Perform Medical Screening

 

INTRODUCTION

Medical screening is a daily, on going, routine mission for medics in todayís army. It provides an opportunity for the sick and injured soldiers to be evaluated by health care providers in the Battalion Aid Station, Troop Medical Clinic, or designated clinic in the hospital.  At any level, you will assist with sick call procedures by providing the best possible care for the soldier.  The use of the Ambulatory Patient Care Algorithm, will help the medic ask the right questions, provide the right answers, and give the correct treatment, when helping to conserve the fighting strength.

Screen medical records for accuracy and completeness

Primary goal of the medical screener is to provide timely, quality care for active duty personnel with minor medical conditions

(1)        Do not function as independent providers

(2)        Work under the direct supervision of a medical officer who is responsible for the care the medic provides

 

The following guidelines must be followed:

(1)        The SOAP format must be used when evaluating a patient

(2)        Consult with the supervising medical officer prior to the patient leaving the treatment facility

(3)        Know your limitations and immediately refer to an MD/PA any patient with one of the following conditions:

(a)        Febrile illness with temperature exceeding 101į F

(b)        Acute distress such as, breathing difficulties, chest pain, acute abdominal pain, suspected fractures, lacerations, etc.

(c)        Altered mental status

(d)        Unexplained pulse above 120 per minute

(e)        Unexplained respiratory rate above 24 or less then 8 per minute

(f)         Diastolic blood pressure over 100 mm Hg systolic BP less than 90 mmHg

 

Soldier medicís responsibilities during medical screening procedures (sick call)

(1)        Validate identification of soldier

(2)        Gather sick slip and review

(3)        Sign patient in and pull soldier's medical record (Initiate a replacement record if required)

(4)        Complete vital signs and document on appropriate form (e.g. DA Form 5181, SF 600, and DD Form 689

(5)        Check for medical profile(s) (temporary or permanent)

(6)        Check Over 40 Physical (as required)

(7)        Check for eyeglasses and protective mask inserts (as required)

(8)        Check for DNA sample

(9)        Check for Medical Warning Tags (DA Form 3365)

(10)      Refer to medical authority as required

(11)      Screen individual IAW APC, Algorithm-Directed Troop Medical Care, HSC Pam 40-7-21, for soldier's chief complaint

(12)      Follow algorithm protocol for disposition and/or treatment and annotate on appropriate form

(13)      Sign individual out of BAS and follow appropriate disposition after screened by medic or PA evaluation

(14)      Clean and set up screening area for next individual reporting to sick call

(15)      Secure medical record

 

Screen immunization records for accuracy and completeness

Screen immunization records

(1)        Validate identification of soldier

(2)        Ensure all immunizations are current on PHS 731 (Shot Record)

(a)        Refer to medical record if shot record is not available

(b)        Inquire regarding allergic reactions

(c)        Check for Medical Warning Tags

(d)        Refer to immunization site if immunizations are required

(3)        Return immunization record to soldier

(4)        Secure medical record

 

Shot Call

(1)        Persons who administer vaccinations must be trained in:

(a)        Management of anaphylaxis

(b)        Immunization procedures

(b)        Proper use and maintenance of equipment

(c)        Indications and contraindications for each vaccine

(d)        Storage requirements

(e)        Management and reporting of adverse reactions

(f)         Immunization record maintenance

(2)        Patients who report to shot call should be:

(a)        Screened for chronic/acute illness

(b)        Screened for pregnancy

(c)        Screened for medications that might interact with immunizations

(d)        Screened for allergies

(e)        Offer Tylenol to minimize local and systemic shot reactions

(f)         Observed for at least 20 minutes after administration for symptoms of anaphylaxis

 

Screen for personnel / administrative matters

S-1 personnel (administration) center will screen these records

 

Validate / inspect Identification Card (DD Form 2A)

 

Validate / inspect Geneva Conventions ID Card (DD Form 1934)(as required)

 

Refer for new card(s) as required

Check Identification tags (2 sets) for accuracy

 

Screen Dental Records

Review date of last dental examination

(1)        Ensure Class 1 or 2

(2)        Ensure Dental X-rays (Panorex) is present and up to date

 

Refer to Dental authority as required

 

Ask and record the following Medical History information on the prescribed form

Purpose of the Chronological Medical Record

(1)        To improve communication among all those caring for the patient

(2)        To display the assessment, problems and plans in an organized format to facilitate the care of the patient and for use in record review and quality control

 

Ask and record medical history information

(1)        Identifying data

(2)        Chief complaint:

(a)        Concise statement

(b)        Primary reason the patient seeks help

(c)        Use patient's own words

(3)        Present illness:

(a)        State of health prior to onset of illness

(b)        Nature and circumstances of onset

(c)        Location and nature of pain or discomfort

(d)        Progression

(e)        Treatment received and its effect

(4)        Past history:

(a)        Childhood diseases

(b)        Previous illnesses and injuries

(c)        Previous hospitalization and surgery

(5)        Family history:

(a)        History of chronic illness

(b)        Familial illness (sickle cell)

(6)        Social history:

(a)        Marital status

(b)        Occupational data

(c)        Habits (tobacco, alcohol, drugs)

 

Use the SOAP Note Format

(1)        S: SUBJECTIVE DATA: what the patient tells you

(2)        O: OBJECTIVE - physical findings and lab/ X-ray

(3)        A.: ASSESSMENT - Your interpretation of the patientís condition

(4)        P: PLAN

 

Perform a patient examination:   Determine what is wrong with the patient based on patient's own statements regarding his specific condition.

 

Determine the chief complaint based on the patient's own statements:  
Focused examination based on chief complaint

 

The S.O.A.P. (E. R.) method is the only accepted method of medical record entries for the military

(1)        S: (subjective) - What the patient tells you

(2)        O: (objective) - Physical findings of the exam

(3)        A: (assessment) - Your interpretation of the patients condition

(4)        P: (plan) - Includes the following

(a)        Therapeutic treatment: includes use of meds, use of bandages, etc.

(b)        Additional diagnostic procedures: any test that still might be needed

(5)        E: (patient education) - special instructions, handouts, use of medications, side effects, etc.

(6)        R: (return to clinic) - when and under what circumstances to return.

 

Components of the patient examination (SOAP note)

(1)        Medical History - Gives you an idea of the patientís problem before you start physical exam

(a)        Biographic data

(b)        Chief complaint

(i)         This is the reason for the patients visit

(ii)        Use direct quotes from patient

(iii)       Avoid diagnostic terms

(c)        Observation: begins as soon as the patient walks through the door

(d)        Listening: listen carefully. This will help you get an accurate diagnosis of the problem

(e)        Open ended questions: help you to get more complete and accurate information

(f)         Provider obstacles: your attitude or predetermination may prevent you from making an accurate judgment

(g)        Patient obstacles: the patient has many obstacles to overcome. Patients must have confidence in you.

(2)        History of present illness/injury (HPI)

(a)        Duration: when the illness/injury started

(b)        Character: use the patientís words to note character of pain

(c)        Location: have the patient explain, then have them point it out

(d)        Exacerbation or remission: what makes it better or worse and is it constant or does it vary in intensity

(e)        Positional pain: does the pain vary with the change of the patientís position.

(f)         Medications/allergies: note any medications whether over the counter or not. Do the medications relate to the problem? Take note of the patientís allergies. Do not rely on the patientís health record or SF 600.

(g)        Pertinent facts: facts that lead you to your diagnosis. Usually consist of classical signs and/or symptoms.

(3)        Another method to take a medical history is by using the key phrase "SAMPLE PQRST"

S:         Symptoms

A:         Allergies

M:        Medicine taken

P:         Past history of similar events

L:         Last meal

E:         Events leading up to illness or injury

P:         Provocation/Position - what brought symptoms on, where is pain located

Q:        Quality - sharp, dull, crushing etc.

R:        Radiation - does pain travel

S:         Severity/Symptoms Associated with - on scale of 1 to 10, what other symptoms occur

T:         Timing/Triggers - occasional, constant, intermittent, only when I do this (Activities, food)

 

(4)        Past History (PH)

(a)        Other significant illnesses

(b)        Prior admissions

(c)        History of major trauma

(d)        Surgery

(e)        Childhood illnesses

(f)         Neurological history

(5)        Family History

(a)        This is the pertinent history of diseases of the family within the patientís bloodline.

(b)        Any disease traced through the family is important. If no history found, note it on SF600

(6)        Social History (SH)

(a)        Drugs, recreational

(b)        ETOH

(c)        Tobacco

(d)        Over the counter medications

 

Disposition Plan

 

Treat illness or injury within prescribed "Ambulatory Patient Care" (HSC PAM 40-7-21) Algorithms

 

Definition of algorithm

A step by step procedure for solving a problem

 

Purposes

(1)        Systematic approach to screening patients

(2)        Guidance for minimally trained medical personnel to provide a logical conclusion when dealing with medical problems within the limits of his/her training

 

Algorithm Dispositions Category

(1)        PHYSICIAN STAT/Category I - medical problem (Emergency) exist that may be life threatening

(a)        Requires immediate attention of a physician that can handle circumstance

(b)       Notify the physician assistant and the senior medic of a Category I patient if a physician is not present.

(a)        First aid should be initiated and ambulance transportation arranged if MTF is outside of hospital

(2)        PA STAT/Category II - medical problem may exists that may develop into a life threatening condition if not evaluated on a priority basis by a physician, PA

(3)        PA TODAY/Category III - medical condition exists which requires PA evaluation

(a)        Patient will be screened IAW APC-21 algorithm and then sent to PA

(b)        Physician or PA will make final disposition

(4)        SELF-CARE PROTOCOL/Category IV--condition exists that can be taken care of by individual

(a)        Instructions and/or medications are offered to individual per algorithm protocol

(b)        Individual or screener may elect to override self-care protocol and have the patient seen by medical officer

 

NOTE:            Overriding this protocol usually depends on appearance of individual or if medical problem is chronic and self-care has already been attempted without results.

 

(5)        HOSPITAL CLINIC REFERRAL/Category V - medical condition exists that requires evaluation by a specialty clinic (e.g. podiatry, OB/GYN, allergy)

(a)        Medical officer at MTF must make referral

(b)        PA may want to attempt treatment care plan at MTF level if qualified personnel and resources are available

 

Steps in screening patient complaint

(1)        Locate category of chief complaint in table of contents.

(a)        Category of complaint, EXAMPLE - Ear, Nose, and Throat (ENT) Complaints

(b)        Complaint, EXAMPLE - sore Throat

(c)        Number and page, EXAMPLE - A-1, 16

(2)        Review preceding page of algorithm prior to, during, and after patient screening

(a)        EXAMPLE - important information on the algorithm

(b)        EXAMPLE - treatment protocol, for instructions and medications to provide patient after screening has been completed

(3)        Begin with Block 1 of algorithm and follow arrows depending on patient's response

(a)        EXAMPLE - is there a history of recent throat or neck trauma?

(b)        EXAMPLE - if NO, (go to block 3)

(c)        EXAMPLE - can the patient touch chin to chest?

(d)        EXAMPLE - if NO, (go to block 4)

(e)        EXAMPLE - is temperature 100 F or higher, or is the patient unable to swallow? (Determine ability to swallow by observing the patient)

(f)         EXAMPLE - if NO, (Category III)

(4)        If disposition is a Category IV, refer to preceding page for treatment protocol.

(a)        EXAMPLE - Block 6, Can the patient clear both ears?

(b)        EXAMPLE - if YES, (Category IV, Treatment Protocol A-1 (6)

(c)        Follow protocol for medication and patient instructions

(5)        If disposition is an associated complaint, refer to complaint algorithm and begin at block 1 with new complaint.

(a)        EXAMPLE - Block 6, Can the patient clear both ears?

(b)        EXAMPLE - if NO, (Screen for Ear Pain, Discomfort, or Drainage, A-2).

(6)        Refer to PA Today, Category III disposition if:

(a)        Complaint not on list

(b)        Patient has already tried the treatment protocol without relief

(c)        Patient will not accept treatment protocol

 

f.          Information needed in the DD Form 689

(1)        MTF personnel are responsible for making sure DD Form 689 blocks 1 through 9 are correctly filled out by a soldier prior to being evaluated by a screener

(2)        MTF personnel may fill out a sick slip for a soldier if he is unable to due injury, illness, or reporting directly to the MTF in the event of an emergency

(3)        All military forms will be filled out in black ink

(4)        Block 1 - box checked by individual that best fits remarks section (block 8)

(a)  Illness--acute or chronic, (e.g. common cold symptoms, athletes foot, nausea, vomiting, etc.)

(b)  Injury--acute (e.g. direct/indirect trauma within 24 to 48 hours)

(5)        Block 2 - date

(6)        Block 3 - name (e.g. complete last, first, middle initial, Doe, Johnny E.)

(7)        Block 4 - service number. SSN (e.g. complete 9 digits, 000-11-0000)

(8)        Block 5 - grade/rank (e.g. pay grade, E-1, etc.)

(9)        Block 6 - organization and Station (e.g. C Co. 232D Medical Battalion, Ft. Sam Houston, TX 78234)

(10)      Block 7 - in line of duty (e.g. yes/no depending on circumstances)

(a)        Company or unit commander ONLY fills out this block when injury occurs

(b)        Often left blank unless negligence is suspected (e.g. soldier was intoxicated at time of injury, or was not at his/her appointed place of duty at time of injury etc.)

(11)      Block 8 - remarks (e.g. sore throat and cough x4 days; right ankle pain, difficulty walking due to injury x24 hrs.)

(a)        Filled out by individual

(b)        Includes chief complaint (c/o). (e.g. sore throat; right ankle pain)

(c)        Associated illnesses/pain. (e.g. cough; difficulty walking)(d) How long?  problem(s) have existed or when injury occurred. (e.g. x4 days; x24 Hrs)

(12)      Block 9 - signature of unit commander.

(a)        First line supervisor or person who is in charge of quarters (CQ) may sign for unit commander (per unit SOP)

(b)        Individual signing the sick call slip must be in individual's immediate chain of command

(13)      Block 10 - in line of duty (e.g. yes/no or left blank).

(14)      Block 11 - disposition of patient.

(15)      Block 12 - remarks (e.g. Quarters x24 Hrs, return in A.M. for follow up or Profiling e.g. no running or marching x5 days)

(a)        Remarks reflect box checked in block 11

(b)        Also indicates:

(i)         Soldier's arrival time at MTF

(ii)        Soldier's disposition

(iii)       Time of release back to unit

 

(16)      Block 13--signature of medical officer ONLY

(17)      Disposition of DD Form 689

(a)        DD Form 689 is returned to individual after medical evaluation has been completed

(b)        Soldier returns original sick slip to first line supervisor or per unit SOP

(c)        Soldier keeps copy of sick slip if quarters or profile given

SUMMARY

As a soldier medic, you will receive additional training on APC-21 Algorithm-Directed Troop Medical Care once assigned to a medical treatment facility.  It's vital for the medic to understand sick call procedures to provide the best possible care for the soldier in his/her unit. Medical officers and Physician Assistants will depend on their medics to gather appropriate patient data and document it correctly to assure adequate patient care whenever possible.