1. Takes, or verbalizes, body substance isolation (BSI) precautions
2. Determine the scene is safe
3. Determine mechanism of injury/nature of illness
4. Determine number of patients
5. Request additional help if necessary
6. Consider stabilization of spine

Initial Assessment

(Medical and Trauma Patient Assessment/Management)

1. Verbalizes general impression of patient
2. Determines responsiveness/level of consciousness
3. Determines chief complaint/apparent life threats
4. Assess airway and breathing
5. Assess circulation
6. Identify priority patients/makes transport decision

Focused History and Physical Exam

or

Rapid Assessment

(Medical Patient Assessment/Management)

1. Signs/symptoms (use OPQRST)
2. Allergies
3. Medications
4. Past pertinent history
5. Last oral intake
6. Events leading to present illness (rule out trauma)
7. Perform focused physical examination (assess affected body part/system) or complete a rapid assessment
8. Obtain baseline vitals signs
9. Perform appropriate interventions (i.e. medications)
10. Transport (if not already doing so)
11. Consider detailed examination

Ongoing Assessment

(Medical Patient Assessment/Management)

1. Repeat initial assessment
2. Repeat vital signs
3. Repeat focused assessment regarding patient complaint or injury

Critical Criteria

(Medical Patient Assessment/Management)

1. Did not take, or verbalize, body substance isolation precautions when necessary
2. Did not determine scene safety
3. Did not obtain medical direction or verbalize standing orders for medical interventions
4. Did no provide high concentration of oxygen
5. Did no find or manage problems associated with airway, breathing, hemorrhage, or shock (hypoperfusion)
6. Did not differentiate patient's need for transportation versus continued assessment at scene
7. Did detailed or focused history/physical examination before assessing airway, breathing, and circulation
8. Did not ask questions about the present illness
9. Administered a dangerous or inappropriate intervention

Focused History and Physical Examination/Rapid Trauma Assessment

(Trauma Patient Assessment/Management)

1. Selects appropriate assessment (focused OR rapid)
2. Obtains, or directs assistant to obtain, baseline vital signs
3. Obtains S.A.M.P.L.E. history

Detailed Physical Examination

(Trauma Patient Assessment/Management)

1. Assess the head
2. Assess the neck
3. Assess the chest
4. Assess the abdomen/pelvis
5. Assess the extremities
6. Assess the posterior
7. Manage secondary injuries
8. Verbalize reassessment of the vital signs

Critical Criteria

(Trauma Patient Assessment/Management)

1. Did not take, or verbalize, body substance isolation precautions
2. Did not determine scene safety
3. Did not assess for spinal protection
4. Did not provide for spinal protection when indicated
5. Did not provide high concentration of oxygen
6. Did not find, or manage, problems associated with airway, breathing, hemorrhage, or shock (hypoperfusion)
7. Did not differentiate patients need for transportation versus continued assessment at the scene
8. Did other detailed physical examination before assessing the airway, breathing, and circulation
9. Did not transport the patient within (10) minute time limit