BLS AIC Preparation Manual

56 Pages·2016·1.48 MB·English

2016
BLS AIC Preparation Manual
EMS Division
Chesterfield Fire and EMS
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Table of Contents
Documentation ........................................................................................................................................... 4
Introduction ............................................................................................................................................ 5
1-1 DACHARTE Documentation Format ........................................................................................... 6
1-2 Approved Abbreviations .............................................................................................................. 12
1-3 Signatures ....................................................................................................................................... 14
1-4 Refusal Documentation ................................................................................................................. 16
Communications and Transfer of Care ................................................................................................. 20
Introduction .......................................................................................................................................... 21
2-1 Pre-Hospital Reports (Phone) ..................................................................................................... 22
2-2 Pre-Hospital Reports (HEAR Radio) ......................................................................................... 24
2-3 Patient Transfer Report ................................................................................................................ 25
2-4 Clearing the Hospital .................................................................................................................... 26
Clinical Decision Making ........................................................................................................................ 27
Introduction .......................................................................................................................................... 28
3-1 ALS vs. BLS Units .......................................................................................................................... 29
3-2 Considering the Need for ALS Care ........................................................................................... 30
3-3 Hospital Determination ................................................................................................................ 32
3-4 Patient Destination Determination .............................................................................................. 33
BLS Equipment Reference....................................................................................................................... 34
4-1 Patient Movement .......................................................................................................................... 35
4-2 Patient Movement Equipment Skills .......................................................................................... 37
4-3 BLS Patient Care Equipment ........................................................................................................ 42
4-4 BLS Patient Care Equipment Skills ............................................................................................. 43
Assisting ALS ........................................................................................................................................... 49
Introduction .......................................................................................................................................... 50
5-1 IV Related ALS Assistance ...................................................................................................... 51
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5-2 Intubation Setup ....................................................................................................................... 54

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Module I
Documentation

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Introduction

Documentation fills many roles in the course of a patient’s journey through the EMS system.
Foremost, it provides a narrative to future healthcare providers as to the nature of illness a patient
has. It also allows for continuity of care as a patient is transferred from one healthcare provider
to another. Imagine if a new medication were given with a painful adverse effect and that
negative reaction wasn’t documented. Future healthcare providers could potentially repeat the
medication, subjecting the patient to more discomfort.
A second function of documentation is to protect the healthcare provider. Good documentation
serves as an official record of what you did, what you saw, and how the patient responded.
Everyone is familiar with the adage “If you didn’t write it down it didn’t happen”. This is
particularly true in the scope of EMS care. In our litigious society, it is essential that we do
everything we can to limit potential liability. Patient management is a complicated task,
comprising of many facets that all require attention and analytical thinking. Without solid
documentation backing up your actions and findings, any action you might try to defend in court
will fall short. Oftentimes providers are required to testify years after the actual incident, once
they’ve interacted with hundreds or thousands of other patients. In many cases, the
documentation that you wrote on the day of the incident will be all you have to rely on.
Finally, documentation provides a detailed record of all the procedures that you performed on the
patient. This allows for accurate billing and increased revenue recovery. This serves both the
patient and the organization. It allows for the patient to have a detailed record of what was done
to them. The organization, in turn, is able to be reimbursed for the costs incurred in treating the
patient.
In short, documentation is one of the most important parts of your EMS care. While it is often
seen as a burden, good documentation can be every bit as helpful to the patient as medical
interventions.

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1-1 DACHARTE Documentation Format

Chesterfield Fire and EMS encourages the use of the DACHARTE
documentation format when composing a narrative. This format provides you
with the means to document everything necessary while maintaining the

flexibility to adapt to unusual calls or situations.

The ePCR allows great detail in documentation by using the pre-loaded information coupled
with notes. However, this does not eliminate the need for a narrative. No ePCR is considered
complete without a written narrative that “paints” an accurate picture of the scene, patient
presentation and all occurrences during the interaction with that patient. DACHARTE is a
variation on the CHART documentation format. The letters stand for:
D - Dispatch – Summarize dispatch information provided, including call type.
A - Arrival - What did the scene look like upon your arrival? Where was the patient?
C - Chief Complaint – Briefly state the reason for request for service.
H - History – History of present event/illness/injury (HPI) & past medical history (PMH).
A - Assessment – List your physical exam findings.
R - Treatment (Rx) – Chronologically list all treatment provided to the patient for this incident,
and WHY THIS TREATMENT WAS PROVIDED.
T - Transport – Describe how and where transported, and what occurred during transport.
E - Exceptions - Any problems encountered, unusual circumstances or deviation from
Guidelines.

In the narrative section of the ePCR, you should clearly and concisely provide the following
information:

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D: Dispatch - Summarize the information provided by the ECC on dispatch and while enroute to
the call.
o What was the call type?
o What other relevant information was provided (CPR in progress, seizure activity,
response priority changed)?
A: Arrival - Describe the scene on your arrival.
o Where did you find the patient? (Street, alley, house, business.)
o Where was the patient located at the scene? (Living room, wedged between the commode
and the bathtub, lying at the bottom of the stairs.)
o Was the patient in a wheelchair, standing, sitting, walking or in bed?
o Was the patient being administered any medical intervention (e.g., oxygen, IV, CPR,
AED shocks)? If so, by what mechanism and by whom?
C: Chief Complaint - Document what the patient stated was his or her primary or chief
complaint.
o What is the reason an ambulance was called?
o Use the patient’s own words and document them in “quotation marks,” if
applicable/available.
o If the patient is confused or not able to communicate, document what you observe about
the patient. Refrain from using “none per patient” for patients who are unable to
communicate with you.
o If the source of information is someone other than the patient, note the source.
H: History - Describe the history of present illness/injury/incident (HPI) and sequence of events
behind the reason why you are there. This includes the subjective information relevant to
describing the patient’s present situation. Also, include relevant past medical history (PMH).
o What is the mechanism of injury?
o What are the patient’s symptoms and pertinent negatives?
o Use SAMPLE history to ensure you ask and document relevant HPI and PMH: o
Surgeries, Allergies, Medications, Pertinent Past History, Last oral intake, Events leading
up to injury/illness.
o Document any relevant statements and quotes from the patient, family members,
bystanders.
A: Assessment - List the results of your head-to-toe examination of the patient. This includes the
objective information pertaining to the patient’s present situation.
o Describe the results of your primary and secondary survey.
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o Document the patient’s complete vital signs, including GCS, Blood Glucose, and Pain.
o Vital signs should be taken initially on patient contact and subsequently as needed (no
less than every five minutes for unstable patients, every 15 minutes for stable patients and
following any medication administration or other treatment/intervention, such as
immobilization, defib., etc. The initial set of vital signs should be taken manually.).
o All transported patients should receive a minimum of two complete sets of Vital Signs.
o Document patient refusal of or other circumstances that prevent assessment of vital signs.
o Describe any injuries the patient sustained. o Use DCAP-BTLS approach to describe
injuries – Deformities/Discolorations, Contusions, Abrasions, Penetrations/Punctures,
Burns, Tenderness, Lacerations, Swelling/Symmetry.
o Describe the patient’s self-reported condition/pain. Is it mild, moderate or severe? Use 1-
10 to rate severity.
o o Use OPQRST to better describe the condition/pain – Onset of event,
Provocation/Palliation, Quality of pain, Region & Radiation, Severity, and Time of
onset/duration.
o Describe patient’s level of consciousness, alertness and pupils. Include GCS, RTS, Stroke
Scale.
o Are the chest and abdomen tender or non-tender?
o Can pt. move all extremities w/distal sensation and pulses present, strength equal
bilaterally?
o Did you use any equipment (ECG, EtCO2, NIBP, etc.) to monitor the patient? (If so,
what was measured, when was the monitoring equipment used and by whom?)
o Describe any remarkable findings.
o Refrain from using “within normal limits” and “no trauma noted.”
R: Treatment (Rx) - Document skills performed/treatment provided with times, who and how,
in the sequence in which you provided the care, and the patient’s response to the intervention.
Also document WHY each treatment was performed. All information documented in the
narrative should correlate with the information in the procedures sections.
o Did you administer oxygen? (List device, flow rate and times? What was the patient’s
response?)
o Did you administer any Medication(s)? (What, how much, what route, when, by whom,
response?)
o Did you defibrillate the patient? (What was the joule setting, when and by whom?
Response?)
o Did you place a basic or advanced airway device?
o Describe any splinting or wound management provided.
o Did you provide any spinal immobilization/motion restriction? (What equipment used?
Patient's condition prior to and following immobilization? Did you rule out need for
spinal motion restriction?)
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o How did you move the patient from the position in which he or she was found? (LBB,
sheet carry.)
T: Transport - Document all the details of the transport.
o What was the reason for transport? Was the patient bed-confined, injured, or medically
unstable?
o If not, why were other means of transportation contraindicated?
o Did the patient’s condition change during transport?
o Document vital signs, assessment, treatment and response occurring during transport.
o Who did you transfer care of the patient to at the destination?
o Do not document “patient transported non-emergently to…” This is already captured in
the ePCR.
E: Exceptions - Document any problems/exceptional circumstances encountered during the
incident.
o Difficulty accessing the patient.
o Language or other barriers.
o Delays in leaving the scene or during transport.
o Deviation from patient care guidelines.

Narrative Example - Medical Complaint

D – Dispatch: 24 year old female complaining of abdominal pain with nausea and
vomiting.

A – Arrival: Arrived at a two-story single family dwelling and was directed upstairs by
the patient’s spouse to the bathroom in the Charlie-Delta corner to find a 24 year old
female patient sitting on the toilet with a trashcan positioned in front of her. The
patient was bent forward with her arms across her abdomen and tearful. Her head was
hanging over the trashcan, which contained emesis consisting mostly of food and clear
liquids. There were anti-diarrheal and anti-nausea medications sitting on the counter.
The home was clean and tidy.

C - Chief Complaint: Severe abdominal cramping with nausea, vomiting and diarrhea
since 02:00, according to spouse. Patient states, “I’ve tried to get up but I start throwing
up again and I’m too weak to walk, even with my husband helping me.”

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