Patient Assessment – Documentation

Turning observations into decisions — and decisions into continuity of care.

In emergency, wilderness, disaster, or prolonged-care environments, patient outcomes depend on more than lifesaving interventions. They depend on structured assessment, disciplined observation, and clear documentation that can be understood hours — or days — later.

This page provides a high-level overview of the patient assessment and documentation framework represented in the attached assessment forms. Each section serves as a jump point to deeper instruction, drills, and printable job aids.

On this page

  1. The Assessment Flow (Big Picture)
  2. Objective Assessment & Vital Signs
  3. Physical Examination (Objective)
  4. Documentation & Continuity of Care
  5. How This Fits Into the Larger System
  6. Training Guidance

The Assessment Flow (Big Picture)

Patient assessment is not a single step. It is a cycle:

  1. Identify and treat immediate threats
  2. Gather subjective information
  3. Perform a focused physical exam
  4. Reassess and trend changes
  5. Document clearly for continuity and review

The forms associated with this page support that cycle — from first contact through extended care and handoff.

Objective Assessment & Vital Signs

Ongoing Clinical Monitoring

Purpose
Measure and trend the patient’s physiological status.
Used when
Throughout care, especially during prolonged or delayed evacuation.

Tracked elements include:

  • Pulse, respirations, and blood pressure
  • Level of consciousness (GCS / AVPU)
  • Oxygen saturation and capnography (if available)
  • Treatments performed and patient response

Why it matters:

Trends tell a story that single measurements cannot. Deterioration is often subtle — until it isn’t.

➡️ Jump to: Vital signs & reassessment intervals

Physical Examination (Objective)

From Immediate Threats to Comprehensive Assessment

Purpose: Identify, prioritize, and manage physical injuries and physiological compromise using a staged approach.

Physical assessment is not a single pass. It occurs in layers, each with a distinct goal.

Initial Physical Assessment — MARCH-PAWS

Purpose
Rapid identification and treatment of immediate, preventable causes of death.
Used when
First contact with trauma patients, high-risk mechanisms, or any situation with suspected life-threatening injury.

MARCH-PAWS focuses on:

  • Massive hemorrhage
  • Airway compromise
  • Respiratory failure
  • Circulatory shock
  • Head injury and hypothermia
  • Then PAWS: Pain, Antibiotics, Wounds, Splinting

This assessment is interventional, not observational — problems are corrected as they are found.

➡️ Jump to: MARCH-PAWS (Initial Life-Threat Assessment)

Secondary Physical Assessment — DCAP-BTLS

Purpose
Systematic head-to-toe evaluation to identify injuries not immediately life-threatening.
Used when
After MARCH-PAWS priorities are addressed and the patient is sufficiently stable.

DCAP-BTLS provides a structured method to assess each body region for:

  • Deformities
  • Contusions
  • Abrasions
  • Punctures / Penetrations
  • Burns
  • Tenderness
  • Lacerations
  • Swelling

This assessment supports decisions about:

  • Movement vs shelter-in-place
  • Splinting and wound care
  • Ongoing monitoring and reassessment

➡️ Jump to: DCAP-BTLS (Comprehensive Physical Assessment)

Patient Interview — SAMPLE + OPQRST

Once immediate threats are controlled and the secondary physical exam is underway or complete, attention shifts to the patient interview.

Purpose
Understand what the patient is experiencing and why — in their own words.
Used when
The patient is conscious, coherent, and stable enough to answer questions (or when information can be obtained from witnesses).

The interview uses two complementary frameworks:

  • SAMPLE for medical history and context
  • OPQRST to characterize pain or primary symptoms

This step often reveals:

  • Mechanisms or causes not obvious on exam
  • Medical conditions contributing to the presentation
  • Changes from the patient’s normal baseline

Findings from the interview are integrated with physical exam results to guide:

  • Treatment priorities
  • Reassessment intervals
  • Reporting and documentation

➡️ Jump to: SAMPLE + OPQRST (Patient Interview)

Documentation & Continuity of Care

Why Documentation Matters in Austere Care

Documentation is not bureaucracy — it is memory under stress.

Good documentation:

  • Preserves critical information across caregiver transitions
  • Supports decision-making during prolonged care
  • Enables accurate reporting and evacuation requests
  • Provides legal and ethical protection

The assessment forms together function as a Patient Care Report (PCR) adapted for emergency and austere environments.

➡️ Jump to: Patient Assessment – Documentation/Forms

How This Fits Into the Larger System

These assessment tools integrate directly with:

  • MARCH-PAWS for immediate life-threat management
  • DCAP-BTLS for systematic physical assessment
  • SAMPLE + OPQRST for structured subjective history
  • CASREP reporting format (for radio calls)
  • TCCC cards and handoff documentation
  • MEDEVAC for requesting evacuations

They are designed to be used together, not in isolation.

Training Guidance

You do not need to memorize every field.

You need to:

  • Understand the logic of the flow
  • Practice with realistic scenarios
  • Build comfort documenting under time pressure

Start simple. Add depth as skill and experience grow.

Related training

Remember, Fortune Favors the Prepared

Semper Paratus, Semper Gumby