Protocol 4-708 - General History and Physical Exam

CMH EMS & MIH Protocols

EMT w/CHW:

• A complete history and physical exam should be completed on all patients that meet one or more of the following criteria:
• It has been greater than one year since a documented visit with their PCP.
• A significant health event has occured since their last documented visit with their PCP.
• Refer to CMH Policy HIM02-01 - History and Physical.
• GENERAL INFORMATION:
• Contact information and PCP information.
• Primary communication language.
• Primary caregiver information.
• Location where medical care is obtained (i.e. PCP, specialist, ER, 9-1-1, etc.).
• Demographic data such as age, gender, race, and ethnicity
• Chief complaint, including location, aggravating factors, complications, signs/symptoms, and treatments.
• Presence of DNR or advanced directives.
• Patient knowledge level of their diseases/conditions.
• PAST MEDICAL HISTORY:
• General vaccination history.
• Medical conditions with details such as onset date, hospitalizations, complications, and treatments.
• Surgical history with dates, indications, and types of operations.
• OB/GYN history with number of pregnancies, number of births, number of living children, menstrual history, and birth control.
• Psychiatric history with dates, diagnoses, hospitalizations, and treatments.
• Age-appropriate health maintenance with pap smears, mammograms, cholesterol testing, colon cancer screenings, and immunizations.
• Childhood illnesses.
• Refer to Protocol 4-833 - General Medications Reconciliation to complete a full assessment of medications.
• Allergies and nature of adverse reactions.
• Occupation and past occupations.
• FAMILY HISTORY:
• Health state or cause of death of parents, siblings, and children.
• Presence of diseases that run in the family such as hypertension, artery disease, strokes, diabetes, cancer, and addictions.
• SAFETY AND SOCIAL ASSESSMENT:
• Refer to Protocol 4-916 - General Safety Assessment to complete a full assessment of safety risks.
• Refer to Protocol 4-957 - General Social Assessment to complete a full assessment of social factors and history.
• GENERAL ASSESSMENT:
• Patient's perceived level of physical health.
• Patient's perceived level of mental health.
• General appearance.
• Position of comfort.
• Level of distress.
• Mobility concerns.
• Sleep patterns.
• Eating habits.
• Bathroom habits.
• Alcohol and drug use.
• Vital signs to include:
• Pulse rate, rhythm, and quality
• Respiration rate, rhythm, and quality
• Blood pressure to include orthostatics
• Temperature
• Pulse oximetry
• Weight and height
• Blood Glucose
• Pain level
• REVIEW OF SYSTEMS:
• Neurological
• Skin
• Head, eyes, ears, nose, and throat
• Cardiorespiratory: Inspection, auscultation, and palpation)
• Abdominal: Inspection, auscultation, percussion, and palpation
• Musculoskeletal: Inspection, palpation, range of motion, muscle strength and tone, and gait
• Consider Peak Flow Meter.
• Consider Urine Analysis

AEMT w/CHW:

• Ensure completion of applicable items above.

RN w/CHW:

• Ensure completion of all applicable items above.
• Consider Capnography.
• Consider Blood Analysis.
• Consider Ultrasound.

Medic w/CHW:

• Ensure completion of all applicable items above.
• Consider Cardiac Monitoring or 12-lead ECG.

CP:

• Ensure completion of all applicable items above.

CMH Pre-Hospital Services Mission: "Provide safe, exceptional, and compassionate care to our communities with an emphasis on highly trained and empowered staff."

CMH Mobile Integrated Healthcare Mission: "Provide exceptional, compassionate, and patient-centered care by a mobile collaborative team to improve patient experience, improve quality outcomes, and reduce healthcare costs."

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