Raven EMS Education Program Manual
Assessment Secondary EMT Medical Evaluation Form

Date:

Student name:

Evaluator name:

Steps:

• Delegate vital signs/diagnostic tools:
• BP,
• HR,
• RR,
• SpO₂,
• blood glucose,
• ECG,
• 12-lead
• Pain scale (1–10) or Wong-Baker FACES scale
• Determine chief complaint/history of present illness: SCORE ONLY ONE OF THE FOLLOWING:
• Allergic reaction: History of allergies? What were you exposed to? How were you exposed? Effects? Progression? Interventions?
• Altered mental status: Description of the episode. Onset? Duration? Associated symptoms? Evidence of trauma? Seizure? Fever? Interventions?
• Behavioral: How do you feel? Determine suicidal tendencies. Is the patient a threat to self or others? Violence? Is there a medical problem? Interventions? Hallucinations? Delusions?
• Cardiac: Onset? Provocation/palliation? Quality? Radiates? Interventions? Severity? Associated shortness of breath? N/V? W/D? Orthopnea? Time?
• Environmental emergency: Source? Environment? Duration? Loss of consciousness? Effects general or local?
• Obstetrics: Are you pregnant? How long have you been pregnant? Complications? Pain or contractions? Bleeding or discharge? Do you feel the need to push? Last menstrual period? Prenatal care?
• Poisoning/overdose: Substance? When did you ingest/become exposed? How much did you ingest? Weight? Over what time period? Interventions?
• Respiratory: Associated chest pain? Pain on breathing/palpation? Cough? One-word dyspnea? Orthopnea?
• Weak/dizzy: Orthostatics? Syncope? Anxious? CP? Shortness of breath? Nausea/vomiting? Overdose/underdose of medications? Recent activity/trauma? Recent illness/fever?
• Determine chief complaint/history of present illness/injury:
• Onset
• Provocation/palliation
• Quality
• Radiation
• Severity
• Time
• Obtain the SAMPLE history: If the patient has a poor GCS score/LOC, ask bystanders or family members for pertinent information and look for medical alert tags, wallet, etc.
• Signs/symptoms
• Allergies
• Medications, medication compliance
• Past medical history
• Last oral intake
• Events leading to present illness
• Perform a focused physical examination pertinent to the patient’s chief complaint: SCORE ONLY ONE OF THE FOLLOWING:
• Cardiovascular: peripheral edema, jugular vein distention (JVD), scars, medication patches, pacemaker/defibrillator, accessory muscle use, tripoding, diaphoresis, medical alert tags
• Pulmonary: color of sputum, tripoding, accessory muscle use, pedal edema, JVD, ascites, diaphoresis, home oxygen
• Neurologic: facial droop, incontinence, slurred speech, emesis, tics, medical alert tags
• Musculoskeletal: twitching/shaking, tetany of muscles, spasms
• Integumentary: scars, difference in pigment, blotches, burns
• GI/GU: emesis, incontinence, diarrhea
• Reproductive: prolapsed rectum/uterus, abnormal bleeding/fluids, hemorrhoids, signs of childbirth
• Psychological/social: suicide marks, scratch marks, tics, Tourette’s, hallucinations
• State field impression of the patient.
• State treatment plan for the patient and provide appropriate interventions.
• Reassess the ABCDs.
• Reassess the vital signs: HR, RR, BP, SPo2, blood glucose (as needed).
• Assess the patient’s response to any interventions and treatments.
• Repeat the focused assessment regarding the patient’s complaint or injuries.
• Accepts evaluation and criticism professionally.
• Shows willingness to learn/ask appropriate questions.
• Interacts with simulated patient and other personnel in a professional manner (ie, uses appropriate name, explains procedures, maintains modesty, is courteous to crew, etc).

Passing criteria:

• Pass: At least 70% (? of ?) successfully completed above. Currently at 0% completed.
• Fail.
• Exceeds 15 minutes.
• Fails to take or verbalize infection control precautions prior to performing assessment.
• Fails to determine scene safety prior to approaching the patient.
• Fails to provide spinal protection when indicated.
• Fails to conduct the appropriate assessment based on responsiveness.
• Fails to provide appropriate oxygen therapy within 3 minutes of starting the scenario.
• Performs other detailed or focused assessment or physical examination before assessing and treating threats to airway, breathing, and circulation.
• Fails to find or appropriately manage problems associated with airway, breathing, hemorrhage, shock, or dysrhythmia.
• Fails to determine the patient’s primary problem.
• Fails to differentiate the patient’s need for immediate transportation versus continued assessment and treatment on scene.
• Orders a dangerous or inappropriate intervention or drug.
• Does not complete treatment modality for the complaint of the patient/scenario.
• Performs any action that is considered dangerous or inappropriate for the performed skill.
• Fails to call for or initiate transport within 15-minute time limit.

Comments:

Evaluator signature:
Clear

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