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| Patient Profile | ||||||||||||
Comprehensive patient assessment.
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| What should an emergency medical record look like? |
| Medical Emergencies Signs and Symptoms |
| Human health symptoms & signs A-Z List. |
| Human health emergency symptoms & signs A-Z List. |
| Criminal Investigations |
| Crisis |
| Complaint |
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What is the consciousness level of the patient? Conscious Confused Delirious Somnolent Obtunded Stuporous Comatose Chronic coma Sleeping Sedated Brain dead What is the pulse rate, blood pressure, respiration rate, and body temperature of the patient? What is the emotional level of the patient? Angry Excited Happy Loving Sad Scared Surprised What causes it? What can be the possibilities? What do you think can help? |
| What should be your first question in case a patient is referred to you? |
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How would you elaborate about your life from your birth up to now? How are you feeling? What are the details of emergencies you faced from your birth until now? Emergency description Date & Time Location Circumstances Details Causes Treatment Treating medical doctor or person Consequences of emergency If many emergencies, list them in chronological order, with date and time. Was it a genuine emergency? What are the details of your birth? Date and time of birth Location of birth Full-term normal delivery Preterm, postterm. Episiotomy Cesarean or any other manipulation. |
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History of the present illness
When or approximately when did it start? Did it begin gradually or suddenly? - If gradually, over what period of time? How long did it take to develop? Did anything cause or contribute to the onset? Have you ever had anything like this before? - If yes, did it feel the same? What was the outcome? Can you point to the exact location of your symptoms? - Describe Does it travel (radiate) to any other part of your body? - Describe Do you have symptoms in any other part of your body? Can you describe the sensation? (dull, sharp, burning, aching, gnawing, throbbing, shooting, constricting, other) How would you describe the intensity? (mild, moderate, severe, other; 1-10 scale) Has it been constant or does it come & go? (Constant, intermittent, episodic) Has it been getting better, worse, or staying the same? Have you found anything that makes it better? (rest, morning, evening, certain position, other) Have you found anything that makes it worse? (positions, activities, morning, evening, coughing, sneezing, straining, other) Has there been a change in any bodily functions? (urination, defecation, respiration, digestion, vision, sexual, other) Has it affected your daily activities in any way? Have you tried store bought or home remedies? - If yes, what was the effectiveness? Have you sought other professional care for this condition? Is there anything else you would like to discuss or that would be important for me to know? Getting Started: Always introduce yourself to the patient. Then try to make the environment as private and free of distractions as possible. This may be difficult depending on where the interview is taking place. The emergency room or a non-private patient room are notoriously difficult spots. Do the best that you can and feel free to be creative. If the room is crowded, it's OK to try and find alternate sites for the interview. It's also acceptable to politely ask visitors to leave so that you can have some privacy. If possible, sit down next to the patient while conducting the interview. Remove any physical barriers that stand between yourself and the interviewee (e.g. put down the side rail so that your view of one another is unimpeded... though make sure to put it back up at the conclusion of the interview). These simple maneuvers help to put you and the patient on equal footing. Furthermore, they enhance the notion that you are completely focused on them. You can either disarm or build walls through the speech, posture and body languarge that you adopt. Recognize the power of these cues and the impact that they can have on the interview. While there is no way of creating instant intimacy and rapport, paying attention to what may seem like rather small details as well as always showing kindness and respect can go a long way towards creating an environment that will facilitate the exchange of useful information. If the interview is being conducted in an outpatient setting, it is probably better to allow the patient to wear their own clothing while you chat with them. At the conclusion of your discussion, provide them with a gown and leave the room while they undress in preparation for the physical exam.
Initial Question(s):
Follow-up Questions:
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