Patient Assesment

The patient assessment process is the single most important skill for an EMT.

It is a systematic, repeatable sequence designed to rapidly identify and manage life-threatening conditions, investigate the patient’s complaint, and determine the appropriate course of treatment and transport.

This section of our NREMT study guide breaks down the five essential components of a complete patient assessment.

1. Scene Size-Up

The scene size-up begins the moment you are dispatched and continues as you approach and arrive at the scene. It is a continuous process of ensuring safety and operational readiness before you ever make patient contact.

• BSI / Standard Precautions / PPE: Your first priority is your own safety. Before exiting the ambulance, you must determine what level of personal protective equipment is necessary. At a minimum, this will be gloves. You should anticipate the need for more advanced protection based on dispatch information. For a patient with a cough and fever, you should don a mask. For a childbirth or major trauma, you should have eye protection and a gown readily available.
• Scene Safety: This is a dynamic assessment of your surroundings for any potential hazards to your crew, the patient, or bystanders. Hazards can include:
  • Environmental: Traffic, weather conditions (ice, rain), unstable surfaces, difficult terrain.
  • Human-Related: Violent patients, hostile bystanders, crime scenes, or weapons.
  • Chemical/Biological: Hazardous materials, risk of infectious disease.
    Never enter a scene that you have not deemed safe. If the scene is unsafe, stage a safe distance away and request the appropriate resources (e.g., law enforcement, fire department, HAZMAT).
• Mechanism of Injury (MOI) / Nature of Illness (NOI):
  • MOI (Trauma): This is the physical force that caused the injury. Understanding the MOI helps you develop an “index of suspicion” for potential injuries. For example, in a head-on motor vehicle collision (MVC), you should suspect head, spine, chest, and abdominal injuries. For a fall, the height of the fall and the surface the patient landed on are critical details.
  • NOI (Medical): This is the type of medical condition the patient is experiencing. You can gather clues from the dispatch information, the scene itself (e.g., medication bottles, home oxygen), and information from bystanders or family members.
• Number of Patients: It is crucial to quickly determine how many patients you have. If the number of patients overwhelms your initial resources (typically considered three or more patients), you must declare a Mass Casualty Incident (MCI), establish command, and request additional resources immediately.
• Additional Resources: Based on your scene size-up, determine if you need help. This could include Advanced Life Support (ALS) for a critical patient, the fire department for extrication or lifting assistance, or law enforcement for scene control. Make these requests early.

2. Primary Assessment

The primary assessment is a rapid, hands-on evaluation to identify and treat all immediate life threats. This process should be swift and systematic. The guiding principle is to address problems as you find them.

• Form a General Impression: This is your “from the doorway” assessment. Note the patient’s age, sex, and general appearance. What is their position (e.g., tripod position suggests severe respiratory distress)? What are their facial expressions (e.g., grimacing in pain, anxious)? Are they tracking you as you approach? This initial impression helps you determine if the patient is “sick” or “not sick.”
• Assess Level of Consciousness (LOC): Use the AVPU scale to determine the patient’s responsiveness.
  • Alert: The patient is awake, has their eyes open, and is aware of you and their surroundings.
  • Verbal: The patient is not alert but responds when you speak to them (e.g., opens their eyes, moans, or speaks).
  • Painful: The patient does not respond to your voice but responds to a painful stimulus, such as a trapezius pinch or a sternal rub. Note their response (e.g., purposeful movement, posturing).
  • Unresponsive: The patient does not respond to any stimulus.
• Assess the Chief Complaint and Apparent Life Threats: Ask the patient, “Why did you call 911 today?” to determine their chief complaint. Simultaneously, perform a quick visual scan for any obvious, immediate life threats, such as arterial bleeding. The approach to your ABCs depends on this finding:
  • ABC Approach: For most patients.
  • C-ABC Approach: If the patient has obvious, life-threatening external hemorrhage, your first priority is to control the bleeding with direct pressure or a tourniquet. You cannot oxygenate blood that is no longer in the body.
• Assess the Airway (A):
  • Is it open? An alert patient who is speaking in full sentences has an open airway. In an unresponsive patient, the tongue is the most common obstruction. If the airway is not open, perform a head tilt-chin lift (for medical patients) or a jaw-thrust maneuver (for trauma patients).
  • Is it clear? Listen for abnormal sounds like snoring (tongue), gurgling (fluid), or stridor (obstruction/swelling). If the airway is not clear, suction immediately.
• Assess Breathing (B):
  • Is the patient breathing? If not, begin ventilations with a bag-valve mask (BVM) immediately.
  • Is the breathing adequate? You must assess three things:
    1. Rate: Is it too fast (tachypnea) or too slow (bradypnea)?
    2. Rhythm: Is it regular or irregular?
    3. Quality/Tidal Volume: Is the patient moving an adequate amount of air with each breath? Look for equal chest rise and fall. Listen for abnormal lung sounds.
  • Intervention: If breathing is inadequate (too fast, too slow, or too shallow), provide supplemental oxygen and be prepared to assist ventilations with a BVM.
• Assess Circulation (C):
  • Pulse: In a conscious patient, assess the radial pulse. In an unresponsive patient, assess the carotid pulse. Note the rate, rhythm, and quality (e.g., “strong and regular,” “weak and thready”).
  • Skin: Assess the skin color, temperature, and condition. “Pink, warm, and dry” is normal. “Pale, cool, and diaphoretic (sweaty)” is a classic sign of shock (hypoperfusion).
  • Bleeding: Perform a rapid body scan to identify and control any major bleeding that was not found earlier.
• Make a Transport Decision: Based on your primary assessment findings (altered mental status, ABC compromise), you will determine if the patient is a high priority for immediate transport (“load-and-go”) or if they are stable enough to allow for a more detailed assessment on scene.

3. History Taking

This is the investigative portion of the assessment, where you gather information about the chief complaint and the patient’s overall health.

• OPQRST (for investigating pain or other symptoms):
  • Onset: What were you doing when this began? Did it start suddenly or gradually?
  • Provocation/Palliation: Does anything make it better or worse? (e.g., movement, rest, leaning forward).
  • Quality: Can you describe the feeling for me? (Use their words: “crushing,” “tearing,” “sharp,” “dull,” “pressure”).
  • Radiation: Does the feeling move or travel anywhere else in your body?
  • Severity: On a scale of 0 to 10, with 10 being the worst imaginable, what number would you give it right now?
  • Time: How long has this been going on? Has it been constant or does it come and go?
• SAMPLE History (for gathering a general medical history):
  • Signs/Symptoms: Start with the chief complaint and associated symptoms.
  • Allergies: Are you allergic to any medications, foods, or environmental factors? What kind of reaction do you have?
  • Medications: What medications do you take? Be sure to ask about prescription drugs, over-the-counter medications, herbal supplements, and any recreational drugs.
  • Pertinent past medical history: Have you had any medical problems in the past? Have you ever had this before?
  • Last oral intake: When was the last time you had anything to eat or drink? This is important in case the patient needs surgery.
  • Events leading up to the incident: What was happening right before this started?

4. Secondary Assessment

This is a more detailed, systematic physical examination to identify any additional injuries or signs related to the patient’s condition.

• Systematic Approach: For any patient, you will assess three main things:
  1. Inspection: Look for abnormalities.
  2. Palpation: Feel for tenderness, swelling, or deformities.
  3. Auscultation: Listen to sounds, primarily lung and heart sounds.
• Trauma Patient: If the patient has a significant MOI or is unresponsive, you will perform a complete head-to-toe secondary assessment, systematically examining each body region using DCAP-BTLS (Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, Swelling). Remember to check pulse, motor function, and sensation (PMS) in all four extremities.
• Medical Patient: For a conscious medical patient, the secondary assessment is typically focused on the body system related to the chief complaint. For a patient with chest pain, you would perform a detailed cardiovascular and respiratory exam. For a patient with abdominal pain, you would inspect and palpate all four abdominal quadrants.
• Vital Signs: Obtain a full set of baseline vital signs: blood pressure, pulse, respiratory rate and quality, oxygen saturation (SpO2), and assess the pupils for size, equality, and reactivity to light (PERRL). A blood glucose level should be considered for any patient with an altered mental status.

5. Reassessment

Reassessment is the ongoing process of monitoring your patient’s condition, the effectiveness of your interventions, and identifying any new problems. It is not a single event, but a continuous loop that continues until you transfer care to a higher-level provider.

• Frequency:
  • Unstable Patient: Reassess every 5 minutes.
  • Stable Patient: Reassess every 15 minutes.
• Steps of Reassessment:
  1. Repeat the Primary Assessment: Re-evaluate the patient’s mental status (AVPU), and re-check their Airway, Breathing, and Circulation (ABCs). Have there been any changes?
  2. Reassess Vital Signs: Obtain and trend a new set of vital signs. Compare them to your baseline.
  3. Re-evaluate the Chief Complaint: Has the patient’s primary symptom changed? For example, has their pain level increased or decreased?
  4. Check Interventions: Are your treatments working? Is the bleeding controlled? Has the patient’s breathing improved after the albuterol? Do you need to adjust or add any treatments?