Raven EMS Education Program ManualAssessment Comprehensive History Evaluation Form
Date:
Student name:
Evaluator name:
Steps:
Take BSI precautions.
Introduces himself/herself to patient.
Learns the patient’s name before beginning the interview.
Explain the procedure to the patient.
Determine age.
Determine weight (estimated/converted to kg).
Determine sex. (If information is obvious, may not need to ask.)
Determine ethnic origin.
Determine source of referral. (“Who called EMS?”)
Determine source of information about illness or injury. (Patient? Family? Witness?)
Determine reliability.
Do you believe the patient to be a reliable historian?
Does the patient have the capacity to consent for care?
Is the patient oriented, and is the orientation normal for the patient?
Ask “How can we help you?” or “What’s bothering you today?”
Determine the duration of this episode of the complaint.
Determine onset/setting. (“Where were you, and what were you doing when this came on?”)
Determine factors.
Provocation/aggravation: “Does anything make it worse?”
Palliation/relief: “Does anything make it feel better?”
Determine quality. “What does it feel like?” or “Can you describe the sensation?”
Determine location.
Region: “Where is your pain or symptoms?”
Radiation: “Does the pain stay there, or go elsewhere?”
Determine severity. “On a scale of 0 to 10, with 10 being the worst pain ever, how would you rate your pain/discomfort right now?”
Determine timing.
Onset: “What time did this start?”
Duration: “How long has this lasted?”
Determine treatments. “Have you done or taken anything to feel better?”
Determine associated symptoms and pertinent negatives. Symptoms expected and present, or expected but conspicuously missing.
Formulate a field impression based on the patient’s answers and presentation.
Determine general health status. Ask the patient how healthy he/she considers himself/herself to be or obtain a statement of the caregiver’s impression of sick or not sick.
Determine current medications.
“What prescribed medications do you currently take?”
“What over-the-counter medications or home remedies are you currently using?”
“When did you take the last dose of medication?”
“Do you take all your medications as directed?”
“Have you started or stopped any medications recently?”
Record medications or bring medications to the hospital with the patient.
Determine any recent illnesses.
“When was the last time something like this happened to you?”
“Is this an acute or chronic illness?”
“What medical care do you currently receive for this illness?”
“What other illnesses are you being treated for?”
Determine allergies.
“Do you have allergies to any medications?”
“Do you have any other environmental, food, or injection allergies?”
Determine surgical history. “What previous surgeries have you had?”
Determine environmental/social history.
Patient nutritional status.
“How often do you drink alcohol?”
“Are you a smoker or do you use chewing tobacco?”
“Any drug use now or in the past?”
Determine the number of members in the primary family and whether the patient is married, has young children, or is caring for a dependent.
Determine health status of the primary family.
Determine health status of the patient’s parents.
Determine diseases noted in the genetic family.
Ask, “Are you able to take care of yourself at home?”
Say, “Please tell me about your daily life activity and routine.”
Ask, “What is your outlook on life?”
Provide a verbal report.
Identify the chief complaint.
Identify the presenting problem or field diagnosis.
Identify the pertinent findings/associated symptoms.
Identify the pertinent negatives.
Provide the report in a logical sequence.
Makes the patient feel comfortable.
Uses appropriate eye contact.
Establishes and maintains proper distance.
Uses communication techniques that show interest in the patient.
Uses reflection to gain patient confidence.
Uses mostly open-ended questions.
Uses clarification/confrontation when needed to get accurate information.
Follows the patient’s lead to converge questions.
Shows empathy.
Provides a professional appearance.
Takes notes of findings during history taking.
Passing criteria:
Pass: At least 70% (? of ?) successfully completed above. Currently at 0% completed.
Fail.
Fails to take BSI precautions prior to performing assessment.
Fails to introduce himself/herself and learn the patient’s name before beginning the interview.
Did not explain and reassure the patient to allow informed consent.
Fails to complete an appropriate, accurate, thorough history.
Fails to obtain vital information necessary for the proper assessment and management of the patient’s condition.
