BLS report requirements on ALS calls

[Eyegor]

This question pertains to documentation requirements but let me paint the picture. We are a volunteer EMS agency with career ALS fly car. Upon dispatch fly car responds immediately, volunteers respond to squad building to pick up ambulance(s), rescue truck, etc.

New York State requires call sheets (PCRs) for each responding unit. This means almost every patient will have the medic's PCR and the ambulance crew PCR. The argument arises when the pt. is ALS. Many of our ambulance crews feel they can have a PCR with almost no pt. info because "it is on the medic's PCR". I disagree. I have always believed in complete documentation. Obviously the BLS crews' documentation will not state procedures performed by the medic. But 1 line reports of "Care provided by ALS" should not be enough either. What do you guys think?

[Ridryder 911]

As always stated " you didn't chart it, it was not performed".. I would use the analogy, if 5 years from now, if the ALS provider only documented that BLS was performed P.T.A., then any action the performed or not performed that could had potential ill effects, how could they defend themselves ?

R/R 911

[paramedicmike]

I agree with Rid. If you do anything, which you most certainly have done, before the medic's arrival it needs to be charted. Otherwise, there will be a hole in terms of care provided and you wind up hanging yourself, your partner and possibly the medic.

Didn't write it down? It never happened. Regardless if it's BLS, ALS or other it needs to be there.

Good luck.

-be safe.

[Nate]

If I arrive on scene after a BLS crew has attempted to do anything then I simply have them write a report up to the point of my arrival, and my report starts from my point of arrival and will state that events PTA can be checked for accuracy by reading run ticket number ?????? I then will turn in my report with their report attached to mine. They however DO NOT leave the ER until I have this report.

For scenes where they make arrival before me simply just put the patient on oxygen (similar to a first responder) I just list what they did PTA and have the medic who performed that skill initial that portion of the run ticket's narrative. Usually I'm first on scene, so I don't come across this to much.

[Ace844]

"Eyegor,"

As everyone else has said you should be documenting any and all pt interactions as well as assessment, V/S's, etc... Next i would also to be sure to clearly document the who, what, what, to whom you rendered care to, and what actions you took after this you will be covered..

Hope this helps,

ACE844

[nsmedic393]

Here is my view on this; If BLS arrives on scene first and hand off to me, they write a PCR for everything that was done up until I took over patient care. Then I continue with my own PCR.

If for some reason, like stated above, the ALS is on scene first and the BLS arrives aftereard to assist.

If ALS remains with the patient the whole time there is only a need for the ALS provider to complete the PCR. In reality the ALS provider will probably be doing all the assesment and treatment, less vitals and oxygen and probably lifting the stretcher.

The ALS provider will fill out a comprehensive PCR including his assesment and ALL treatment performed as well as all vitals (regardless by whome they were taken). What is the point of having the BLS provider write a PCR for a patient that was not in their care and to have it duplicate the info on the ALS PCR?

[Ridryder 911]

It is medical charting and documentation. Remember, the purpose is documenting is whom, when, and what was found & performed. This includes all agencies and representing staff. This would be like no charting done in ER if the patient went to ICU ...

R/r 911

[nsmedic393]

It is medical charting and documentation. Remember, the purpose is documenting is whom, when, and what was found & performed. This includes all agencies and representing staff. This would be like no charting done in ER if the patient went to ICU ...

R/r 911

Not really, the ER would document what they did, then the ICU would doucment what they did. Should every member of the er staff write seperate documentation?

Just to be more clear, on our PCR we have spots to enter, skills, meds, defib and so on. You initial each skill/drug with your number. Each medic signs on skills they perform. There is not a seperate PCR. Much like if you have a nursing summary. Each nurse adds on what they did for the patient or what they assesed. I'm pretty sure that each nurse does not start their own chart.

[Ridryder 911]

I understand on more of what you are discussing. I agree...

R/r 911

[PRPGfirerescuetech]

now, should medics be doing charts for patients they let their Basic take?