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It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
The Pediatric Assessment Triangle or PAT is a tool used in emergency medicine to form a general impression of a pediatric patient. [1] In emergency medicine, a general impression is formed the first time the medical professional views the patient, usually within seconds. [ 2 ]
This is the patient's description of the pain. Questions can be open ended ("Can you describe it for me?") or leading. [9] Ideally, this will elicit descriptions of the patient's pain: whether it is sharp, dull, crushing, burning, tearing, or some other feeling, along with the pattern, such as intermittent, constant, or throbbing. Region and ...
For example, a fully alert patient might be considered "alert and oriented x 4" if they could correctly identify the time, their name, their location, and the event. EMS crews may begin with an AVPU assessment, to be followed by a GCS assessment if the AVPU score is below "A."
Generally, rapid trauma assessment is indicated if: [3] [4] There was a significant mechanism of injury (for example, a high-speed car accident, falls >20 ft); OR; The patient has an altered mental status; OR; The medical responder suspects that the patient has multi-systems trauma
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.