EMS / Ambulance Documentation Q&As


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Question 136:      Are we allowed to use fluids administered by Emergency Medical Services (EMS) in route to our facility?

Answer 136:        Yes, depending on the rate at which they are administered and whether or not there is an order or protocol that serves as an order. Fluids must be given at a rate greater than 125 ml/hour (equivalent to 1000 ml over 8 hours) to be considered in the total volume. There must also be an order and the order must include the duration over which to infuse, or an infusion rate.


Question 313:      If the ED physician documents reference to the ambulance record and BP 70/40 and fluids given, can we count the low BP as Organ Dysfunction with time of OD being the ED physician note or the time actually written in the ambulance record if that ambulance record is available?

Answer 313:             Yes.


Question 116:         What if criteria were met prior to arrival (e.g., recorded by EMS or collected at a nursing home)?

Answer 116:            This would mean the patient arrived to the ED with Severe Sepsis, and you would use triage time for Severe Sepsis Present Time data element.


Question 265:         How would you define Sepsis present on arrival? What documentation would be needed?

Answer 265:            This could occur with physician documentation. For example, the physician documents patient arrived to ED with Severe Sepsis in a progress note. This could also occur based on clinical criteria. For example if a patient arrives by ambulance from home meeting all the criteria for Severe Sepsis, and this was communicated to the hospital prior to or on arrival.


*Content is based on Specifications Manual Version 5.0b – October 2015 through June 2016 discharges.

**The article is part of the Registry Partners Quality Division Sepsis Newsletter.  Follow the blog to read more articles from the Newsletter or contact us to receive a copy of the full newsletter to share with your team!