Doing documentation on "first aid"
When entering the ambulance, the paramedic paramedic must sign in the journal of working hours. Then he takes a medical box-packing with medicines, an electrocardiograph, an oxygen device, a tonometer and a phonendoscope, an anti-shock( resuscitation) styling, a generic package, inventory, as well as other equipment and objects in accordance with the internal regulations of the substationand make notes about it in the relevant journals. Separately, he receives narcotics and strong drugs and makes a corresponding entry about it.
When using narcotics and strong drugs, the paramedic immediately after arrival at the substation should make a note about writing them off in special magazines.
When a call is received, the paramedic receives from the dispatcher a "call card", which is the main document. It shows: the card number, the time of the call and departure of the brigade, the reason for the call, the full name.patient, his age, address( street, house, apartment, porch, floor, entrance door code - if any, as well as landmarks - intersection of which streets, next to what famous objects, etc.), as well as the surname of the calling SMP( first aid) and the name of the dispatcher who recorded and transmitted the call. In addition, the "Call Card" indicates the number of the brigade and the names of the paramedic, the driver and other members of the brigade.
After arriving at the place of call, the paramedic writes down the full name, age of the patient, address( it can be different), as well as the place of permanent residence( registration) of the patient.
On the back of the card patient complaints, anamnesis, objective research data on organs and systems, diagnosis, assistance, and results are recorded. In the case of the introduction of drugs and potent drugs, a separate entry is made about this, indicating the date, time of introduction and the painting of the paramedic and other medical personnel-members of the brigade.
If it is necessary to call a medical specialist team or transfer an active call to a doctor of a polyclinic, an appropriate entry is made about this and is notified to the dispatcher.
When the patient is hospitalized, the method of transportation( on foot, on stretchers, etc.), accompanying persons, referral to a particular hospital is indicated. In the waiting room the patient is transferred to the doctor on duty( paramedic), which he must sign in the "Call Card".
The "Call Card" marks the time of arrival to the patient, the time of departure from the patient, the time of arrival in the hospital, and the time of departure from the hospital. The dispatcher puts the time of arrival at the substation. When the next call is received by the radio, the time of the end of the previous call is indicated by the paramedic himself.
If the patient is transported to a hospital, and he does not have a referral( for example, from a district or other doctor), the visiting paramedic fills out the "Accompanying sheet" and "Talon to the accompanying sheet".
These documents specify the same data: the number of the "call card", the name of the person.and age of the patient, his address, diagnosis, circumstances of the accident( where, when and what happened), assistance provided, the mode of transportation, to which hospital is delivered and when( date and time) the surname of the paramedic SMP.
These documents are attached to the medical history. After the patient is discharged, the "Accompanying Leaf" is handed over together with the history of the disease to the archive, and the coupon is indicated by the diagnosis of the admission department and the final clinical diagnosis( in the case of the patient's death, the pathoanatomical conclusion), then the coupon is sent to the ambulance station.
After the end of the duty, the paramedic hands over the medicines, equipment and inventory that he received to the signature, to the senior paramedic of the substation or to his changer and signs in the work time register where the time for the end of the duty is marked.