you are reviewing a prehospital care report for a patient with altered mental status

What is altered mental status?

Altered mental status is a simple yet definitive indicator that something is wrong with the patient. AMS is relatively easy to determine in the field, but getting to the root cause of AMS requires a complete patient assessment.

How do you document altered mental status in a PCR?

Documentation of Altered Mental Status should be included in the Patient Care Report (PCR) in the form: Pertinent positives and negatives should be included in a narrative. Example: "Patient has history of diabetes with poor compliance with medications. Patient BSL 820 mg/dL. Patient is obtunded AxO 2 normally AxO 4.

How do you assess altered mental status?

A complete patient assessment and consideration of multiple causes will help make sure the patient's altered mental status is correctly assessed Altered mental status is a simple yet definitive indicator that something is wrong with the patient.

Why perform a complete patient assessment for AMS?

AMS is relatively easy to determine in the field, but getting to the root cause of AMS requires a complete patient assessment. Here are six reasons, from actual patient cases, that demonstrate why it is critical to perform a complete patient assessment with every AMS patient. 1. Anything can cause altered mental status.

After a patient, who is short of breath, signs a refusal of service, which one of the following statements would be appropriate prior to leaving the residence? A) "Try taking an aspirin and get a good night's rest; you will probably feel better." B) "If you change your mind and want to be transported to the hospital, call 911." C) "We will leave this oxygen for you; call us when you feel better." D) "Call our dispatch in the morning to let us know how you made out."

B) "If you change your mind and want to be transported to the hospital, call 911.

Which one of the following statements shows an accurate understanding of the legal aspects of the prehospital care report (PCR)? A) "A PCR can be used in a lawsuit only if that lawsuit is filed within six months." B) "A copy of the PCR should be forwarded to the police any time law enforcement is involved in the call." C) "The PCR may be subpoenaed even if the case centers around alleged negligence that occurred in the emergency department." D) "The PCR is considered a legal document only when it describes a crime or act of violence."

C) "The PCR may be subpoenaed even if the case centers around alleged negligence that occurred in the emergency department."

Last week, on a computer generated report, you accidentally documented that a patient suffered from hypertension when, in fact, he did not. Unfortunately, the report has been locked by the computer and cannot be changed; however, it can be printed. Your first action would be to: A) retype the entire report and include the change. B) notify the medical director so that she can fix the error. C) print the report and draw a line through the error. D) contact the hospital and have them change it in the patient's medical record.

C) print the report and draw a line through the error.

A pertinent negative would be illustrated by: A) "nausea without vomiting." B) "hypertension and taking medication." C) "dizziness for three days without notifying the doctor." D) "short of breath with history of lung problems."

A) "nausea without vomiting."

Consider the following narrative from a patient care report: "pt. restrained passenger involved in 2 car MVC; c/o left lower leg pain rated 2/10; LOC A/O to person, place, time, and event; BBS clear; abd. Soft with tenderness LLQ; hx of NIDDM with am glucose level of 133 mg/dL." Which of the following is true? A) The patient's abdomen appears uninjured. B) The patient is being tested for diabetes. C) The patient is confused following the accident. D) The patient's lungs sounds are clear and equal.

D) The patient's lungs sounds are clear and equal.

A patient with asthma is using his inhaler tid and prn. You would recognize that: A) the patient is suffering asthmatic attacks three times a week. B) the patient is only prescribed his inhaler three times a day. C) the patient uses his inhaler only when the symptoms are bad. D) the patient uses an inhaler at least three times a day.

D) the patient uses an inhaler at least three times a day.

When writing a prehospital care report, you accidentally document that a laceration was on the left side of a patient's face when it was actually on the right side of the face. How would you correct this mistake? A) Carefully use White-Out to cover the term "left" but nothing else in the narrative. B) Color over the term "left" with black ink and write the word "right" next to it. C) Draw a single line through the term "left" and write the word "right" next to it. D) Start the entire prehospital care report over from the beginning.

C) Draw a single line through the term "left" and write the word "right" next to it.

Your partner states that he is the "world's worst speller" and has great difficulty using medical terms. Which one of the following statements is appropriate? A) "Do not document information that requires medical terms you are unsure of." B) "Consider abbreviating medical terms that you are unsure how to spell." C) "Ask the emergency physician or nurse how to spell the words of which you are unsure." D) "Use plain English if you are unsure of how to apply or spell a medical term."

D) "Use plain English if you are unsure of how to apply or spell a medical term."

A nauseated patient with fever and abdominal pain states that he has not vomited. Which one of the following describes how that fact should be documented? A) As a subjective finding B) This fact would not be documented. C) As a pertinent negative D) As a treatment finding

C) As a pertinent negative

What is altered mental status?

Altered mental status is a simple yet definitive indicator that something is wrong with the patient. AMS is relatively easy to determine in the field, but getting to the root cause of AMS requires a complete patient assessment. Here are six reasons, from actual patient cases, that demonstrate why it is critical to perform a complete patient ...

Why was it difficult to believe that the patient's problem was not a result of a previous condition?

The emergency department nurse and physician found it difficult to believe that the patient's problem was not a result of a previous condition because the patient was now fully alert and had a normal heart rate. The complete assessment ensured that the underlying problem was correctly identified.

What was the initial assessment of a patient with hypoglycemic?

The paramedic assumed that the patient was hypoglycemic, so the initial assessment consisted of vital signs and a glucose check. The patient was indeed hypoglycemic, so the paramedic administered dextrose in an attempt to wake the patient and obtain a refusal.

Why is it important to do an AMS assessment?

1. Anything can cause altered mental status. One of the core duties of EMS practitioners is to determine the root cause of AMS in a patient. In practice, however, this can be a challenge ...

Why is a complete mental assessment important?

Altered Mental Status: 6 reasons why a complete assessment is critical. A complete patient assessment and consideration of multiple causes will help make sure the patient's altered mental status is correctly assessed. Altered mental status is a simple yet definitive indicator that something is wrong with the patient.

What is the purpose of a complete patient assessment and consideration of multiple causes?

A complete patient assessment and consideration of multiple causes will help make sure the patient's altered mental status is correctly assessed

What is an example of a paramedic crew responding to a call at a business for a middle?

For example, a paramedic crew responded to a call at a business for a middle-aged male patient whose only complaint was that he could not stay awake. The patient was alert, oriented and able to answer all questions appropriately. In between questions, however, the patient would close his eyes and drift off, as if he were asleep.

SAMPLE History

AEIOU-TIPS is a mnemonic acronym used by many medical professionals to recall the possible causes for altered mental status, and there are many versions. Below is the version typically used in prehospital EMS which includes the S ymptoms, M edications and P ertinent Medical History elements of the S A MP LE History.

Documentation

Documentation of Altered Mental Status should be included in the Patient Care Report (PCR) in the form:

Self Assessment

Use the AEIOUTIPS acronym and practice asking the relevant questions to determine the patient's likelihood of exposure to the altering agent until comfortable with the work flow

Tips and Tricks

Even if you find a viable reason for your patient to be altered, keep checking for other possible causes. There have been many cases where an EMS crew has transported Code 3 stroke alert for a patient whose blood glucose levels were low.

What to call if you change your mind and want to be transported to the hospital?

B) "If you change your mind and want to be transported to the hospital, call 911 ."

When is PCR considered a legal document?

D) "The PCR is considered a legal document only when it describes a crime or act of violence."

How long can PCR be used in a lawsuit?

A) "A PCR can be used in a lawsuit only if that lawsuit is filed within six months."