The "First 21" Flashcards
Step 1
Ensure the exam room is set up with standard clinic tools and supplies. Check all equipment to ensure it is operational. Verify th scale’s batteries are charged.
Step 2
Introduce yourself and confirm the patient’s identity, i.e. “ Hello, I’m HS3 Hastings. Can you please tell me your name, DOB, and last four of your social.
Step 3
Offer same sex chaperone i.e “would you like a chaperon present during the exam?”
If pt is not familiar reference policy located in exam room
Step 4
Obtain an initial impression of the patient. Ask the following:
* Does the pt appear to be in distress?
* If yes, is the distress mild, moderate, or severe?
* Could this be an emergency situation?
Step 5
Obtian Pt’s height and weight
Attempt to obtain this prior to the Pt sitting down
Step 6
Document Pt’s age, race, rank, gender born with, gender identity as and job within the Coast Guard.
Document all findings on the SF-600 or MHS genesis
Step 7
Obtain Pt’s pregnancy status and LMP. Ask “When was your last menstrual period? Was it normal?” If not ask, “ what was different?”
If the Pt is male defer this question
Step 8
Ask Pt’s chief complaint
Use plain language when addressing and speaking with Pts. Avoid the use of any medical terms or Jargon
Step 9
Determine major signs and symptoms of Pt’s chief complaint.
If the Pt already declared why they are being seen, ask amplifying questions
Step 10
Obtain the Pt’s OPQRSTTT
This is a mere tool, not a set in stone method to determine a diagnosis
Step 11
Determine wether or not the Pt has had any contact with people possessing similiar symptoms
Ask,” have you been in close contact with anyone who has had similar symptoms such as roommates, partners, or co-workers?”
If the Pt has been in contact ask if they were diagnosed and had seen a Doctor
Step 12
Ask 3 System Specific Questions
i.e. Circulatory, respiratory, GI, Nervous, Endocrine, Lymphatic etc…
Step 13
Determine any pertinent symptoms in related systems. Ask, “Do you have any nausea, vomiting, or Diarrhea? Any fever or chills? Headaches? A general feeling of tiredness or lack of energy?
(Malaise)
Step 14
Obtain Pt’s Medical History (PMH) i.e.
Have you ever felt this way before? if yes ask, “Did you see a doctor and was there a diagnosis?”
or
Do you have any history of significant injuries or past medical history such as: asthma, high blood pressure, high cholestrol, diabetes, cancer, or heart disease? If yes ask,” When were you diagnosed and how was it treated?”
Step 15
Obtain Pt’s Surg Hx. i.e.
Have you ever had surgery?
if yes ask,
“What for, at what age, and were there any complications?”