CP 4.2: Initial Assessment Screen

Updated:
Reviewed: 

Purpose

To assist the Community Paramedic (CP) in observing and documenting objective and subjective information for the purpose of identifying the patient’s state of health and comparing it to the ideal.  It should be noted that CPs are not authorized to make a diagnosis or clinical assessment.  Any findings that are outside the expected range must be reported immediately to the primary health care provider/team unless specified otherwise in the care plan.

Policy Statement

The CP will respond to a request for CP care and will perform a patient health assessment screen during the initial visit to a patient’s home.  The initial health assessment screen will be documented on the Community Paramedicine Initial Assessment Screen Form.  Parts of this screen may be omitted, depending on the situation and the instructions given in the Request for Service/care plan.  A more targeted screen may be required based on the individual needs of the patient and the care plan.

Procedure

1. OBTAIN verbal consent from the patient to conduct the screen.  Be clear regarding signals for ‘YES” and “NO” for non-verbal patients and use of communication aids or devices.  Ensure translator is present if required.
2. ASK questions of the patient, or caregiver if present, and complete pertinent sections of Initial Assessment Screen form as applicable.  If specific items are not assessed, √ column and document in additional comments/exceptions the reason(s) for not assessing (e.g., patient declined, assessment not indicated, etc).
3. UTILIZE supplementary tools as required: Falls Risk Screen; Braden Scale; Home Safety Assessment Screen; Pain Assessment Tool; and Mental Health Screening tools.
4. NOTIFY health care provider/team of concerns that arise from the screen, or for any assessments requiring follow-up.

References

1. Eagle County Paramedic Services. Community Paramedic Protocols Manual. 2013. [Link]
2. Tri-County Health Care Emergency Medical Services. Community Paramedic Policy & Procedure Manual. 2016. [Link]
3. Vancouver Coastal Health. Vancouver Community AOA Practice Guidelines. Initial Assessment Tool – Guidelines for Use. March