Total Patient Assessment & Documentation Exercise

In ambulance and other areas of health care there is a saying “if it is not written down, it hasn’t been done”. This is very relevant to patient assessment. While most Western ambulance services now use detailed electronic patient report forms which prompt paramedics to acknowledge holistic patient concerns and relevant body system assessments, several services still rely on the paramedic to design and report on findings unprompted.

The aim of this final assignment is to demonstrate a holistic range of assessment practices (which we have covered in this topic) that you may be called upon to use and report on, within the pre-hospital setting.

EXERCISE:
1. Find a person to volunteer to be a patient for you (friend, family member etc).
2. Please complete and report on a holistic assessment of this person
3. You may assume that your patient has presented with a “Conscious Collapse”. The rest of the information presented can be a blend of your own creative licences & actual findings from your chosen patient
4. Please report on all findings, both positive and negative as a way of evidencing that the assessment has been completed/considered
5. Your completed document should resemble an extremely comprehensive/ extensive case card
6. You are required to report on any assessment which would be available to a paramedic. Please create your own findings where you do not have access to the required equipment (eg. ECG, BP, BGL)
7. You are not required to treat your patient
8. Dot point / concise reporting is suitable for this assessment
9. You are not required to explain your assessments.
# Please do not attempt to complete this on an actual SAAS case card as you will not have enough space for the information expected to satisfy this assignment requirements.
There is an approximate 2 page word limit for this assignment and no references are required.
# Please note ISBAR is not a recommended documentation tool
Please familiarize yourselves with the specific marking rubric and documentation guide provided
Total Patient Assessment & Documentation Exercise/ Rubric
Guide which will be used when critiquing your submission and awarding marks
• Well presented, logical flow. Reader can see from the assessments performed and findings presented how the student arrived at their provisional diagnosis

• Comprehensive inclusions of positive and negative findings are suitable to suggest the provisional diagnosis while simultaneously suggesting other differential diagnoses are less likely

• The report evidences a holistic & comprehensive coverage of all standard areas of patient assessment and demonstrates all key areas main body systems have been considered

• Assessment and findings presented are sufficient to consider all relevant “red flags” relating to the patient presentation
• All subjective and objective data collected from and/or relating to the patient is clear to the reader

• Language used in the patient report is appropriate, only widely accepted abbreviations are included (minimal please. If in doubt write in full)

• Report remains free of assumptions about the patient or diagnoses that require further testing to confirm.
Grade /5
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