Patient Care Data Entry: Assessment Page > Situation Tab

Primary Symptom Section

Estimated Symptom Onset - Recommended (eSituation.01)

• The estimated date/time when symptoms began
• Can be marked as "Approximate" if exact time is unknown
• Important for time-sensitive conditions (stroke, MI, trauma)

Estimated Last Known Well - Optional (eSituation.18)

• The date/time the patient was last known to be in their normal state of health
• Particularly important for stroke and neurological emergencies
• Helps determine treatment windows for time-sensitive interventions

Initial Patient Acuity - Recommended (eSituation.13)

• The initial acuity level of the patient upon this EMS unit's arrival at scene
• Clarifies assessment in multi-unit scenarios
• Options:
  • Critical (Red)
  • Dead without Resuscitation Efforts (Black)
  • Emergent (Yellow)
  • Lower Acuity (Green)
  • Non-Acute/Routine

Primary Symptom - Recommended (eSituation.09)

• The primary symptom documented for the patient
• Select the main presenting complaint or condition
• Begin typing to activate auto-complete function
• Click the Orange T (tier) button to browse through the value list by category

Anatomic Location - Optional (eSituation.07)

• The anatomic location of the chief complaint
• Options:
  • Abdomen
  • Back
  • Chest
  • Extremity-Lower
  • Extremity-Upper
  • General/Global
  • Genitalia
  • Head
  • Neck

Organ System - Optional (eSituation.08)

• The organ system associated with the chief complaint
• Options:
  • Behavioral/Psychiatric
  • Cardiovascular
  • CNS/Neuro
  • Endocrine/Metabolic
  • GI
  • Global/General
  • Lymphatic/Immune
  • Musculoskeletal/Skin
  • Pulmonary
  • Renal
  • Reproductive

Primary Impression - Recommended (eSituation.11)

• The provider's primary clinical impression or working diagnosis
• Should reflect the most likely condition based on assessment
• Begin typing to activate auto-complete function
• Click the Orange T (tier) button to browse through the value list by category

Patient Size and Pediatric Assessment

Estimated Body Weight (kg) - Optional (eExam.01)

• Patient's estimated body weight in kilograms
• Important for medication dosing, especially in pediatric patients

Estimated Body Weight (lbs) - Optional

• Patient's estimated body weight in pounds
• Alternative to kg measurement
• System may auto-convert between kg and lbs

Length Based Tape Measure - Optional (eExam.02)

• Color-coded length-based tape measurement for pediatric patients
• Options: Blue, Green, Grey, Orange, Pink, Purple, Red, White, Yellow
• Used with Broselow tape or similar color-coded resuscitation systems
• Helps determine appropriate equipment sizes and medication doses

Clinical Indicators

Stroke / CVA Symptoms Resolved - Optional (eExam.21)

• Indicates whether stroke symptoms resolved during the encounter
• Options:
  • No
  • Yes-Resolved in EMS Presence
  • Yes-Resolved Prior to EMS Arrival
• Important for determining treatment protocols and destination decisions

Possible Injury - Recommended (eSituation.02)

• Indicates whether the patient may have sustained an injury
• Options: No, Unknown, Yes
• Helps determine if trauma protocols should be considered

Work-Related Information

Work Related - Optional (eSituation.14)

• Indicates whether the illness or injury is work-related
• Options: No, Unknown, Yes
• Important for workers' compensation and occupational health reporting

Occupation - Optional (eSituation.16)

• The patient's occupation category
• Options include:
  • Architecture and Engineering Occupations
  • Arts, Design, Entertainment, Sports, and Media Occupations
  • Building and Grounds Cleaning and Maintenance Occupations
  • Business and Financial Operations Occupations
  • Community and Social Services Occupations
  • Computer and Mathematical Occupations
  • Construction and Extraction Occupations
  • Educational Instruction and Library Occupations
  • Farming, Fishing and Forestry Occupations
  • Food Preparation and Serving Related Occupations
  • Healthcare Practitioners and Technical Occupations
  • Healthcare Support Occupations
  • Installation, Maintenance, and Repair Occupations
  • Legal Occupations
  • Life, Physical, and Social Science Occupations
  • Management Occupations
  • Military Specific Occupations
  • Office and Administrative Support Occupations
  • Personal Care and Service Occupations
  • Production Occupations
  • Protective Service Occupations
  • Sales and Related Occupations
  • Transportation and Material Moving Occupations

Occupation Industry - Optional (eSituation.15)

• The industry in which the patient works
• Options include:
  • Accommodation and Food Services
  • Administrative and Support and Waste Management and Remediation Services
  • Agriculture, Forestry, Fishing and Hunting
  • Arts, Entertainment, and Recreation
  • Construction
  • Educational Services
  • Finance and Insurance
  • Health Care and Social Assistance
  • Information
  • Management of Companies and Enterprises
  • Manufacturing
  • Mining, Quarrying, and Oil and Gas Extraction
  • Other Services (except Public Administration)
  • Professional, Scientific, and Technical Services
  • Public Administration
  • Real Estate and Rental and Leasing
  • Retail Trade
  • Transportation and Warehousing
  • Utilities
  • Wholesale Trade

Additional Documentation Sections

Complaints - Optional (eSituation.03, eSituation.04)

• Document multiple patient complaints
• Each complaint includes:
  • Description: Text description of the complaint
  • Action: Actions taken or status

Secondary Impressions - Optional (eSituation.12)

• Additional clinical impressions beyond the primary impression
• Allows documentation of multiple working diagnoses
• Each impression includes:
  • Description: The secondary diagnosis or impression
  • Action: Related actions or notes

Other Symptoms - Optional (eSituation.10)

• Associated symptoms beyond the primary symptom
• Document all relevant symptoms the patient is experiencing
• Each entry includes:
  • Description: The symptom description
  • Action: Status or related information

Activities - Optional (eSituation.17)

• Patient activity at the time of symptom onset or injury
• Helps establish mechanism and context
• Each activity entry includes:
  • Description: What the patient was doing
  • Action: Related details or notes

Usage Notes

Primary vs Secondary:

• Primary Symptom and Primary Impression should reflect the main reason for EMS activation
• Secondary Impressions document additional conditions that may require treatment or affect care

Time-Sensitive Conditions:

• Always document Estimated Symptom Onset and Last Known Well for:
  • Stroke/CVA
  • Myocardial infarction
  • Trauma with possible spinal injury
  • Other time-sensitive emergencies

Pediatric Patients:

• Use Length Based Tape Measure for quick reference
• Estimated weight is crucial for medication dosing
• Document weight in the unit most familiar to you (system can convert)

Work-Related Documentation:

• Complete work-related fields when injury or illness occurred at work
• This information is important for workers' compensation claims
• Include occupation and industry details when available

Multiple Entries:

• Complaints, Secondary Impressions, Other Symptoms, and Activities sections all allow multiple entries
• Use "Add" buttons to create additional records as needed