IX. Patient Assessment System – Checklist

Part 9 of 9: PATIENT ASSESSMENT CHECK LIST:

SCENE SURVEY:
Is the SCENE SAFE?
Is the PATIENT SAFE?

PRIMARY SURVEY: 
Are they CONSCIOUS?
Do they have an OPEN AIRWAY?
How is their BREATHING?
Do they have a PULSE? 
Are they BLEEDING?
Are there any serious injuries on the CHUNK CHECK?
Is their neck and spine STABLE?
Do they need to be MOVED?
Do we need to protect them from the ENVIRONMENT?
How is everyone else DOING?

SECONDARY SURVEY – VITAL SIGNS:
What is their RESPIRATORY RATE & EFFORT?
What is their HEART RATE & EFFORT?
What is their LEVEL OF CONSCIOUSNESS?
What is their SKIN COLOR, TEMPERATURE, & COLOR?

SECONDARY SURVEY – PATIENT EXAM:
HEAD  – scalp, face, eyes, nose, mouth.
NECK  – spine, trachea.
CHEST – clavicles, shoulders, ribs.
ABDOMEN – compress the abdomen.
PELVIS – compress the pelvis anterior/posterior and lateral.
LEGS  – circulation, sensation, and motion.
ARMS  – circulation, sensation, and motion.
BACK  – log roll and palpate the length of the spine.

SECONDARY SURVEY – AMPLE HISTORY:
ALLERGY – allergy to drugs, foods, insects, etc. 
MEDS  – prescription and non-prescription drugs.
PREVIOUS – significant past medical history, surgeries, etc.
LAST   – last intake & last output.
” EVENT – events leading up to this crisis.

SOAPnote:
Putting it all together and creating a treatment plan.

RESCUE PLAN:
” Looking at all factors and creating a rescue or evacuation plan.

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