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Download medical assessment forms in .PFD format.
Medical Assessment: A Life-Saving Tool
A medical assessment of a patient, one who is either involved in some type of accident or suffering from a serious illness, is a time-sensitive document that can help doctors and surgeons quickly decide and act on a treatment strategy. These assessments, which are typically taken by emergency response technicians, paramedics in the field or nurses in the ER, are typically used to record all of the necessary information with regard to a patient’s current status and any past history that may give doctors a clue to what’s actually going on.
Medical Assessment: The First Steps
Many medical assessments are typically taken when a patient is en route to a hospital. At this point, the EMT or paramedic usually focuses on the part of the body they believe to be responsible for the patient’s symptoms. A physical examination is usually performed first, and then the following questions or determinations should be recorded on the medical assessment:
• Onset. To treat the patient properly, doctors will need to know when the symptoms started. Naturally, if the symptoms are a result of an accident, the onset would be the moment the accident occurred.
• Provocation. When the assessment is taken on a person with some type of illness or medical condition, emergency personnel need to record what specifically made the symptoms worse.
• Type of Symptoms. In this section, paramedics will try to determine how the symptoms feel. For example, are the pains more of a throb-like sensation or sharp pains?
• Radiation. If the patient is experiencing pain, the next step is to determine if the pain is radiating to other parts of the body.
• Severity. To record the severity of a patient’s symptoms, EMTs and other emergency personnel will often ask the patient, if conscious, to rate their pain or symptoms on a scale of 1-10.
• Time. In this section, personnel will obtain information with regard to how long the pain tends to last. For example, is the pain constant or do the pains tend to come and go in waves?
Medical Assessment: Medical History
After the patient has been evaluated using the six criterion above, the next step is to record the patient’s medical history. This can be difficult to do if the patient is struggling with severe pain, but it is a necessary step that can dramatically facilitate rapid treatment. Below are just a few pieces of information that are usually collected:
- Patient’s name
- Date of birth
- Contact information
- Person or people that should be contacted
- Allergies
- Medications being taken by the patient
- Past medical history (illnesses, surgeries, medical conditions)
- Family medical history
The medical assessment is the first step in effectively diagnosing and treating a patient. Not only does it give doctors an early indication of what’s happened and what needs to be done, it also serves as a tool for prioritizing patient treatment when a doctor is dealing with multiple cases at once.