Assessment and Clinical Impression

Status: Current

Effective date: August 24, 2026

Last revised: August 24, 2026

Progressive assessment

Begin with what can reasonably be observed or reported. Do not assume a cause before the assessment supports it.

1. Initial presentation

Record the scene context, chief complaint, apparent distress, level of responsiveness, position, visible bleeding or injury, breathing effort, skin signs, and immediate safety concerns.

2. History

Obtain the history appropriate to the complaint, including onset, provoking or relieving factors, quality, region or radiation, severity, time course, relevant symptoms, allergies, medications, medical history, last intake when relevant, and events leading to the presentation.

When the patient cannot provide a history, identify the source of collateral information and its limitations.

3. Examination

Perform a focused or systematic examination appropriate to the presentation. Record pertinent positive and negative findings. Repeat examination after movement, treatment, or meaningful change.

4. Vital signs and diagnostics

Obtain a baseline set of vital signs and trend them at intervals appropriate to the patient's condition. Use diagnostics only when they are available, authorized, clinically relevant, and within the provider's certification.

A single normal value does not erase concerning history or examination findings. An unexpected result should be verified when practical and interpreted with the full presentation.

5. Clinical impression

Form a clinical impression from the history, examination, vital signs, available diagnostics, and response to care. Use language such as:

• findings consistent with;
• suspected;
• concern for;
• cannot exclude; or
• no current evidence of.

The clinical impression guides care but does not replace documented findings.

6. Treatment and reassessment

Choose treatment within scope and protocol based on the patient's presentation and clinical needs. Record the response, adverse effects, new findings, and any change in impression or disposition.

Handoff

Provide the receiving clinician with the chief complaint, relevant history, significant examination findings, vital-sign trends, diagnostics, treatments, response, safety concerns, and current clinical impression.