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Medical Patient Assessment Guide

Master the complete medical patient assessment process from BSI to reassessment. Learn the systematic approach that will help you confidently evaluate and treat every patient.

Medceptor Team· EMT Training Specialists10 min read

Doing a medical patient assessment can be overwhelming and kind of daunting, especially when you're new to the whole EMS game. There are quite a few steps to remember, and it's easy to miss a few along the way. But don't worry! This Medical Patient Assessment Guide will help treat your stress before you treat your patients!

1. BSI/Scene Safety

The first step to ANY and EVERY patient assessment scenario is to make sure that your scene is safe and that you are wearing appropriate Personal Protective Equipment (PPE). You won't be able to help any patients if your life is in danger, so always take a quick look around your scene before entering it.

BSI (Body Substance Isolation) is just a fancy way of saying "protect yourself from germs and body fluids." Before even coming near the patient, make sure you won't get any blood, spit, vomit, or other fluids on you. This includes standard PPE such as:

  • Gloves
  • Mask (if needed)
  • Eye protection (if needed)
  • Gowns (if needed)

Think BSI = Barrier!

2. Scene Size-Up

Once you've ensured that your scene is safe, it's time to size up your scene.

Key Steps:

  • Determine the nature of illness (NOI) or mechanism of injury (MOI)
  • Determine the number of patients
  • Request additional EMS assistance if necessary
  • Consider spinal stabilization if trauma is suspected

Then take a quick doorway assessment

  • what can you tell from that first look?

  • Make sure there aren't any other patients

  • Look for bystanders or witnesses

  • Check for items of importance (like medications, drug paraphernalia, or clues to the illness)

3. Primary Assessment / Initial Impression

Now it's time to focus on your patient.

General Impression

How does the patient look? Are they in distress, pale, diaphoretic, or unresponsive?

Level of Consciousness

Use AVPU (Alert, Verbal, Pain, Unresponsive).

You can also ask A&O questions (Person, Place, Time, Event):

  • "Do you know your name?"
  • "Where you are?"
  • "What day it is?"
  • "What happened?"

Chief Complaint / Apparent Life Threats

Ask, "What seems to be the problem today?" or "What's bothering you?"

Airway and Breathing

  • Assess if the airway is patent (open)
  • Check breathing rate, quality, and effort
  • Are they in a tripod position or showing signs of distress?
  • Assure adequate ventilation and initiate oxygen therapy if needed

Circulation

  • Control any major bleeding
  • Check pulse (rate, rhythm, quality)
  • Assess skin color, temperature, and condition

Identify Patient Priority

Based on findings, decide if the patient is stable, potentially unstable, or unstable, and make your treatment/transport decision early.

4. History Taking: SAMPLE and OPQRST

Once immediate life threats are handled, gather your patient's history.

SAMPLE

  • S – Signs and Symptoms
  • A – Allergies
  • M – Medications
  • P – Pertinent Past Medical History
  • L – Last Oral Intake
  • E – Events Leading Up to the Illness

OPQRST

  • O – Onset (When did it start?)
  • P – Provocation (What makes it better/worse?)
  • Q – Quality (Describe the pain)
  • R – Radiation (Does it move anywhere?)
  • S – Severity (Scale of 1–10)
  • T – Time (How long has this been happening?)

For more information, check out the separate guide on how to perfectly conduct a history and pain assessment

  • linked in our blog list!

5. Secondary Assessment & Vital Signs

Now that you have a history, it's time to assess the affected body system(s) and take vitals.

System-Based Assessment Examples

Cardiovascular:

  • Pulse, chest pain, perfusion

Respiratory:

  • Lung sounds, effort, oxygen level

Neurological:

  • Pupils, speech, movement, mental status

GI/GU:

  • Abdominal pain, nausea, output

Psychological/Social:

  • Behavior, stress level, environment

VITAL SIGNS!!! Get these early!

  • Blood Pressure
  • Pulse
  • Respiratory Rate and Quality
  • Oxygen Saturation
  • (If indicated: Temperature, Blood Glucose, Pupils)

You can use the acronym HOT BERPS to remember some of them: Heart rate, Oxygen, Temperature, Blood glucose, Eyes, Respirations, Pressure, Sound of lungs.

State your field impression

  • what you believe is going on
  • and begin appropriate interventions within your EMT scope.

6. Interventions / Treatment

Once you've identified the problem, treat what's within your training and protocols.

Examples:

  • Oxygen therapy
  • CPR or assisted ventilations
  • Splinting injuries
  • Applying C-collar for suspected spinal trauma
  • Controlling bleeding with bandages or gauze
  • Medication assistance (Aspirin, EpiPen, etc.)

Always check the Five Rights before administering any medication:

  1. Right Patient
  2. Right Medication
  3. Right Dose
  4. Right Route
  5. Right Time

For more details, check out the Quick and Easy Guide to NREMT Medications linked in our resources.

7. Reassessment

After interventions and before/during transport:

  • Take another set of vitals
  • Recheck ABCs and your chief complaint
  • See if your patient's condition improved, worsened, or stayed the same
  • Reevaluate your transport decision and prepare a clear verbal report for the arriving EMS or hospital staff

Final Thoughts

This might look like a lot at first glance, but with practice, you'll breeze through this list like the back of your hand! And with Medceptor, you get to put these scenarios into action and receive personalized feedback to help you improve each time.

Ready to turn knowledge into muscle memory? Try Medceptor today and start practicing smarter.

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