Knowledgebase:
Document Care by a Non-Agency ALS Provider
Posted by on 11 January 2012 04:54 PM
Question: If we have an ALS provider ride on our truck (not affiliated with our agency) and they perform ALS procedures (IV, 12 Lead, etc) what crew member do we put in for those ALS procedures performed?

Answer: Assuming the original crew on the EMS unit is BLS and the ALS provider is from an area agency then the correct way to document this would be that the ALS provider should be documenting the response and her patient care from the time they assumed patient care. I would advise the BLS crew to note in their narrative the time and name of the ALS provider or agency that assumed care of the patient and not document the ALS provider should then document their own procedures. Remember, when the ALS provider begins an assessment or begins to provide a higher level of care they are legally assuming care of the patient.

Some agencies want to track the use of the vehicle or crew, but remember you are creating a medical record and not an incident report. From an EMS medical record stand point the call should following who is the Attendant in Charge (AIC) and not the ambulance. The AIC is ultimately responsible for the patient care being provided by other providers.

Given the diversity of the Virginia EMS system we recognize there will be multiple scenarios where the above scenario may not fit. For agencies that will encounter scenarios outside the ideal scenario above often, then we recommend creating a “user defined” question such as outside provider name. Agencies can add custom fields for use on the agency level. See creating user defined questions in the VPHIB user manual or help videos. Another choice is to document to use the narrative to make a record of care provided by a non-crew member.

If an agency will be using outside providers routinely you may consider adding those providers to your agency’s staff list.

If the original crew is ALS and they are assisted by an additional ALS provider from a different agency within their system or even another off duty provider from elsewhere in the state, we would recommend the following: Since the original ALS provider would not be surrendering care of the patient, it is recommend that the original ALS provider document the procedure as their own and then make a note in the narrative noting who actually performed it. For example Note: IV#2 16g IV(R) AC placed by Paramedic John Smith from ABC agency/county.