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This is the patient's description of the pain. Questions can be open ended ("Can you describe it for me?") or leading. [9] Ideally, this will elicit descriptions of the patient's pain: whether it is sharp, dull, crushing, burning, tearing, or some other feeling, along with the pattern, such as intermittent, constant, or throbbing. Region and ...
SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1] [2] Documenting patient encounters in the medical record is an integral part of practice ...
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
The Emergency Medical Treatment and Active Labor Act ( EMTALA) [1] is an act of the United States Congress, passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospital emergency departments that accept payments from Medicare to provide an appropriate medical screening examination (MSE) for anyone ...
The chief complaint, formally known as CC in the medical field, or termed presenting complaint ( PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter ( RFE ), presenting problem, problem on admission or reason for presenting. [citation needed][ 1] The chief complaint ...
National Registry Emergency Medical Technician. Emergency Medical Technician is the entry level of Emergency Medical Technician (pre-hospital emergency medical provider) in the United States . EMTs are not trained to provide definitive medical care, but instead focus on rapid in-field treatment and transport to higher medical providers.
AVPU. The AVPU scale (an acronym from "alert, verbal, pain, unresponsive") is a system by which a health care professional can measure and record a patient's level of consciousness. [1] It is mostly used in emergency medicine protocols, and within first aid . It is a simplification of the Glasgow Coma Scale, which assesses a patient response in ...
An emergency medical technician (often, more simply, EMT) is a medical professional that provides emergency medical services. [1] [2] EMTs are most commonly found serving on ambulances and in fire departments in the US and Canada, as full-time and some part-time departments require their firefighters to be EMT certified.