Patient Assessment in EMS: Primary and Secondary Assessment, Step by Step
The EMS patient assessment in order: scene size-up, primary assessment, history, secondary assessment, vital signs and reassessment, and how medical and trauma calls differ.
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Patient assessment is the structured way EMTs and paramedics find out what is wrong with a patient and how urgently it needs fixing. Every call follows the same backbone: size up the scene, do a primary assessment for life threats, take a history, do a secondary assessment, take vital signs, and keep reassessing until you hand the patient over. This guide walks through that sequence, explains why it runs in that order, and points you to the guides in this library that cover each step in depth.
The order, and why it runs that way
- Scene size-up: is it safe, what protection do you need, what happened, how many patients, and who else do you need.
- Primary assessment: find and treat whatever will kill the patient first, then decide how urgent they are.
- History taking: the chief complaint explored with OPQRST, and the patient's history with SAMPLE.
- Secondary assessment: a physical exam, focused on the complaint or covering the whole body.
- Vital signs: a baseline set, then repeated.
- Reassessment: repeat what matters, check whether your treatment worked, and change the plan if the patient changes.
The order is a priority list. Your own safety comes first because an injured provider helps nobody. Life threats come next because an airway that is closing or a bleed that is pouring will kill the patient before any history matters. Only once those are found and managed do you spend time on the details that explain the problem. Reassessment comes last in the list and never stops, because the patient you assessed ten minutes ago is not necessarily the patient in front of you now.
The sequence is a backbone, not a script. The NREMT medical and trauma assessments both follow it, and both guides in this library describe it phase by phase. On a real call the history and the exam sometimes swap places, as the sections below explain, and you treat a life threat the moment you find it rather than when the list reaches it.
Scene size-up
Before you touch anyone: scene safety, standard precautions and PPE, the mechanism of injury or nature of illness, the number of patients, and the additional resources you need. Texts and skill sheets order the five parts slightly differently, so learn the order your program expects. Keep sizing up for the whole call, because a scene that was safe when you arrived can stop being safe. The guide Scene Size-Up and Primary Assessment covers each part in detail.
The primary assessment: find the life threats
The primary assessment, which older texts and some sheets call the primary survey, has one job: find the problems that will kill the patient in minutes and fix them as you find them. It is short, it is done on every patient, and it ends with a decision about how urgent the patient is.
| Step | What you are asking |
|---|---|
| General impression | Sick or not sick? Age, position, how they look from the doorway, and any obvious life threat such as massive bleeding. |
| Level of responsiveness | AVPU: alert, responds to verbal stimulus, responds to pain, or unresponsive. Ask the chief complaint if the patient can answer. |
| X: exsanguinating hemorrhage | Is there major external bleeding that will kill within minutes? Control it now. |
| A: airway | Is it open and clear? Position, suction and adjuncts as needed, with spinal considerations where the mechanism or the findings call for them. |
| B: breathing | Is the patient breathing adequately? Rate, depth, effort, breath sounds and chest wall injury, with oxygen or assisted ventilation as indicated. |
| C: circulation | Pulse rate and quality, skin color, temperature and condition, and any remaining bleeding. |
| D: disability | Responsiveness, pupils, gross movement and sensation, and a glucose check where mental status is altered. |
| E: exposure | Expose to find hidden injuries, then cover the patient again. |
Many curricula now put massive external bleeding first in a trauma patient, ahead of the airway, because a patient can bleed to death faster than they suffocate. Older material teaches A, B, C with bleeding under circulation. Use the order your program and your current skill sheet expect, and use it the same way every time. A patient who is unresponsive and not breathing, or only gasping, moves straight to a pulse check and to CPR if there is no pulse.
The priority decision
The primary assessment ends with a decision: is this a high-priority patient who needs rapid transport with the rest of the assessment and treatment done on the way, or a stable patient who can be assessed further on scene? A poor general impression, an altered level of responsiveness, an airway or breathing problem, signs of shock and bleeding that is hard to control all point toward high priority, as do chest pain with signs of poor perfusion, a severe headache with altered mental status, a complicated childbirth, uncontrolled pain, and a mechanism that suggests serious hidden injury. The Scene Size-Up and Primary Assessment guide lists them. The principle is that time on scene has to buy the patient something. Which patients go where, and how, is set by your protocol, not by this page.
Score a level of consciousness you can repeat on reassessment
Children and older adults
With a child, the general impression has its own tool: the pediatric assessment triangle, a look from across the room at appearance, work of breathing and circulation to the skin before you touch them. It does not replace the hands-on primary assessment; it tells you how fast to move and what to look at first. Our Pediatric Assessment Triangle guide covers it. Then do the full hands-on assessment, take vital signs and judge them against the norms for the child's age, and estimate or establish a weight before anything that depends on one.
With an older adult, the textbook signs are less reliable. A heart attack may come without chest pain, an infection without a fever, and shock with a normal heart rate because of a rate-controlling medication. A blood pressure that looks normal on paper may be low for this patient, and new confusion is a symptom to explain, not a personality. Our Geriatric Patients in EMS guide covers these in detail.
History taking: OPQRST and SAMPLE
Once life threats are managed, the history explains the problem. Two mnemonics carry most of it, and each has its own guide in this library.
- OPQRST describes the complaint: onset, provocation and palliation, quality, region and radiation, severity, and time. Ask open questions and let the patient choose the words.
- SAMPLE describes the patient: signs and symptoms, allergies, medications, past pertinent history, last oral intake, and events leading up. Ask what the allergic reaction was, and ask directly about inhalers, over-the-counter drugs and blood thinners.
- The two overlap at S, where OPQRST is how you work through a symptom, and at M, where you ask what the patient has already taken. Follow the conversation, and check every letter of both before you report.
A patient who cannot answer still has a history. Family, caregivers, bystanders, medication bottles, medical alert jewelry, care facility paperwork and the scene itself all carry it. Record where each piece came from.
Medical and trauma patients: the same backbone, different emphasis
The NREMT skill sheets split patient assessment into a medical assessment and a trauma assessment, and so do most textbooks. The backbone is the same. What changes is where the information comes from and how much of the body you examine before you move the patient.
| Patient | What usually comes first after the primary assessment | The physical exam |
|---|---|---|
| Responsive medical patient | The history, from the patient: OPQRST for the complaint and SAMPLE for the patient | A focused exam of the body systems related to the complaint |
| Unresponsive or altered medical patient | A rapid full-body exam, then vital signs, then a history from family, bystanders and the scene | Head to toe, looking for anything that explains the presentation: injuries, track marks, a medication patch, a medical alert tag |
| Trauma patient with a significant mechanism or an altered mental status | A rapid head-to-toe exam with DCAP-BTLS, looking for other life threats before you package and move | Every region, front and back, then a more detailed exam en route if time allows |
| Trauma patient with an isolated injury and no significant mechanism | A focused exam of the injured area and the areas around it, and a SAMPLE history, unless the patient's age, medications or primary assessment give you reason to look further | The injured region with DCAP-BTLS, plus distal pulse, motor function and sensation in an injured limb |
In trauma, the mechanism of injury tells you where to look for injuries you cannot see. A high-speed crash, a fall from a height, an ejection or a penetrating wound to the head, neck or torso suggest hidden injury even in a patient who looks well. In an older adult, and especially one taking a blood thinner, a fall from standing can cause serious injury, including bleeding inside the skull that is not apparent at first; our Geriatric Patients in EMS guide covers why. These are examples to make you look harder, not a list that decides triage or destination; those are set by your protocol and your regional trauma triage guidelines. Whether to restrict spinal motion is also part of the trauma assessment and is your protocol's decision.
Our guides NREMT Medical Assessment and NREMT Trauma Assessment walk through each station phase by phase. Neither reproduces the official sheet, and neither does this one: the National Registry publishes the current sheets and exam formats for each level at nremt.org, and those are the ones to learn from.
The secondary assessment
The secondary assessment is the systematic physical exam that follows the primary assessment and the history. The National EMS Education Standards use the term; older textbooks split the same work into a rapid trauma assessment, a focused assessment and a detailed assessment. It runs at different speeds depending on the patient: a quick sweep for anything else life-threatening before you move a critical patient, a focused exam of the area or system that matters for a stable patient with one complaint, and a slower complete exam when time allows, often during transport.
The full-body exam and DCAP-BTLS
A full-body exam goes region by region, usually head to toe, looking and feeling for the same findings in each: deformities, contusions, abrasions, punctures or penetrations, burns, tenderness, lacerations and swelling. Add the checks the mnemonic does not prompt for, such as tracheal position, breath sounds, pelvic stability assessed once and gently according to your protocol, never rocked repeatedly, and distal pulse, motor function and sensation in each limb. Expose to assess, cover the patient again, and do not forget the back. Our DCAP-BTLS guide covers each region.
The focused exam, by body system
On a medical patient the focused exam follows the complaint. A patient with chest pain needs a different exam from one with a headache and slurred speech. The table below is a starting point, not a complete list.
| System | Common complaints | What you look at |
|---|---|---|
| Respiratory | Shortness of breath, cough | Work of breathing, position, ability to speak in full sentences, breath sounds on both sides, accessory muscle use, skin color, pulse oximetry |
| Cardiovascular | Chest pain, palpitations, fainting | Pulse rate, rhythm and quality, skin, neck veins, swelling of the legs, lung sounds for fluid, the cardiac monitor and a 12-lead where your protocol calls for one |
| Neurological | Weakness, confusion, headache, seizure | Level of consciousness, orientation, speech, pupils, facial symmetry, grip and arm drift, a stroke screen, and blood glucose |
| Abdominal and gastrointestinal | Abdominal pain, vomiting, bleeding | Inspection, tenderness by quadrant, rigidity, guarding and distention, and what the patient has lost and how |
| Musculoskeletal | Pain or injury in a limb or the back | Deformity, swelling, tenderness, and distal pulse, motor function and sensation |
| Skin | Rash, swelling, wounds | Color, temperature, moisture, hives or swelling of the lips, tongue or throat, and the extent of any wound or burn |
| Endocrine and metabolic | Diabetic emergency, weakness, altered mental status | Blood glucose, skin and mental status, and the medication history |
Practice a stroke screen as part of a neurological exam
Vital signs: a set, taken again and again
A full set of vital signs commonly includes the pulse, respirations, blood pressure, skin color, temperature and condition, and pupils, with pulse oximetry on most patients, and blood glucose and body temperature where the presentation calls for them. Many services also record a pain score, which is the patient's report rather than a measurement.
The first set is a baseline, not an answer. Its main value is that every later set can be compared with it, and the trend often tells you more than any single reading. A heart rate that creeps up over three sets, or a pulse pressure that narrows, can show a patient getting worse before any one number looks alarming. Normal ranges differ by age, and this guide deliberately does not list them; the pediatric guides in this library and your program's references cover the norms for each age group.
Calculate a shock index from a heart rate and a systolic pressure
Reassessment
Reassessment is where the assessment turns into care over time. Repeat the primary assessment, take another set of vital signs, repeat the focused exam, and check each intervention: is the bleeding still controlled, did the oxygen help, is the splint still allowing a pulse? A patient who is getting worse should change your plan.
EMT and paramedic textbooks commonly teach reassessing an unstable patient about every 5 minutes and a stable patient about every 15 minutes, and many protocols expect more frequent checks for children. Those are commonly taught figures, not a rule, and your protocol sets its own. If you are not sure a patient is stable, reassess them as unstable. Whatever the interval, reassess after every intervention and whenever the patient's condition seems to change.
Common mistakes
- Tunnel vision on the obvious injury. The open fracture draws every eye while the patient's breathing quietly gets worse. Finish the primary assessment before you fix what is dramatic but not life-threatening.
- Skipping the primary assessment because the complaint seems minor. The patient who called about a sore ankle can still be the one who fainted first.
- Skipping reassessment, or doing it only on the way in the door. Reassess on a schedule and after every intervention, and record what changed.
- Treating the numbers rather than the patient. A normal blood pressure does not rule out shock, a normal pulse oximetry reading does not mean the patient is breathing well enough, and a single reading is less useful than the trend.
- Being reassured by a normal reading in a child or an older adult. Children hold their blood pressure until late, and an older adult's medications can hide a fast heart rate.
- Assessing through clothing, and forgetting the back.
- Asking leading questions in the history, or accepting no medications without asking about inhalers, supplements and blood thinners.
- Reaching a diagnosis early and stopping assessing. A field impression is a working answer, and the next finding can change it.
Practice handing your assessment over in a structured report
The short version
- Scene size-up, primary assessment, history, secondary assessment, vital signs, reassessment.
- The primary assessment finds life threats and treats them as they are found: general impression, responsiveness, then X, A, B, C, D, E, ending with a priority decision.
- History is OPQRST for the complaint and SAMPLE for the patient. An unresponsive patient's history comes from everyone and everything around them.
- Responsive medical patients get history then a focused exam; unresponsive medical patients and trauma patients with a significant mechanism get a rapid full-body exam first.
- Vital signs are a baseline and then a trend. Compare every set with the last.
- Reassess on a schedule your protocol sets, after every intervention and whenever the patient changes. Treat the patient, not the numbers.