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Patient Care Data Entry: Activities Page > Procedures Tab

This section documents all procedures and interventions performed on the patient during the EMS event.

Event Timeline

These date/time fields appear at the top of the tab and show the user these contextually relevant date/time intervals. 

Quick Selection Buttons

The Procedures Tab features four quick selection buttons that provide fast access to commonly used procedure categories:

Heart Button - Opens cardiac-related procedures including:

  • Cardiac monitoring
  • Defibrillation
  • Cardioversion
  • Pacing procedures
  • Other cardiac interventions

IV Button - Opens vascular access procedures including:

  • IV insertion
  • IO insertion
  • Central line access
  • Blood administration
  • Other vascular access procedures

Assessment Button - Opens assessment and diagnostic procedures including:

  • 12-Lead ECG
  • Blood glucose testing
  • Pulse oximetry
  • Capnography
  • Other assessment procedures

Green Plus Button - Creates a new procedure record without automatically opening a specific category, allowing you to manually select any procedure type from the full procedure list.

When any of the first three quick buttons are selected, you will be taken directly to those common procedure categories, making documentation faster and more efficient. The Green Plus Button provides flexibility to document any procedure not in these common categories.

Procedure Information

Date - Required (eProcedures.01)

  • The date/time when the procedure was performed on the patient

Procedure Performed - Required (eProcedures.03)

  • The specific procedure performed on the patient
  • Select from the standardized procedure list
  • Enter procedure code (6-15 digit number)
  • Note: Procedures recorded as vital signs do not need to be documented here

Prior to EMS Care - Required (eProcedures.02)

  • Indicates whether the procedure was performed before this EMS unit's arrival
  • Options: No, Yes
  • Use "Yes" to document prior aid performed by other providers

Procedure Performed by Another Unit - Optional (Custom)

  • Indicates whether the procedure was performed by another EMS unit or agency
  • Options: No, Yes

Size of Procedure Equipment - Optional (eProcedures.04)

  • The size of equipment used in the procedure
  • Numeric field (1-20)
  • Examples: ETT tube size, catheter gauge, blade size

Number of Procedure Attempts - Required (eProcedures.05)

  • The number of attempts taken to complete the procedure, regardless of success
  • Numeric field (1-10)

Successful - Required (eProcedures.06)

  • Indicates whether this individual procedure attempt was successful
  • Options: No, Yes

Response to Procedure - Required (eProcedures.08)

  • The patient's response to the procedure
  • Options: Improved, Unchanged, Worse

Complications - Required (eProcedures.07)

  • Any abnormal effects on the patient associated with performing the procedure
  • Multiple complications can be selected
  • Options:
    • Altered Mental Status
    • Apnea
    • Bleeding
    • Bradycardia
    • Bradypnea
    • Diarrhea
    • Esophageal Intubation
    • Esophageal Intubation - immediately recognized
    • Extravasation
    • Hypertension
    • Hyperthermia
    • Hypotension
    • Hypothermia
    • Hypoxia
    • Injury
    • Itching
    • Nausea
    • None
    • Other
    • Respiratory Distress
    • Tachycardia
    • Tachypnea
    • Urticaria
    • Vomiting

Vascular Access Location - Recommended (eProcedures.13)

  • The location of the vascular access attempt site on the patient
  • Only applicable for IV/IO procedures
  • Options:
    • Antecubital-Left
    • Antecubital-Right
    • External Jugular-Left
    • External Jugular-Right
    • Femoral-Left IV
    • Femoral-Right IV
    • Foot-Left
    • Foot-Right
    • Forearm-Left
    • Forearm-Right
    • Hand-Left
    • Hand-Right
    • Internal Jugular-Left
    • Internal Jugular-Right
    • IO-Femoral-Left Distal
    • IO-Femoral-Right Distal
    • IO-Humeral-Left
    • IO-Humeral-Right
    • IO-Iliac Crest-Left
    • IO-Iliac Crest-Right
    • IO-Sternum
    • IO-Tibia-Left Distal
    • IO-Tibia-Left Proximal
    • IO-Tibia-Right Distal
    • IO-Tibia-Right Proximal
    • Lower Extremity-Left
    • Lower Extremity-Right
    • Other Central (PICC, Portacath, etc.)
    • Other Peripheral
    • Radial-Left
    • Radial-Right
    • Scalp
    • Subclavian-Left
    • Subclavian-Right
    • Umbilical
    • Upper Arm-Left
    • Upper Arm-Right
    • Venous Cutdown-Left Lower Extremity
    • Venous Cutdown-Right Lower Extremity
    • Wrist-Left
    • Wrist-Right

Airway Placement Technique - Optional (Custom)

  • Documents the specific technique used for airway placement procedures
  • Only applicable for airway management procedures

Crew Member Information

Crew Name/ID - Recommended (eProcedures.09)

  • The statewide assigned ID number of the EMS crew member performing the procedure
  • Free text field

Certification Level - Required (eProcedures.10)

  • The certification level or type of person performing the procedure
  • For procedures performed prior to EMS arrival, this may be a non-EMS healthcare professional
  • Options:
    • Advanced Emergency Medical Technician (AEMT)
    • Community Paramedicine
    • Critical Care Paramedic
    • Emergency Medical Responder (EMR)
    • Emergency Medical Technician - Intermediate
    • Emergency Medical Technician (EMT)
    • Family Member
    • Fire Personnel (non EMS)
    • Law Enforcement
    • Lay Person
    • Licensed Practical Nurse (LPN)
    • Nurse Practitioner
    • Other Healthcare Professional
    • Other Non-Healthcare Professional
    • Paramedic
    • Patient
    • Physician
    • Physician Assistant
    • Registered Nurse
    • Respiratory Therapist
    • Student

Authorization Information

Authorization - Optional (eProcedures.11)

  • The type of treatment authorization obtained
  • Options:
    • On-Line (Remote Verbal Order) - Verbal order from physician via phone/radio
    • On-Scene - Direct order from physician present on scene
    • Protocol (Standing Order) - Performed per established protocols
    • Written Orders (Patient Specific) - Based on written orders for this specific patient

Last Name - Optional (eProcedures.12)

  • Last name of the authorizing physician
  • Required if authorization was by any method other than Protocol (Standing Order)

First Name - Optional (eProcedures.12)

  • First name of the authorizing physician
  • Required if authorization was by any method other than Protocol (Standing Order)

Usage Notes

Documenting Multiple Procedures:

  • Each procedure performed should be documented as a separate entry
  • Click "Add Procedure" or similar button to create additional entries

Procedure Attempts:

  • Document the total number of attempts made, regardless of success
  • Each attempt should indicate whether it was successful

Prior Aid Documentation:

  • Use "Prior to EMS Care = Yes" for procedures performed before EMS arrival
  • This includes procedures performed by:
    • Family members or bystanders
    • Other healthcare professionals on scene
    • Patient self-care
    • Other EMS units that arrived first

Vascular Access:

  • Only complete Vascular Access Location for IV/IO procedures
  • Left blank for other procedure types

Complications:

  • Select "None" if no adverse effects occurred
  • Multiple complications can be selected if applicable
  • Document any unexpected complications or adverse events

Response Assessment:

  • Assess and document patient response after an appropriate time interval
  • Response should reflect condition change attributable to the procedure