Documentation question

OOBmedic

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So I’d like to get peoples thoughts and arguments about something that one of our EMTs puts down in their run reports. Our service has a medic on every truck and we all know that not all calls require ALS care and in those cases we pass it along to our BLS partners. The EMT in this particular incident when writing their report includes the phrase “medic deemed call BLS”. We have some that find this totally wrong and uncalled for. I find no wrong with it..... What are your thoughts??
 

mgr22

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I think "medic deemed call BLS" isn't clear or specific enough to have much meaning. All calls involve elements of BLS, and "BLS" isn't even a universal standard. If the purpose were to document the call being handed off to a BLS crew, that could be expressed more clearly. If "medic deemed call BLS" were an EMT's impression that not enough "ALS" was done, one could question the capability of the EMT to draw that conclusion.

If it were up to me, I'd start by asking the EMT to explain what was meant, then go from there. It might just need a little tweak.
 

gotbeerz001

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Stick with facts. Write the report in a way that shows a BLS level of care was appropriate and cite where ALS diagnostics were performed but deemed unremarkable.
 

DrParasite

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Why is it wrong? I believe the intent of the phrase is for the EMT to document that the paramedic assessed the patient, and determined that ALS services were not needed.

If they don't include the phrase, and someone asks why they took the patient in BLS (QA, medical director, attorney in a lawsuit against the provider or agency regarding the call), what documentation exists to show that it was because the higher medical authority said to?
 

gotbeerz001

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Why is it wrong? I believe the intent of the phrase is for the EMT to document that the paramedic assessed the patient, and determined that ALS services were not needed.

If they don't include the phrase, and someone asks why they took the patient in BLS (QA, medical director, attorney in a lawsuit against the provider or agency regarding the call), what documentation exists to show that it was because the higher medical authority said to?

Not necessarily wrong unless it’s used as an excuse to be lazy in the rest of the chart.

Using the phrase “ALS assessment performed at scene by XXFD and found unremarkable” may be a bit more proper.
 
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DesertMedic66

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IMO writing “medic deemed the patient BLS” followed by a thorough BLS assessment is fine. In that BLS assessment should be all the information needed as to why this patient able to be treated at the BLS level.
 
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OOBmedic

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I agree, if the medic found the patient to not need ALS care and if they did their part it should be fine. Even if the PT were to suddenly take a turn for the worse and they two switch rolls as long as proper documentation was done then there should be no wrong with it
 

Aprz

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I have no problem with it. My EMT partner has written a similar phrase in her narratives the few times I've read her narratives (when she ask me to review it or billing has us review it). Technically, if she takes the calls, both of us deemed it BLS. She shouldn't be taking calls that aren't beyond her scope, and she isn't 100% off the hook just because I thought it was BLS. Crew resource management.
 

johnrsemt

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Most of the pt evaluation is BLS: Vital signs; blood glucose (in most areas is a BLS skill), SPO2, etc. So 90% of patient evaluation is BLS. When I worked with medics and we went to an ECF the medic would go and get the paperwork and oral report from the nurse and I would go check out the patient and get them ready to transfer, and I would make the decision if they needed to be transported BLS or ALS. When the medic walked in to the room I would tell him or her my decision and they would decided if they agreed or not.
When I became a medic I taught my basic partners the same things and we did the same things.

On 911 calls I would talk to the family and let my partners evaluate the patients: works the same way. Compare notes in the truck before transport starts, decide who is transporting and how; if the EMT-B isn't comfortable transporting, be prepared to defend why, and patient is crazy isn't a good answer, funny, but not a good reason. Medic too tired to drive was a good answer a few times
 
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