Documentation of your patient care, assessment, and times is very important. A very important item that must be documented includes any medications that are administered including saline and oxygen and those pertinent medications that were given before your arrival.
For instance, if you have a patient with chest pain, if the patient took a full dose of ASA a few hours ago, you should still list that in the medications along with oxygen, normal saline flush, NTG by the engine and your additional NTG.
Instructions on PTA items (meds and procedures) can be found here: https://www.vbems.com/2017/01/03/documentation-proceduresmeds-pta/
The AIC is responsible to record all medications that were administered to the patient to include the following information:
- Time administered
- Be as accurate as possible
- Name of person who administered it
- Ambulance crews should remember to ask and fire crews should remember to make a note on the handoff sheet if given by the engine crew
- Include role/type of person (this will be all that is entered if the patient, family, Dr office administered it
- Dose administered
- There are preset values so ensure you list the accurate amount
- Route administered
- Ensure the accurate route is listed
- Response to the medication (unchanged, improved, worse)
- Were there complications?
- Medication Authorization (standing order, physician order, etc.)
- Some are defaulted to standing order. If you obtain physician orders, please make sure you make that change here.