Documentation of Procedures/Meds by VBPD, Bystanders, Patient

Documentation of Procedures/Meds by VBPD, Bystanders, Patient

The old reporting software had a multi-select box for various procedures and items that may have been performed prior to EMS arrival.  Elite has a more streamlined way for these items to appear in line with your other procedures and medications for better documentation.  It allows for the time and other data to be entered as well. Documentation of these items are very important and save you time later in the report!

For example, if your patient has chest pain and took 325 mg of ASA 30 minutes before calling 911, you don’t have to make a note in the narrative that you deliberately omitted it from your treatment since they already took it.  Just enter it in the medication section, add the time, role of person giving it and dose/route.  You will need to check the Yes box for prior to EMS arrival.  The name of the crew member is left blank and it will not affect validation.

Items that should be listed in this manner include:

  • Narcan by police/bystanders/health care staff
  • Tourniquets by police/bystanders
  • Epinephrine by patients/family/health care staff
  • Cardiac arrest meds/intubations/IV/12 lead/etc. by healthcare staff

Bandages, CPR, Aspirin, NTG and any other items on our lists should be listed if they are appropriate to the case at hand.  This does not apply to fire and EMS providers on duty who are participating in patient care.  They should be listed by name and in the usual fashion.  Here is an example of both a medication and procedure entry before EMS arrived:

 

Don’t forget to enter all of the medications and procedures that you and your team performed as well! Remember that items only entered in the narrative cannot be queried later and are much harder to find.  Items that are entered on the report do not have to be duplicated in the narrative section.  Remember that if it isn’t documented, it wasn’t done!

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