INTRODUCTION:

All patients, whether accepting or refusing care, should be as thoroughly assessed as is possible and appropriate.

1. Patient Assessment should include the following.
   1. General Appearance
      1. Age, Gender, and Weight
      2. General state of health
      3. Amount of distress (mild, moderate, severe, acute)

   2. Objective Signs
      1. Respiratory assessment
      2. Skin: Temperature, color, general appearance
      3. Neurological status

   3. Vital Signs
      1. Pulse: rate, regularity, and quality
      2. Respiration: rate, character, breath sounds
      3. Blood pressure
      4. Level of consciousness (GCS & TS if applicable)
      5. Pulse Oximetry (if applicable)
      6. Temperature

   4. Head to Toe Physical Exam

2. History of episode (obtain from patient, family, or observer)
   1. Chief Complaint
   2. Time of incident or onset of symptoms and/or prior treatment as related to present illness or injury.
   3. Mechanism of injury (if trauma patient)
   4. Self-treatment, medications, and results
   5. Pertinent medical history
      1. Previous medical problems and conditions
      2. Routing medications
      3. Patient's physician, if applicable
      4. Allergies

The physical assessment and history (present and pertinent past history) should be documented on the patient care report.