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NREMT Patient Assessment / Management Medical Skill Sheet

Start Time:
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Stop Time:
1 Date: 1
Candidate's Name:
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Evaluator's Name:
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Move your mouse over the different steps. Respiratory only at this time. These are EXAMPLES of questions and verbalizations. This is NOT a script. Points
Possible
Points
Awarded
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SCENE SIZE-UP
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Determines the number of patients 1 1 1
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INITIAL ASSESSMENT
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Assessment
Indicates appropriate oxygen therapy
Assures adequate ventilations
1
1
1
1
Assessment of circulation
Assesses and controls major bleeding
Assesses pulse
Assesses skin (color, temperature, and condition)
1
1
1
1
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FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID ASSESSMENT
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Respiratory Cardiac
Altered Mental
Status
Allergic Reaction
Poisoning/
Overdose
Environmental
Emergency
Obstetrics
Behavioral
Onset?
Description of
the episode
History of allergies?
Substance?
Source?
Are you pregnant?
How do you feel?
Provokes?
Onset?
What were you exposed to?
When did you ingest/
become exposed?
Environment?
How long have you been pregnant?
Determine suicidal tendancies
Quality?
Duration?
How were you exposed?
How much did you ingest?
Duration?
Pain or contractions?
Is the patient a threat to self or others?
Radiates?
Associated symptons?
Effects
Over what time period?
Loss of Consciousness
Bleeding or discharge?
Is there a medical problem?
Severity?
Evidence of trauma?
Progression?
Interventions
Effects-general or
local
Do you feel the need to push?
Interventions?
Time?
Interventions?
Interventions?
Estimated weight?
Last menstrual period?
Interventions?
Seizures?
Fever?
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Vitals (obtains baseline vital signs) 1 1 1
Interventions (obtains medical direction or verbalizes standing order for medication inverventions and verbalizes proper additional intervention/treatment) 1 1 1
Transport (re-evaluates the transport decision) 1 1 1
Verbalizes the consideration for completing a detailed physical examination 1 1
ONGOING ASSESSMENT (verbalized)
1Interactivity stops here 1 11
Repeats initial assessment 1 1 1
Repeats vital signs
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Repeats focused assessment regarding patient complaint or injury 1 1 1
Total
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Critical Criteria
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____Did not take, or verbalize, body substance isolation precautions as necessary
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____ Did not determine scene safety
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____ Did not obtain medical direction or verbalize standing orders for medical interventions
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____ Did not provide high concentration of oxygen
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____ Did not find or manage problems associated with the airway, breathing, hemorrhage or shock (hypoperfusion)
1 1 1
____ Did not differentiate patient's need for transportation versus continued assessment at the scene
1 1 1
____ Did detailed or focused history/physical examination before assessing the airway, breathing and circulation 1 1 1
____ Did not ask questions about the present illness
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____ Administered a dangerous or inappropriate intervention 1 1 1
I am wearing my gloves and other proper BSI
Is my scene safe? No dogs or threatening people?
Why was the ambulance called? What is wrong?
Is there just 1 person sick or are there others?
If we need additional resources, personnel, law enforcement I would call for it now.
I would consider stabilizing the spine, but do not see an immediate need.
The patient appears stable/unstable.
The patient is conscious / unconscious. On the AVPU scale they are ______
The patient's chief complaint is chest pain and this could be a life threat
There is no visible bleeding, the patient's pulse is ______ and their skin is warm, moist and pink.
The patient's airway is open because they are talking to me. They appear to have adequate respirations and I will put them on high flow O2 via non-rebreather mask.
If this is a priority patient we will load and go. If not we will continue assessing at the scene or in the ambulance.
If I have something to FOCUS on (the patient is conscious and and can tell me what is wrong) I will perform an exam FOCUSED on that complaint. If the patient is unconscious I will do a rapid head to toe assessment.
I will begin the interview process with the conscious patient. Maybe get some history from bystanders of an unconscious patient.
When did you begin having trouble breathing? What were you doing?
Does anything make it feel better or worse?
Can you describe how your breathing feels right now?
Is the breathing difficulty stationary in your chest or does it move?
Where are you at on a scale of 1 to 10 if 1 is very easy to breath and 10 is very hard to breath?
Has the problem been constant since it started or does it come and go?
Have you tried anything to make it feel better?
Are you allergic to anything?
Are you taking any medications? Are you using any herbal supplements or other drugs?
Have you ever had problems like this before? Have other people in your family had any similar problems?
When was the last time you had anything to eat or drink? What did you have?
Have you fallen or been hurt recently? Other than this problem has today been a fairly normal day?
I am going to do a focused exam of the affected body part or system. I will auscultate the lungs for breathing problems, BP for chest pain etc. If I do not have a chief complaint to focus on I will finish a rapid assessment.
I am going to gather baseline vitals with the help of my assistant.
After utilizing online medical control and/or standing orders I will administer/assist with proper interventions. Metered dose inhalers, nitroglycerin, etc.
If the patient's condition is getting worse I might consider a helicopter rendezvous or transport to a closer hospital.
If time is available AND there is a necessity I would do a detailed physical exam.
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