History taking, assessment and documentation for paramedics
Abstract
Paramedic practice is progressing at a more rapid pace now than at any time in its history. Paramedics need to align their method of assessing patients to integrate into the multi-disciplinary team involved in the patient's journey of care and treatment. The review of systems (RoS) approach is widely used and accepted in healthcare, and easily assimilates into paramedic practice. RoS improves patient care by holistically assessing the patient, and can make the inter-professional handover of a patient to another team more professionally acceptable. Documentation using the RoS is more comprehensive and less prone to errors.
Most of us are familiar with the 999 call to a patient who fits into the category of ‘generally unwell’, but what can we do for these patients? NHS drivers and policies (Department of Health (DH), 2005; 2011; Health and Care Professions Council (HCPE), 2012) are rightfully directing ambulance clinicians away from taking every patient to the local emergency department and more towards treating patients at home or utilising alternative pathway referrals. The Department of Health state:
‘[the ambulance service] is recognised as having a wider role, as a conduit to other NHS services and in ensuring patients can access the facilities they need, close to their home (DH, 2011:7).’
To do this safely, ambulance clinicians require a recognised method of assessment that leaves nothing to chance, and ensures the most appropriate care for the patient.
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