Knowledgebase:
Rule 1108 Documenting Care Given Prior to Arrival.
Posted by on 28 August 2013 08:32 AM
The validation rule is correct. Submission requirements have always required that in the scenario you described that the first arriving unit would document their response and the care they provided, including the procedure in question, up to the time the ALS unit assumed care of the patient. We do not find it medically legally correct for a certified provider to document the care provided by another certified provider unless they were present and observed the procedure and are willing to assume responsibility for that procedure. For example an AIC that directs BLS provides or other team members is ultimately responsible for the patient and observing and directing care. Similarly, the preceptor student relationship would function this way.

OEMS did adjust rule 1108 some time ago to allow an EMS unit to document care given by another provider, unit, or agency. Again, it needs to be clear that the procedure was performed prior to arrival and not by the unit/provider completing the report. The way this is done correctly for Virginia rules, to be consistent with the national standard, and medically legally appropriate is to utilize date element E19_02 / Procedure Performed Prior to this Units EMS Care.

If you are not collecting E19_02 you will need to add it to your run form. We would recommend setting its default to no and educate your providers that when documenting another units care they need to change this answer to yes clearly identifying they did not perform the skill, but the patient received a medication of procedure.

You can further see how the validation rules is written in the knowledgbase at http://oemssupport.kayako.com/staff/Knowledgebase/ViewKnowledgebase/Article/57/10


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