Documenting maximum level of care, level of care provided, and primary role in Elite

Documenting maximum level of care, level of care provided, and primary role in Elite

If it seems like you are documenting the same thing 3 times, you are not alone.  Trying to understanding the national reporting requirements for these fields was a challenge, even more challenging how best to communicate and teach it.  These 3 fields are distinct and have separate meaning while they may appear to overlap.

Level of Care Provided For This Patient

2016-12-06_0920The intent of this field (itResponse.009) is to document the care that was PROVIDED to the patient.  Did an ALS provider act as AIC for this patient and provide ALS care?  If yes, select ALS.  Otherwise, select BLS.

Level of Care Of This Unit

2016-12-06_0921

The intent of this field (eResponse.15) is to document the highest level/certification of care AVAILABLE on this vehicle for this transport, and, the care certification of this vehicle.  All ambulances within VBEMS are certified at the ALS/Paramedic level, so it will always be the crew certification that determines this value.  If a paramedic is part of the crew but not acting as AIC, you would still select Paramedic.  The idea is that that person’s knowledge and skills are present and may influence patient care even if not leading the call or actively participating.

It is my hope that, in the future, this field can be calculated once you enter the crew and their certifications.

Also note that when care is provided by one of our EMS Fellows (physicians), the highest level of care this agency is certified to provide is Paramedic.  Care may be rendered above that level by a Fellow and will be documented in the report narrative.

Primary Role Of The Unit

 

2016-12-08_1607This field (eResponse.07) has been greatly simplified to indicate the role the unit completing the report.

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