Home > TripTix > Assessments > Assessment Fields

Assessment Fields

Most fields in the tabs can be completed without assistance or explanation. Some specialized fields, however, are unique, and several built-in features allow for even faster completion of this section.

The following tips can help you properly and thoroughly complete each subsection of the Assessment section.

Assessment

Assessment Type
Type of assessment performed on the patient.

Performed By
For the Crew Member field, select the provider who performed the assessment. For Provider Role, the second field, select the provider's certification level.

Set Within Normal Limits
Depending on your department's configurations, you may see the Set Within Normal Limits button just underneath the Assessment Type field. Clicking this button automatically populates certain fields with a default value that coincides with a normal reading for the respective field. 

TTCDX_newassessmentwindow.png

After you click this button, a pop-up message opens to indicate success in applying normal values for various fields. The message also reminds you to still review all fields to verify the proper values were applied. Edit values as applicable to ensure accurate and honest reporting of assessment findings.

TTWeb_normalvaluesapplied.png

Vital Signs

Tip: If the information in some of the fields is not applicable or cannot be supplied, tap the Not Value button. From the list in the pop-up window, select a reason for not capturing information for these vital signs.

TTCDX_not_value_button_field.png

Pulse
In TripTix Windows, use the first field to enter the numerical pulse rate in beats per minute (bpm). Use the second field to document how you assessed the pulse rate.

Blood Pressure
Use the first field to enter the numerical value for the Systolic reading. Use the second field to enter the numerical value for the Diastolic reading. This field accepts P as an entry.

If you enter a number in both the Systolic and Diastolic fields, TripTix automatically calculates the mean arterial pressure (MAP) and populates the Mean Arterial field with this result.

Use the final field to select the method used to assess the patient's blood pressure. If you select a method that does not require or result in a Diastolic reading, the Diastolic field populates with P and becomes read-only.

Temperature
Use the first field to enter the numerical temperature. Use the second field to select the units used to measure the temperature. In the last field, select the method you used to assess the patient's temperature. In TripTix Windows, use the last field to select the method you used to assess the patient's temperature.

Glasgow Coma Score
Use this section to document the patient's Glasgow Coma Score (GCS), or their level of alertness and responsiveness. The following definitions can be used to help you select the options that best describe your patient's condition.

  • Eye – The patient's ability to open their eyes with or without stimulus.

  • Verbal – The patient's ability to articulate, form words, and complete sentences.

  • Motor – The patient's reaction to pain and their ability to obey commands related to motor activity.

  • Qualifier – An inherent factor or intervention that prevents the accurate completion of the assessment.

The Score field is automatically calculated based on the values you entered for this section.

Cardiac Rhythm
In TripTix Windows, use the first field to select the cardiac rhythm observed, the second to select the leads used to interpret the rhythm, and the third to select the method used to interpret the rhythm.

AVPU
The AVPU scale (Alert, Verbal, Painful, Unresponsive) is used to determine the patient's level of consciousness (LOC). Select the appropriate options from the list based on the following explanations:

  • Alert – The patient is awake and responsive without prompting or stimulus.

  • Verbal – The patient becomes alert and responsive only after verbal stimulus.

  • Painful – The patient becomes alert and responsive only after painful stimulus.

  • Unresponsive – The patient is not alert or responsive, even after prompting with both verbal and painful stimuli.

Pain Score
The patient's numerical rating of their pain intensity.

Note: This field only allows a two-digit numerical entry. If a non-numeric pain scale was used, leave this field empty.

RTS
The rapid trauma score, or RTS, is a scoring system used to determine the severity of patient injury. A lower score indicates a higher severity of injury.

Use the Glasgow Coma Scale, Systolic blood pressure, and respiratory rate of the patient to determine the score, which must be in the range of 0-12.

APGAR
The APGAR scale (Appearance, Pulse, Grimace, Activity, Respirations) determines the physical condition and vitality of newborns directly after birth. Select the appropriate option from the list for each field based on the following explanations:

  • Minutes – How many minutes after birth that the APGAR score was calculated: 1 or 5 Minutes.

  • Color – The color of the newborn's skin (Appearance).

  • Heart Rate – The pulse rate of the newborn in beats per minute (bpm) (Pulse).

  • Muscle Tone – The newborn's muscle tone and ability to flex (Grimace).

  • Reflex Irritability – The newborn's response to external stimuli (Activity).

  • Respiratory Effort – The newborn's ease of respiration and ability to cry (Respirations).

The Total Score field is automatically calculated based on the values you entered for this section.

Mental/Neuro

Note: To enter any exam findings not present upon assessment (pertinent negatives), click the Not Value button.

TTCDX_not_value_button_field.png

LOC
The patient's level of consciousness.

Mental Status
For TripTix Windows, in the top field, select the option that best describes the mental status of the patient. In the field below the first, select any exam findings not present upon assessment (pertinent negatives).

Neurological Status
For TripTix Windows, in the top field, select the option that best describes the patient's neurological status. In the field below the first, select any exam findings not present upon assessment (pertinent negatives).

Pupils

Pupils
For TripTix Windows, in the top fields, select the right and left pupil readings from the pick lists. In the fields below the first, select any exam findings not present upon assessment (pertinent negatives).

Skin/Perfusion

Capillary Refill
The refilling of the capillary beds after a period of ceased circulation. Select the option corresponding to how long it took, in seconds, for capillary refill to occur.

Systemic

When completing this tab, use the second field below each header to document exam findings not present upon assessment (pertinent negatives).

Stroke

Scale
Select the stroke scale used to perform the stroke assessment. This is the only field option available until a specific scale is chosen. Depending on the scale selected, applicable input fields appear. For more information on a specific scale's sections and fields, click any one of the following scales.

Note: By default, the Scale field can automatically be set to a certain scale per department specifications. If your department has set a default scale for this field, you only need to change your selection if a different stroke assessment is performed.

Cincinnati Prehospital Stroke Scale

Stroke Score

  • Facial Droop – The patient's facial symmetry and ability to move both sides of the face equally.

  • Arm Drift – The patient's ability to maintain arm control.

  • Speech – The patient’s ability to speak clearly, without slurring, incomprehensible words, or inappropriate words.

Los Angeles Prehospital Stroke Screen (LAPSS)

Exam (Look for Obvious Asymmetry)

  • Facial Smile/Grimace – The patient's facial symmetry and ability to move both sides of the face equally. Select the check box if the patient’s facial smile/grimace is symmetrical and normal per patient’s baseline. If the patient’s facial smile/grimace is abnormal, select an option in both the Right and Left fields that best describes the patient’s facial smile/grimace for each respective side.

  • Grip – The patient's ability to grip objects with equal strength in both hands. Select the check box if the patient’s grips are normal per the patient’s baseline. If the patient’s grips are abnormal, select an option in both the Right and Left fields that best describes the patient’s grip for each respective side.

  • Arm Weakness – The patient's ability to maintain arm control. Select the check box if the patient’s arm movement is normal. If the patient is experiencing arm weakness or drifting, select an option in both the Right and Left fields that best describes the patient’s arm strength for each respective side.

  • Patient Has Only Unilateral (Not Bilateral) Weakness – Select an option that best describes the patient’s weaknesses in respect to both sides of their body.

  • LAPSS Screening Criteria Met – Based on the data entered or selected in the fields listed above, this field auto populates with a determination as to whether LAPSS Screening Criteria has been met.

Note: A blue, highlighted field appears at the bottom of the Exam section, indicating when to suspect a stroke, based on the data entered, and how to proceed accordingly.

NIH Stroke Score (NIHSS)

Stroke Score

  • Visual Fields – The patient’s ability to see different visual fields.

  • Sensory – The patient’s ability to sense.

  • Arm Motor – The patient’s ability to maintain arm control.

  • Leg Motor – The patient’s ability to maintain leg control.

  • Language – The patient’s ability to speak clearly, without slurring, incomprehensible words, or inappropriate words.

  • LOC – The patient’s level of consciousness and orientation.

  • Total Score (27 Possible) – This field automatically populates based on the data entered for this assessment.

Additional Details

  • Finger to Nose Test – A test that requires the patient to touch their nose with a finger. Select an option that best describes the patient’s results for the Finger to Nose Test as it applies to each hand.

  • Vertical Nystagmus – The repetitive, involuntary movement of the eyes in a vertical direction. Select an option that best describes the patient’s vertical nystagmus.

  • Criteria for Transportation to Comprehensive Stroke Center – Select an option that best describes whether the patient meets the criteria for transportation to a comprehensive stroke center based on the stroke assessment.

Rapid Arterial Occlusion Evaluation Scale (RACE)

Stroke Score

Tip: For each field, an information icon is displayed next to each assessment feature. Hover over the icon to learn more about how to test for the given field.

  • Facial Palsy – The patient's facial symmetry and ability to move both sides of the face equally.

  • Arm Motor – The patient’s ability to maintain arm control.

  • Agnosia (If LEFT Side Weakness) – The inability to process or interpret sensory information correctly; the recognition of self and presence in space. If the patient has left-sided weakness, select an option that best describes the patient’s recognition of self and presence in space.

  • Head or Gaze Deviation – The deviation of head or gaze to one side even after requests for the patient to look forward.

  • Leg Motor – The patient’s ability to maintain leg control.

  • Aphasia (If RIGHT Side Weakness) – Impairment of language; inability to say or hear words correctly. If the patient has right-sided weakness, select an option that best describes the patient’s ability to simultaneously close their eyes and make a fist.

  • Total Score – This field automatically populates based on data entered for the above assessment.

Destination Determination

Note: If a check box within the following fields is selected, a blue, highlighted box appears to indicate the need for the medic to call a Stroke Alert.

  • Transport to Comprehensive Stroke Center if RACE Scale Score >=5 or if ANY of the below are checked – Select any and all applicable options regarding the patient and the particular call.

  • Transport to Nearest Stroke Center (Primary or Comprehensive Stroke Center) if ANY of the below are checked – Select any and all applicable options regarding the patient and the particular call.

Texas Stroke Intervention Prehospital Stroke Scale

Stroke Score

  • Leg Strength – The patient’s ability to maintain leg control and exert resistance.

  • Gaze – The deviation of eyes to one side even after requests for the patient to look forward.

  • Eyes/Visual Fields – The patient’s ability to see different visual fields.

  • Speech/Language – The patient’s ability to speak clearly, without slurring, incomprehensible words, or inappropriate words.

  • Total Score – This field automatically populates based on data entered for the above assessment.

You must to post a comment.
Last modified
11:27, 2 Feb 2017

Tags

Classifications

This page has no classifications.