In addition to documenting the story that leads up to the 911 call, your detailed assessment and pertinent negatives, documenting all of the procedures that you perform is crucial.
If you are not performing a procedure because it was done before your arrival, it should be listed as well if it applies to patient care or would be expected. You are able to accurately document procedures such as tourniquets, bandaging, IV’s, even medications, etc. that were performed by bystanders, the patient, nurses, doctors, family or VBPD. For instructions on how to list those items appropriately, check out this post: https://www.vbems.com/2017/01/03/documentation-proceduresmeds-pta/ .
The AIC is responsible to record all procedures that were performed on the patient to include the following information:
- Time performed
- Be as accurate as possible
- Name of person (or lead person) who performed it
- Ambulance crews should remember to ask and fire crews should remember to make a note on the handoff sheet if performed by the engine crew
- Location is was performed on (if appropriate)
- A c-collar may be self-explanatory but IV’s, bandaging, splinting, and chest decompressions should have a location listed
- Size of item used (when appropriate)
- Gauge, joules, ETT size, even a color (if it applies) should be placed here
- Number of attempts
- Numerous attempts to one location can be listed here if attempted in very quick succession.
- If the times, provider performing or locations are different with additional attempts, they should be listed separately
- An IV attempt in the left hand and one in the right should be listed on separate lines since they are in separate locations
- An intubation attempt followed by BVM and then a reattempt should be listed on separate lines since the time is very different
- Response to the procedure (unchanged, improved, worse)
- Was it successful?
- Were there complications?
- Procedure 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
Please note that 12 leads performed by a doctor office should be repeated so it can be transmitted to the ED and added to your report.