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.
The Assessment Flow (Big Picture)
Patient assessment is not a single step. It is a cycle:
- Identify and treat immediate threats
- Gather subjective information
- Perform a focused physical exam
- Reassess and trend changes
- 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
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
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 and evacuation reporting
- TCCC cards and handoff documentation
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.