We should be documenting medications and procedures that are performed prior to EMS arrival (PTA) on the EPCR. This includes items such as 12 leads, meds or IV’s by Dr office staff, bandaging by family, Epi pen by the patient, Narcan by police, etc. It is not necessary to document daily medications or other items unless they are truly pertinent to the issue at hand.
Instead of a little list box that we had in the old system, pertinent procedures, medications and vitals should be listed directly into the same section that you would enter meds or procedures that you perform. You would click “Yes” for Prior to this unit, enter the time it was done, leave the crew member area blank, select the role/type of person, the med/procedure, dose, route and any other pertinent information. Here is an example of what a police Narcan entry might look like and an IV from a Dr. Office.
It is really important to capture the times and other data that impact our patients. These entries also help to explain why you did or didn’t do something and create the timeline for patient care. The narrative section is great place to explain further details but items that may need to be queried for skills, meds, dosing, etc should be listed in the proper sections.
If the fire department or zone car perform skills, takes vital signs or administer medications, those should be documented with a crew member name but you may still need to check “yes” to the prior to this unit question. That box takes your onscene time as the start so the report may not validate if the time of a procedure is before the arrival of the ambulance.
It is imperative that the person performing the skill gets the credit for it in the report and that items that occurred prior to arrival are not attributed to a provider who arrived later. You should not take credit for other providers skills.
And as always, if you didn’t enter it, it isn’t done. 🙂