1. Survey for hazards

2. Determine MOI

3. Establish BSI

4. Determine # of patients

5. General impression of patient: very sick/hurt, not seriously sick/hurt

Acronym for Initial Assessment surveying immediate threats to life.

Airway

Breathing: look, listen, feel

Circulation: check pulse, control life-threatening bleeding

Disability/Decision: If MOI for spine injury, begin manual stabilization

Environment/Expose: Environmental life threats, Expose life-threatening wounds

LOR

HR, rhythm, quality

RR, rhythm, quality

SCTM

BP

Pupils (PERRL)

T

Scene size-up

Initial Assessment (ABCDE)

Head to Toe Physical Exam

Vital Signs

Patient History (CC, MOI/HPI, SAMPLE)

Complete treatment

SOAP note

Decision to evacuate or not

Awake

Verbal, responsive to

Pain, responsive only to

Unresponsive

Acronym for chief complaint questions

Onset: sudden or gradual?

Provokes/Palliates: what makes it worse or better?

Quality: describe the pain: sharp, dull, constant, etc.

Radiation/Region/Referred: where is the pain, does it move?

Severity: 1-10 scale

Time/Trend: how long have you had this? Is it getting better or worse?

SAMPLE

Acronym for MOI/HPI

Symptoms

Allergies

Medications

Pertinent medical history

Last intake/output (incl. quality and quantity)

Events leading up to it

Acronym for documenting the situation

Subjective/summary/story (who, what, where)

Objective/Observations/Findings (head to toe, vitals, history)

Assessment (problem list)

Plan