Total Patient Assessment & Documentation Exercise

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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

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