Sudden cardiac arrest documentation tips for medics
Updated February 16, 2015
Out-of-hospital cardiac arrest patients present a significant challenge to document the multiple interventions, personnel involved, and treatment impacts
Cardiac arrest patients are some of our most challenging patient care situations. Steve Krantz, a paramedic with 35 years of experience as a medic and EMS educator in Wisconsin, gave me these tips for improving cardiac arrest patient documentation. Krantz performed quality assurance on all of the CPR patient documentation for his service.
1. Document any interventions performed by bystanders before EMS arrival.
Did bystanders initiate CPR? If yes, when? Did bystanders do compressions only or did they also deliver rescue breaths? Knowing bystander involvement can help guide public education programs and understand why interventions, like defibrillation, may or may not have succeeded.
2. Confirm last time patient was seen or heard to be alive.
If the patient’s spouse reports hearing a thud in the other room, did she check right away or finish what she was doing before finding the patient in cardiac arrest?
3. Obtain past medical history for the patient.
This is especially important for patients that are transported or for which field termination of resuscitation is being considered. Conditions like cancer, kidney disease, or diabetes may have contributed to the arrest or could complicate resuscitation.
4. Capture time of field termination.
If allowed by local protocol to terminate resuscitation efforts, make sure to record the time when the last compression was delivered. The actual time at which resuscitation efforts ended will likely be much sooner than the time you left the scene.
Finally, I asked Krantz for his recommendation regarding the top measure that EMS providers could take to improve outcomes for cardiac arrest patients. From his frequent review of documentation, he confirmed what many of us should already know: minimize interruptions in compressions.