, cramping, contractions, and pelvic pressure is asked, as well as an OB history (year, gestational age, sex, weight, length of labor, complications for every delivery. Gestational age for any spontaneous abortion (miscarriage) or therapeutic abortions (both elective and non-elective), and reason for non-elective theraputic abortions. Additionally, I'll ask about any complications during the pregnancy ("Any complications... like high blood pressure, too much fluid, not enough flood, diabetes..." Fluid referring to amniotic fluid, if the patient doesn't have a clue what you're talking about, it's most likely negative), as well as where they're getting their prenatal care at. If it's an impending birth, I guess EMS can ask the patient about her "group B strep" status, but a date is required (the test is only good for about 4 weeks), and PCN is likely to be started without actual documentation anyways.


If I'm writing an inpatient progress note on a patient, I look up the labs, vital signs, orders over the past 24 hours, and the last days progress note and any other notes written in the chart. Go in, see the patient. Ask general symptom questions (pain, fevers, chills, SOB, chest pain, ABD pain, N/V/D/C, swelling, as well as anything pertinent to any issues the patient is currently being treated for and any side effects. Additionally, post op surgery patients get asked about BM/flatus, ambulation, inspiratory spirometry use, and about their incision site (which is also checked). The PE is generally a basic head to toe, with attention paid to anything related to the reason for their admission.