Our firm frequently conducts in-house documentation continuing education programs for ambulance services, and one of the questions we are most frequently asked is whether an EMT should document on the BLS patient care report those interventions or assessments performed by the paramedic. This might be an issue where EMS is provided in “tiered” systems; that is, where the BLS and ALS is provided by separate organizations. BLS will respond in a transporting ambulance and ALS will respond in a non-transporting paramedic intercept or “fly car” unit.
Some EMTs tell us, for example, that it is their practice to document that the ALS provider applied a cardiac monitor and often document the EKG rhythm displayed on the monitor. Some EMTs also document that the paramedic started an IV, how many attempts it took to establish the line, the medications and solutions administered through the IV and other such information about the ALS care.
As a general rule, EMS providers, in our view, should document according to their scope of practice and not attempt to document skills beyond that which they are trained to perform themselves. There is too great a risk for inconsistent and inaccurate records when a provider documents beyond his or her scope of practice. In addition, such “beyond the scope” documentation may impair the credibility of the provider if he or she ever ends up on a witness stand defending a lawsuit. If an EMT documents a particular cardiac rhythm, for example, that provider leaves himself wide open for a stinging and damaging cross examination about their training and qualifications, or lack thereof, to make such determinations, and why he/she would document care beyond their scope of practice. Not being able to answer questions in a deposition or on the witness stand about all the documentation, including the EMT-documented ALS care, could call into question the EMT’s quality of BLS treatment by undermining the credibility of the witness.
This is not to suggest that EMTs cannot document anything that happens with regard to ALS. For instance, the EMT should certainly document the fact that the paramedic participated in patient care, and should certainly document the EMT’s role in the care. For instance, if the paramedic intubated the patient and the EMT handled the bagging, the BLS patient care report certainly should reflect that. Other general observations on a BLS trip sheet like “paramedic intubated the patient,” “paramedic applied a cardiac monitor,” “IV medications administered by the paramedic” likewise wouldn’t raise any problems, as long as the EMT refrains from describing details like the intubation technique employed or the tube size used, the particular cardiac rhythm displayed on the monitor, or the names and dosages of specific medications administered by ALS.
The bottom line: In many areas, the provision of EMS is a team effort between BLS and ALS providers, with each group performing specific responsibilities in patient care. Just as providers must render patient care within their scope of practice, their documentation likewise shouldn’t exceed their scope of practice either.
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