PATIENT ASSESSMENT
All patients in a mental health or behavioral crisis should undergo an assessment by a paramedic to the extent that it can be safely done or permitted by the patient. In general, a calm approach to an assessment can provide comfort to the patient who is feeling out-of-control. This is especially true of touching and reassuring the patient. The assessment should be made up of a detailed history, vital signs, a head-to-toe examination, and a discussion with the patient of the findings. The goal is two-fold: calm the patient and find any clues to a medical or traumatic origin to the crisis or contributing to the crisis.
1. Approach the patient calmly and ask permission to ask questions, take their vital signs, and examine them.
2. The history is important
a. History of the present illness or crisis.
b. Past medical and psychological history of similar episodes, mental illnesses, medical problems, recent trauma (especially head), medications and therapy, compliance with medications and therapy, allergies or medication intolerance.
c. Any psycho-social experiences that may be contributing to the present crisis.
3. The physical examination can be comforting to the patient and reassuring that something is being done to help them.
a. Vital signs
b. Primary survey (ABC’s)
c. Secondary survey (Head-to Toe examination)
d. Make every effort to assess the patient’s capacity (competence) to understand and consent to treatment and/or transport and insight into their present crisis.
e. Point of care testing as available and necessary for evaluation at an Acute Behavioral Health Facility (this will vary with each facility).
i. BGL
ii. Breathalyzer for estimated blood alcohol level
4. Inform the patient of any significant findings and reassure that they are safe and in competent hands.
5. Document the full assessment in a PCR.
All patients in a mental health or behavioral crisis should undergo an assessment by a paramedic to the extent that it can be safely done or permitted by the patient. In general, a calm approach to an assessment can provide comfort to the patient who is feeling out-of-control. This is especially true of touching and reassuring the patient. The assessment should be made up of a detailed history, vital signs, a head-to-toe examination, and a discussion with the patient of the findings. The goal is two-fold: calm the patient and find any clues to a medical or traumatic origin to the crisis or contributing to the crisis.
1. Approach the patient calmly and ask permission to ask questions, take their vital signs, and examine them.
2. The history is important
a. History of the present illness or crisis.
b. Past medical and psychological history of similar episodes, mental illnesses, medical problems, recent trauma (especially head), medications and therapy, compliance with medications and therapy, allergies or medication intolerance.
c. Any psycho-social experiences that may be contributing to the present crisis.
3. The physical examination can be comforting to the patient and reassuring that something is being done to help them.
a. Vital signs
b. Primary survey (ABC’s)
c. Secondary survey (Head-to Toe examination)
d. Make every effort to assess the patient’s capacity (competence) to understand and consent to treatment and/or transport and insight into their present crisis.
e. Point of care testing as available and necessary for evaluation at an Acute Behavioral Health Facility (this will vary with each facility).
i. BGL
ii. Breathalyzer for estimated blood alcohol level
4. Inform the patient of any significant findings and reassure that they are safe and in competent hands.
5. Document the full assessment in a PCR.