Baltimore County Fire Department

Emergency Medical Services

A Guide to Documenting Patient Care

 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Introduction
Hello! Accurate reporting of patient care is vital for multiple reasons; namely, it serves as
a record of everything that occured during a call and becomes a legal document if
need be. Additionally, it is the primary means of obtaining data for use in quality as-
surance/quality improvement (QA/QI) processes. As such, reporting becomes two-
fold; on one hand, it is critical that a provider document accurately and completely
what occured during a call. On the other hand it is important that this be done in
such a way that is conducive to easily being able to pull data from PCRs.

We hope that you will find this guide useful in helping to clarify any questions you
may have surrounding documentation, especially what selection you should use to
respond to sepcific fields as we know that this is not always as clear as we would like
it to be. Additionally, we hope that you will find this guide easy to navigate; we have
designed it such that you can, as much as possible, get to the right page simply by
matching what you see on the eMEDS screen to visuals provided in this document.
If you are viewing this document on a computer or mobile device, you will find that
many of the images are interactive; rather than having to scroll to a page, simply click
the corresponding tab in the image and you will be taken directly to the correct page.
We know reporting can be a pain, so we hope this guide will be a rememdy to that
as much as possible.

General Guidelines
➢➢ Documentation serves two main purposes: record all of the care rendered to a
patient and generate data about care provided over extended periods of time.
■■ Accurate documentation of all assessments and interventsions ensures
that the PCR becomes a sound legal document should it be called on in
court.
■■ The data generated by compiling large numbers of PCRs makes it pos-
sible to assess the efficacy of treatments in the pre-hospital setting, such
that protocols can be adjusted or implemented to continuously improve
patient care.
➢➢ Documentation can be complete but not necessarily completed in such a way that
is conducive to the collection of data.
■■ The goal of this guide is to help providers understand how they can pro-
vide complete documentation that maximizes the ability to collect data
from their reporting while not being redundant.

2
! Dispatch
! Call Info
Patient
Provider Actions
Transport
! Narrative etc...
! Signatures
*Billing
Opioid Crisis
Patient Refusal
! Dispatch
! CAD

! Response

! Crew

Incident Location
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Notations in this document

Tabs

Subcategories

Symbols All symbols in this document direct you to more information on a given topic. If
it is not immediately below the text that it refers to, it can be found below the table
containing the given topic.

Symbol Meaning

➊, ➋, etc. See note immediately below table for more information.

 A short piece of information or and explanation on a given topic/entry.
 A quick tip to help you streamline the reporting process in eMEDS Elite.
W A critical reporting or patient care guideline/requirement.
ⒶⒷⒸ Explanation of a question’s response options to be found below.


In referring to navigating to a specific portion of eMEDS Elite, this guide
uses the following style:
TabàSubcategoryàField/pop-up dialogue (if necessary).

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Getting started
Log-in Upon opening Elite Field Login, if there is no user logged in, you will be prompted
to enter your username and password. If you have forgotten your password, click
the “Forgot your Password?” link at the bottom of the dialogue box. You will be
prompted to enter your e-mail address, username, and last name. If the information
entered matches the information on file, an email will be sent to the email address
on your account with instructions on how to reset your password. ➊
➊ If you cannot find the email in your inbox, make sure to check your spam/
junk folder.

Home-page Once logged in, you will be brought to the homepage. Here you can view all
incidents assigned to you in the center portion of the page. On the left, you have the
option to preset crew, unit, and shift.  v For more information on presetting the
crew, see Tab-by-Tab Crew.
Like in the former version of eMEDS, presetting the crew will automat-

 ically fill that information in in all future reports. Presetting the unit v
and shift will do the same.

v Ensure that you select the proper unit based on staffing level (i.e., if it is a

Create a new To create a new report, simply click “+ New Incident” at the top of the homepage. If
you have no preset any information for crew, shift, or unit, the new report will open
report immediately. If there is any preset information, you will be prompted to confirm
any preset information including crew, unit, and shift. ⒶⒷⒸ
Ⓐ “Yes” will confirm your presets and immediately open the new report. If
you would like to open a new report and change this information later, select
“Yes” and change the applicable information from within the report.
Ⓑ “No-switch user” will immediately log you out. You will have to login
again before being able to begin a report.
Ⓒ “Cancel” will close the dialogue box without opening a new report.

Select a report Clicking anywhere in the white area of a box will select that report and allow you to
post or delete (only users with the proper permissions can delete reports) it without
having to open it. 

You can select multiple reports by simply clicking on multiple.

 Alternatively, at the top of the homepage are two buttons: “All” and
“None.” These allow you to select all of the reports at once or unselect all
reports. This allows you to post or delete multiple reports at once.

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Writing a report
Validation Anything highlighted in red requires that you enter information. Clicking on a tab
along the left side of the window will open a set of subcategories. Subcategories
with a red line next to them are those that still require information. Clicking on
each subcategory will display the corresponding information entry dialogue. Fields
required by validation are outlined in red with a ! next to them. 
Generally filling information in these fields will satisfy the validation

 rule. If you have filled the field and it is still failing validation, hover the
cursor over the ! next to the text box for an explanation of why the field
is still failing validation.

CAD import You can save yourself time by importing information from the CAD. To do so,
click the button alone the top of the page. From the dialogue box, then
select the correct incident and click .

The CAD can import the following fields:

• Incident number incident
• Dispatch reason • Incident address
• Responding unit • Zone/box number
• Unit call sign • City, state, and county
• Level of care of the unit for the • Primary role of the unit at the end

W You must verify that all information input from the CAD is correct.

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Tab-by-tab
The following portion of this guide will walk you through each tab and its respective subcategories aiding you
in ensuring that the response you input is conveying the information you desire to report. Table entries in bold
denote required fields. Entries in italics denote the most common response(s) to a question if one exists.

DISPATCH

CAD Field
Response Format/
Explanations
Options
Dispatch assigned incident number,
Incident Number Free text
can be imported from CAD
Station Run Number Free text Same as incident number
911 Response Most common selection for any unit
(Scene) dispatched to a 911 call.
Utilized for a unit that met another
Intercept unit already in transit, generally to
upgrade level of care.
Interfacility
Not used by BCoFD.
Transport
Type of Call Medical Transport Not used by BCoFD.
Utilized if responding to a call in
Mutual Aid another county to provide mutual
aid.
Utilized if providing patient care as a
Standby
unit stationed at an event.
Public Assistance/ A general, “catch all” option. Rarely
Other Not Listed if ever utilized.
EMD Performed? No
Yes, UNKNOWN Only necessary if relevant. Most
if PAI Given common example would be if a
Yes, WITH PAI dispatcher provided instructions on
PAI=Pre-arrival Yes, WITHOU doing CPR to caller.
instructions PAI
EMD Card Number Free text Filled by CAD or leave blank.
EMD Level Free text Leave blank.
Triage Tag/Medical
Rarely used. Can be utilized to track
Record/Tracking Add dialogue
patients in an MCI.
Number
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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Response Field Response Format/Options Explanations

eMEDS PCR Number assigned to each
Autofilled
Number incident by eMEDS.
Unit designation
consistent with highest
Responding Unit Multi-select
level of care unit is
capable of providing.
Same as “Responding
Unit Call Sign Multi-select
Unit.”
Unit Type
Highest level of care unit
PFR=Physician Multi-select
is capable of providing.
field response
Unit Station or
Multi-select Not relevant for BCoFD.
Dispatch Location
BLS-EMT Select based on level of
Level of Care of Unit BLS-EMT-IV care your unit provided
for Incident [At ALS-CRT to the patient.
Patient Side] ALS-Paramedic
BLS-First Responder/EMR
 This may not be ALS-Community
the same as the Paramedicine
highest level of care ALS-Nurse Rarely/never used by
your unit is capable ALS-Physician BCoFD.
of providing. ALS-SCT
ALS-Neonate
Rarely/never utilized by
Report Format Multi-select.
BCoFD.
Unit responded non-
No Lights/Sirens emergency from dispatch
to arrival on scene.
Unit was dispatched and
began response as non-
No Lights/Sirens
emergency but switched
UPGRADED
to an emergency response
en route.
Response Mode to
Unit responded with
Scene
lights and sirens from
Lights/Sirens
dispatch to arrival on
scene.
Unit was dispatched
and began response as
Lights/Sirens
emergency but switched
DOWNGRADED
to a non-emergency
response en route.

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Crew Field
EMS Shift
Crew Member
Crew Member Level
Crew Member Response
Role
 Select all roles of the
provider on that call (i.e.
select “Primary Patient
Caregiver-At Scene”
AND “Primary Patient
Caregiver-Transport”).
 If preselecting roles
on homepage, select
all roles the provider
is eligible to serve on
the shift. If necessary,
change the role on
individual reports.
Incident Field
location
Location Type
Address, Address 2
Apartment, Suite, or
Room
Favorite Locations
Zone/Box Number
16
Response Format/
Explanations
Options
Select the shift that
Multi-select corresponds to this
incident.
Search based on
Multi-select provider’s name or
provider ID.
Corresponds to the level
Multi-select, auto-filled of care associated with
the provider in eMEDS.
Driver/Pilot-Response Driver during response
Driver/Pilot-Transport Driver during transport
Primary Patient Caregiver- Provider responsible for
At Scene patient care on scene.
Provider responsible
Primary Patient Caregiver-
for patient care during
Transport
transport.
Other Patient Caregiver-At Secondary provider on
Scene scene.
Other Patient Caregiver- Secondary provider
Transport during transport.
Field Training Officer/
—
Supervisor
Ride Along Observer
No other appropriate
Other
selection.
Response Format/
Explanations
Options
Most appropriate category of
Multi-select location where patient contact
was made.
Free text May be filled by CAD.
Free text If applicable.
Searchable drop-down that
allows you to search for an
Multi-select area. Selecting from this
menu will autofill ZIP Code,
City, State, and County.
May be filled by CAD,
Multi-select otherwise can leave blank if
unknown.
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
City, State, County Free text Filled based on ZIP Code.
Scene GPS Location
Can be utilized if patient is in
 If you use this feature, Location based a location that is difficult to
make sure to do so while still describe (i.e. on a hiking trail).
on scene.

CALL INFO

Disposition Field Response Format/Options Explanations

Unit transported patient to

Ambulance Transport
Non-Transport - Rescue
Primary Role of
Non-Transport - Supervisor
Unit at End of
Incident Non-Transport - Other
Reason
Fixed Wing Transport
Helicopter Transport
Non-Transport - Delivered
Personnel to Scene
hospital.
Unit only provided
equipment and manpower
for a rescue.
Supervisor unit responding
to scene.
Most commonly selected for
patient refusals.
Not applicable to BCoFD.
Unit delivered manpower
only to scene.

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Treatment & Treated, Transported by This
Transport Unit
Disposition
Patient Refused Care-
Accepted Transport by this
Unit
Treated, Transferred Care to
Other EMS Unit
Dead at Scene WITH
Interventions (Transport)
Dead at Scene WITHOUT
Interventions (Transport)
Transport of Non-Patient,
Organs, etc.
Treated, Transported by
Private Vehicle (Refusal
Form Required)
Treated and Released Per
Protocol W
Patient Assessed/Treated-
Refused Transport
No Treatment Required
Dead at Scene WITH EMS utilized TOR
Interventions (No Transport) protocol—provided some
interventions prior to calling
for a priority 4.
18
Unit provided EMS care and
transport; details of transport
included in this PCR if
multiple units were on scene.
Patient only wished to
be transported; allowed
minimal to no care from
EMS personnel.
One unit began patient care
but care was transferred to
a different unit (i.e. BLS to
ALS).
EMS attempted resuscitation
prior to POD then
transported corpse from
scene.
Patient not able to be
resuscitated; EMS only
transported corpse from
scene.
Not used by BCoFD.
Patient accepted EMS
assessment/intervention, but
decided to go to hospital via
their own means.
EMS contacted medical
control to advise on a
patient requesting refusal
after EMS provided
significant interventions (i.e.
medications).
Patient accepted EMS
assessment and interventions
but refused transport.
Patient required no medical
care.
BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Dead at Scene WITHOUT EMS utilized POD protocol
Interventions (No determining that patient
Transport) was not a candidate for
resuscitation.
Standby-Treated and Unit on a standby detail,
Released provided intervention and
released patient (i.e. bandage
small wound).
Standby Only-No Patient Unit on a standby detail in
Contacts which there were no patients.
Operational Support Unit responsible for
Provided-No Patient providing manpower only
Contact (i.e. directing traffic around
MVC).
Operational Support Unit provided manpower
Provided-Patient Contact and made contact with
patient, but was not
responsible for patient
transport.
Patient Refused Assessment/ Patient refused all EMS care.
Treatment-Not Transported
Patient Treated, Transported EMS made patient contact
by Law Enforcement but patient was taken by
PD (common for psych
patients).
Assist, Agency

Assist, Public

Cancelled On Arrival-No Unit cancelled on arrival by

Patient Found other unit/PD that advised
no patient present/no need
for EMS.
Cancelled On Arrival-By Unit already on scene
Other Unit cancelled your unit once
calling arrived (i.e. determine
patient only needed a BLS
unit).
Cancelled en Route Unit cancelled after calling
en route but prior to calling
arrived.
Cancelled Prior to Response Unit cancelled before calling
out of station, en route.

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Were you the first EMS unit Yes/No Include engine?
on scene?
Number of Patients on Scene Single, Multiple, Select “None” if no patient
None  was found.

This option is intended for situations in which you provided a significant

W treatment (i.e. medication), and you contacted medical control prior to
allowing the patient to refuse transport. This is different from a simple
refusal where no major interventions were provided and medical control
was not contacted.
If you select multiple patients, and you cared for mutliple patietns on the

 scene, you can add patients to an incident by going to Patient Patient

Info and clicking on “Add Additional Patient” at the top of the page.

Conditions Field Response Format/Options Explanations

Medical Patient Primary NOI is medical.
Trauma Patient Primary NOI is trauma.
Type of call for Patient presentation consis-
patient contact? BOTH Medical & Trauma tent with both medical and
Patient traumatic NOIs (i.e. MVC
secondary to hypoglycemia).
ALS assessment reveals
Yes patient inclusion in STEMI
criteria.
ALS assessment reveals pa-
Meets STEMI Cri-
No tient does not meet criterion
teria?
for a STEMI alert.
No index of suspicion for
Not Applicable STEMI and/or patient only
received BLS care.
EMS was called for a cardi-
ac arrest/ EMS was advised
Yes, PRIOR TO EMS Arrival
while en route that patient
was in cardiac arrest.
Cardiac Arrest? Patient was no in cardiac ar-
rest when EMS first arrived,
Yes, AFTER EMS Arrival
but arrested later on while
under EMS care.
No No cardiac arrest occured.

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Patient with a positive Cin-
Yes
cinnati Stroke Scale.
Meets Stroke Alert? Cincinnative Stroke Scale is
No negative/no reason to suspect
a stroke.
Patient meets MIEMSS crite-
Yes
ria for SEPSIS alert. 
Meets SEPSIS Patient does not meet
Alert? No MIEMSS criteria for SEPSIS
alert.
Not Applicable No reason to suspect SEPSIS.


SEPSIS criteria, MIEMSS 2018:
For an adult patient, 18 years of age and older, to qualify for this protocol,
they
must have a suspected source of infection AND also present with at least
two of the following criteria:
(1) Temp greater than 100.4ºF (38ºC) or less than 95.9ºF (35.5ºC)
(2) HR greater than 100 bpm
(3) RR greater than 25 (or EtCO2 less than or equal to 32 mmHg)
(4) Hypotension (systolic BP less than 90 mmHg)
(5) Point of care lactate reading greater than or equal to 4 mmol/L (if
available)
➢➢ Patients with hypotension or altered mental status should be consid-
ered to have septic shock and treated and transported rapidly. Patients
may be treated under this protocol if they do not meet the above crite-
ria with medical consultation.

Call While none of the fields in this subcategory are required, it is imperative that you
complete the section if there were any delays during the course of a call. Options
Delays that are most likely to be seleted from each field’s dropdown are listed below:

Field Common Selections

During Dis-
None/No Delay
patch of Call
None/No Delay; Crowd; Directions/Unable to Locate; HazMat;
During
Scene Safety (Not Secure for EMS); Traffic; Vehicle Crash Involv-
Response
ing this Unit; Vehicle Failure of this Unit; Weather
None/No Delay; Crowd; Directions/Unable to Locate; Extrica-
On Scene
tion; HazMat; Patient Access; Safety-Crew/Staging; Weather
During
None/No Delay; Patient Condition Change (e.g., Unit Stopped)
Transport
Returning to None/No Delay; Decontamination; ED Overcrowding/Transfer of
Service Care
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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Other This section only allows you to specify other agencies on a scene—it does not
allow you to specify specific units. Including agencies other than the BCoFD that
Agencies responded to the call will allow for better data collection, and thus is encouraged. It
On Scene does not, however, take the place of specifying particular units that were present in

Field Response Format/ Explanations

Options
Can only select one; must
Other EMS or Public Safety
Multi-select create separate entry for each
Agencies at Scene
agency.
Other EMS or Public Safety Autofull based on response to
Autofill
Agency ID Number previous question.
Make a selection based on the
primary service this agen-
cy provided on the incident
Type of Other Service at being reported (i.e. if anoth-
Multi-select
Scene er county’s fire department
provides mutual aid for EMS
services, select “EMS Mutual
Aid” instead of “Fire.”

Transfer To/ Field

From
Transferred to Agency ID
Transferred to Call Number
Received From Agency ID
Received From Call Number Free type
Response Format/
Explanations
Options
Multi-select Searchable list.
Incident/PCR number of
Free type
receiving agency.
Multi-select Searchable list.
Incident/PCR number of
transferring agency.

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

PATIENT


You can search for repeat patients by clicking the “Find a Repeat Patient”
button under the “Patient Info” subcategory. The program requires only
one field in the query to be filled (i.e. you can search just by DOB or last
name). Alternatively, while working on a report, if the program detects
matches with a patient already in the system, a notification will pop up
at the top of the page. In either case, selecting the patient will input all
information the system has on him/her including contact information,
medical history, medications, allergies, etc. W

W You must ensure that all patient information is up-to-date including medical
history, medications, and allergies.

Patient Info Field Response Format/ Explanations

Options
First Name Free type
If unable to obtain patient’s
name, type “unknown” and
Middle Initial/Name Free type
document circumstances in
narrative.
Last Name Free type

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Generation I, II, III, IV, Jr, Sr --

Male, Female, Un-
Gender known (Unable to --
Determine)
Race Multi-select Ask patient if unsure.
Date of Birth Free type --
Age Free type
Autofill based on DOB
Age Units Free type
Kilograms will autofill based
Patient Weight Free type
on pounds.
If unknown, type “999-99-
Social Security Number Free type 9999” and document cir-
cumstances in narrative.
Patient’s Home Address If you’re copying from an ID
Can select same as or using information already
Street Address 2
incident address. in the system, ensure it’s up-
Apartment, Suite, or Room to-date.
Can be used to set city,
ZIP Code ➊ Free type
county, and state.
City
County ➊ Free type/autofill Can be set from ZIP code.
State ➊

Country ➊ Preset United States only.

Phone Numbers Free type --

Driver’s License Number Free type --
Driver’s License State Free type --
W If illness/injury is work
Work-Related Illness/Injury No; Yes; Unknown related, must select “Yes”
here.

➊ If patient does not reside in the U.S., input their international address. For Zip
Code, County, and State, select “Not Applicable” by clicking on the . For the Coun-
try field, ensure United States is unselected (it will be white instead of blue).

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Chief Field Response Format/ Explanations

Options
Complaint
Must select appropriate
Bystander/Other;
Medical History Obtained response if medical history
Family; Healthcare
From primarily obtained from
Personnel; Patient
someone other than patient.
Date/Time of Onset Free type --
Chief Complaint(s) “+ Add”
Chief
Type Secondary
Other
Patient’s explanation of the
Complaint ➊ Free type
problem.
Duration Free type --
Time Units of Duration Multi-select --
Anatomic Location of
Multi-select --
Chief Complaint
Chief complaint may be
due to multiple organ sys-
Organ System of Chief
Multi-select tems--select one that is most
Complaint
relevant or most likely to be
the culprit.
Sign/symptom associated di-
Primary Symptom ➊ Multi-select rectly with the patient’s chief
complaint.
Signs/symptoms resulting
Other Symptoms ➊ Multi-select
from chief complaint.
Only select if relevant to
Alcohol/Drug Use Multi-select
patient care.
Patient Activity During
Multi-select The “E” in SAMPLE.
Illness/Injury

Barriers to Patient Care ➋ Multi-select Select any/all that apply.

➊ For example, the chief complaint may be a migraine, the primary symptom a
headache, and another symtom is nausea.

➋ Providing accurate responses to this question allows data to be tracked that can
ultimately help better train providers for scenarios they may encounter. It can also
provide insight as to new equipment that may help providers in the field.

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Assessment eMEDS Elite offers two ways to document an assessment. The first is through the
“Assessment” subcategory under the “Patient” tab. The second way is using the
assessment power tool (for more information on the power tool, go to the “Power
Tools” section of this guide [P. X]). In either case, you must complete the top portion
of the “Assessment” subcategory:
Field Response Format/Options Explanations
Initial Priority Priority 1 Critical
Priority 2 Potentially life threatening
Priority 3 Non-emergent
Priority 4 Medical attention not re-
quired
Dead without Resuscitation Patient was dead on arrival,
Efforts and EMS did not attempt
resuscitation.
Provider’s Primary Multi-select Provider’s assessment of the
Impression patient’s primary presenting
problem.
Provider’s Second- Multi-select Provider’s assessment of any
ary Impression secondary issues if present.


The assessment sub-category pop-up window only requires that the
provider enter the date/time of the assessment. The provider may
then simply fill in responses for the areas assessed. Providers should
enter all pertinent findings from their assessment by selecting multiple
responses from drop downs if necessary. All areas of the assessment
specified by eMEDS allow providers to add additional notes; however,
providers should strive to enter as much information as possible using
the drop downs.

Past Medical Field Response Format/Options Explanations

History Current Medications Multi-select Select all that apply.
Medication Allergies Multi-select Select all that apply.
Environmental/Food Aller- Multi-select Select all that apply.
gies
Medical/Surgical History Multi-select Select all that apply.
Other Medical History Free type --
Advance Directive Multi-select Select all that apply.

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Injury/Trau- Field
ma Cause of Injury
 There is a distinction
made between accident, as-
sault, self-harm, and unde-
termined. Make sure you
select the proper entry based
on your findings.
Use of Occupant Safety
Equipment
 This must be filled out
any time the report involves
an MVC.
27
Response Format/ Explanations
Options
Multi-select (Common options listed below)
Traffic Related, Collision in which the pa-
Bicycle tient was on a bike.
Fall from Seating/ Fall from ground level.
Standing
Accident, Fall from Any fall in which the patient
Height was not on the ground when
he/she fell,
Accident, Sharp The patient unintentionally
Object cut him/herself (i.e. while
slicing vegetables).
Assault, Sharp Patient was attacked and
Object wounds were inflicted via
knife or other sharp object.
Fight/Brawl, Un- Assault in which no weapons
armed (including were involved (i.e. fist fight).
Bite)
Machinery, Contact Traumatic injuries caused by
with heavy machinery.
Multi-select (Common options listed below)
Child Booster Seat
Infant Car Seat
Rear Facing
Shoulder and Lap Traditional seatbelt that goes
Belt Used across the chest and waist.
Protective Clothing Generally worny by motor-
cyclists.
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

OSHA Personal Eye and Face Any type of face mask, gog-
Protective Equip- gles, etc.
ment Used Foot Steel toed boots or other
 This section type of foot protection.
must be completed Head Helmets
in situations involv-
Hearing Noise muffling earphones.
ing workplace inju-
ries. Respiratory Any type of mask or respi-
rator.
Safety Belts, lifelines, and Ropes or other types of
lanyards equipment used to stop
someone from falling.
Safety Nets Large nets designed to catch
someone in case of a fall.
Mechanism of Blunt Traumatic injury resulting
Injury Falls, even with some from a non-penetrating
bleeding, should be consid- injury (generally no external
ered “Blunt” trauma. bleeding, but not always).
Burn Burns resulting from chem-
icals, fire, or other heat
source.
Penetrating Trauma resulting directly
from something that punc-
tured the skin.
Other --
Trauma Crite- Multi-select Must click the icon
ria-Cat. A or B W next to the non-applicable
Trauma Crite- Multi-select field and select “Not Appli-
ria-Cat. C or D W cable.”
Trauma Referral Yes/No --
Center Notified
Which Trauma Free text --
Center was notified?
Main Area of the Free text Area of the vehicle with the
Vehicle Impacted by most intrusion/significant
the Collision damage.
 This must be
filled out any time
the report involves
an MVC.

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 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Driver and/or passenger

FRONT-Airbag Deployed
airbag deployment.
Airbag Deployment Airbag deployment from any
 This must be SIDE-Airbag Deployed
vehicular pillar.
filled out any time
Airbag not included in one
the report involves
OTHER-Airbag Deployed of the above categories (i.e.
an MVC.
knee airbag).
 Select all that
apply. None Deployed No airbag deployment.
Vehicle is not equipped with
None Present
airbags.
Feet from ground or if stand-
Height of Fall (feet) Free type
ing, height of patient.

Remember that just because the patient may have some sort of traumatic
W injury does not mean they will actually be classified as a trauma and receive
a trauma category designation. Assigning a trauma category implies that
you will be calling a trauma alert; if you do select a category, your destina-
tion hospital should reflect this as should your reasoning for choosing that
hospital.

STEMI/ACS Field
Response Format/Op-
Explanations
tions
If no, explain reasoning in
12 Lead Used Yes/No
narrative.
12 Lead Interpreted By Multi-select Select all that apply.

12 Lead Transmitted Yes/No --

Inconclusive Unable to determine.
Improbable/does not meet
No MIEMSS criteria for STEMI
STEMI Probable
alert.
Meets MIEMSS criteria for a
Yes
STEMI alert.

29
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Stroke Field
Response Format/
Explanations
Options
Date/Time Last Known Free type As reported by person
Well W other than patient.
Previous Stroke or Head No/Unknown/Yes --
Trauma

W New 2018 MIEMSS protocols require that providers document a phone

number for at least one individual with information about stroke patient’s
health history for physician use. This should be done utilizing the “Guard-
ian or Closest Relative” subcategory directly below the “Stroke” category.

Guardian or This section should be utilized to document contact information for anyone that
may be able to provide further information concerning the patient’s medical history.
Closest As much information as possible should be filled in. Should you select either
Relative “Other (Relative)” or “Other (Non-Relative),” use the field directly below to type the
patient’s relationship to the person.

PROVIDER In a study of 4,744 trauma patients, “Among those patients who died [290 deaths],
110 (37.9%) were missing respiratory rate values, 104 (35.9%) were missing
ACTIONS systolic blood pressure values, and 87 (30%) were missing heart rate values.”1

1
Laudermilch, D. J., Schiff, M. A., Nathens, A. B., & Rosengart, M. R. (2010). Lack of Emergency Medical Services
Documentation Is Associated with Poor Patient Outcomes: A Validation of Audit Filters for Prehospital Trau-
ma Care. Journal of the American College of Surgeons, 210(2), 220-227. doi:10.1016/j.jamcollsurg.2009.10.008

30
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Vitals Field Response Format/Op- Explanations

Prior to Arrival
Selecting “No” incorrectly
may result in eMEDS giving
an error once call times
have been input since it will
be out of order.
Date/Time
Patient Position
tions
No These vitalss were obtained
by you or someone else on
scene in your presence.
Yes A unit that arrived prior to
you obtained this set of vitals
prior to your arrival.
Free type Ensure this is accurate; if
inconsistent with call times
in eMEDS, you will receive a
validation error.
Fowlers

Left Lateral Recumbent

Right Lateral Recum-

bent

Prone

Semi-Fowlers

2
Laudermilch, D. J., Schiff, M. A., Nathens, A. B., & Rosengart, M. R. (2010). Lack of Emergency
Medical Services Documentation Is Associated with Poor Patient Outcomes: A Validation of Audit
Filters for Prehospital Trauma Care. Journal of the American College of Surgeons, 210(2), 220-227.
doi:10.1016/j.jamcollsurg.2009.10.008
31
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Shock

Sitting

Standing

Supine

Trendelenburg

Provider Taking Multi-select Provider predominantly tak-

Vitals ing this set of vitals.
Responsiveness Alert Patient reacts appropriately to
your presence.
Verbal Patient responds when spo-
ken to.
Painful Patient only responds to rig-
orous physical stimuli.
Unresponsive Patient is unresponsive.
Respiratory Rate Free Type --

Airway Patent No threats to airway/airway

 Patients that secured.
have been sucessfully Compromised Potential for or presence of
intubated should
partial or total blockage of
have their airway
airway.
status marked as
“Patent.” Oral Oropharyngeal airway.

Tracheotomy Patient has a trach tube.

Other Nasopharyngeal airway.

32
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Breathing Normal Normal rate and depth.
Apneic Patient not breathing.
Labored Visible respiratory distress
(tripoding, accessory muscle
usage, etc.).
Mechanically Assisted Breathing is being done or
(BVM, CPAP, etc.) supplemented by a provider
intervention.
Rapid Patient breathing noticeably
quickly/respiratory rate is
well above normal limits.
Shallow Patient inhales for a short
period of time with little to
no chest rise.
Weak/Agonal Patient breathing insuffi-
ciently with no detectable
rhythm. May present as
random gasps.
ETCO2 Free type --
Pulse Free type --
Pulse Quality Normal Normal strength.
Weak Radial or carotid pulse
is particularly difficult to
palpate (often due to low
BP)--further documentation
needed in narrative.
Rapid Pulse rate is noticeably fast.
Bounding Pulse is noticeably strong.
Absent Patient has no pulse.
Pulse Rhythm Regular Pulse has a normal, constant
rhythm.
Regularly Irregular Pulse experiences the same
abnormality at constant
intervals.
Irregularly Irregular Pulse has random abnor-
malities with no detectable
pattern of when they occur.
SBP (Systolic Blood Free type --
Pressure)
DBP (Diastolic Free type If BP is palpated, click on
Blood Pressure) the and select “Unable to
Complete.” Then select “Pal-
pated Cuff ” as the method of
BP measurement.
33
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
BP Location Multi-select --
Method of Blood Manual Cuff BP obtained with a cuff and
Pressure Measure- stethoscope.
ment Automated Cuff BP obtained using a Lifepak.
Palpated Cuff BP obtained via palpation
with a normal cuff (see note
for diastolic BP).
Arterial Line Invasive BP method.
Doppler BP obtained using a BP cuff
and a doppler for ausculta-
tion instead of a stethoscope.
Venous Line Invasive BP method.
ECG Type Multi-select Make sure that the type re-
sponds to this interpretation
even if the type was later
changed.
Cardiac Rhythm Multi-select --
Cardiac Free type --
Rhythm-Other
Method of ECG Computer Interpretation Interpretation provided by
Interpretation monitor (not preferred).
 Select the method Manual Interpretation Provider interpreted ECG.
that corresponds to
Transmission with No Inter- ECG was transmitted to a
the interpretation
being documented. pretation hospital but no interpreta-
tion from receiving hospital
was given.
Transmission with Remote ECG transmitted to hospital
Interpretation and interpreted by hospital
personell.
Pulse Oximetry Free type --
Pulse Oximetry Multi-select If patient is normally on
Qualifier home O2, ensure that is
reflected here.
Carbon Monoxide Free type --
(CO)
GCS-Eye; GCS-Ver- Multi-select --
bal; GCS-Motor 
GCS-Qualifier Multi-select Selection should reflect cur-
rent status of the patient.
GCS-Score Free type/Autofill Autofilled if each individual
category is selected above.

34
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Axillary Probe placed under patient’s
armpit.
Temperature Method Oral Probe placed under tongue.
Rectal Probe placed in patient’s
(Only relevant options listed anus.
and explained) Temporal Artery Probe placed on patient’s
forehead.
Tympanic Probe placed in patient’s ear.
Pain Scale Score Free type --
Patient asked to rate pain on
Numeric (0-10)
a scale from 0-10.
Patient asked to point to
Pain Scale Type
a face that represents how
Faces
they feel (used with pedat-
rics)
APGAR Score Free type 0-10
Region of body correspond-
PQRST Region Multi-select ing to your OPQRST assess-
ment.
PQRST: Narrative (use?) Free type --
Area to which pain radiates
PQRST Radiation Multi-select (select “Non-radiating” if
pain is localized).
Activities/states that make
the problem worse (select
PQRST: Provoked Multi-select
“Unprovoked” if nothing
makes the problem worse).
PQRST: Quality Free type --

Blood Glucose Level Free type --

If glucometer reads Hi/
Blood Glucose Other Hi/Low Low instead of displaying a
number.
Stroke Scale Type Cincinnati/Lams --
Stroke Scale Facial Droop;
Stroke Scale Speech; Stroke
Fields correspond to the
Scale Arm Drift; Stroke Scale Multi-select
scale type selected above.
Grip Strength; Stroke Scale
Score

35
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Stroke Scale Score Value Free type For LAMS only.
Vital Comments Free type --
Photo/upload of graph of
Vitals Waveforms Upload
specific vital sign over time.


If patient is GCS 15, you can enter 15 in the “GCS’Score” field rather than
selecting each category individually; however, if the patient is not GCS 15,
you must select each category individually.

Procedure Field
Response Format/
Explanations
Options
Prior to Arrival? You or another provider
 Selecting “No” incorrectly No completed this procedure in
may result in eMEDS giving an your presence.
error once call times have been A unit that arrive prior to
input since it may be out of Yes you completed this proce-
order. dure.
Certification level of provid-
Role/Type of Person Per-
Multi-select er that completed the inter-
forming the Procedure
vention.
Time when intervention was
Date/Time Multi-select
implemented.
Specific provider that com-
Performed By Multi-select
pleted the intervention.
Procedure Name Multi-select Intervention provided.
Signs or symptoms (i.e.
vitals, pain score, etc.) have
Improved
improved after the proce-
dure.
There was no change in signs
Patient’s Response or symptoms (i.e. vitals, pain
Unchanged
score, etc.) after the proce-
dure.
Signs/symptoms (i.e. vitals,
Worse pain score, etc.) deteriorated
after the procedure.
Only select “Yes” if your final
attempt was successful, and
Success No/Yes
you have evidence to support
its success.
Region of the body where the
Location Multi-select
procedure was performed.
36
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Size/Type of Equipment
Attempts
Comments/Reason for Pro-
cedure
Authorization
 Particularly important
to fill out this section if the
procedure is not a standing
order.
Authorizing Physician
Complication
Tube Secured With
Waveform Capnography
Medication Field
Prior to Arrival?
 Selecting “No” incorrectly
may result in eMEDS giving an
error once call times have been
input since it may be out of
order.
Role/Type of Person Per-
forming the Procedure
Date/Time
Crew Giving Medication
Free type --
Total number of attempts
Free type made including the success-
ful one if successful.
Clinical indications for pro-
Free type
cedure.
On-Line (Remote Physician consult through
Verbal Order) EMRC.
On-Scene ???
Protocol (Standing Standard protocol per cur-
Order) rent MIEMSS protocols.
Instructions from the pa-
Written Orders (Pa- tient’s healthcare provider on
tient Specific) special care specific to that
patient.
If you received orders via
Free Type consult, you must document
the physician’s name.
Any issues that arose during
Multi-select
the procedure.
Either “Commercial Tube
Multi-select
Securing Device” or “Tape.”
Multi-select Observed waveform.
Response Format/
Explanations
Options
This medication was admin-
No istered by you or another
provider in your presence.
Another responder admin-
Yes istered this medication prior
to your arrival.
Certification level of re-
Multi-select sponder that administered
the medication.
Time when the medication
Multi-select administration was com-
plete.
Provider that directly ad-
Multi-select
ministered the medication.
37
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Must add separate entry for

each medication; cannot
Medication Name Multi-select
select multiple medications
at once.
Dosage Free type --

Units Multi-select --
Route

Signs or symptoms (i.e.

vitals, pain score, etc.) have
Improved
improved after receiving the
medication.
There was no change in signs
or symptoms (i.e. vitals, pain
Response Unchanged
score, etc.) after receiving the
medication.
Signs/symptoms (i.e. vitals,
pain score, etc.) deteriorated
Worse
after receiving the medica-
tion.
Comments Free type --

38
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
On-Line (Remote Verbal Physician consult through
Order) EMRC.
Authorization On-Scene ???
 Particularly
Standard protocol per cur-
important to fill out Protocol (Standing Order)
this section if the rent MIEMSS protocols.
procedure is not a Instructions from the pa-
standing order. Written Orders (Patient tient’s healthcare provider on
Specific) special care specific to that
patient.
If you received online orders
Authorizing Physi- from medical control, you
Free type
cian must document the physi-
cian’s name.
Any issues that arose during
Complication(s) Multi-select the administration of the
medication.

TOR/POD Field Response Format/Options Explanations

Crew who Select primary provider of
Multi-select
Pronounced Death crew responsible for POD.
Time when resuscitation
was stopped or when it was
Pronouncement of determined that the patient
Date/Time field
Death Date/Time met the Pronouncement of
Death in the Field criteria as
per MIEMSS protocols.
If resuscitation attempt was
made, select all that applied
Criteria for Termi- when resuscitation was ter-
nation of Resuscita- Multi-select minated to explain criteria
tion (TOR) met for TOR.
If resuscitation was not at-
tempted, select leave blank.
If resuscitation was attempt-
ed, select “Termination of
Criteria for Pro- Resuscitation Protocol.” If
nouncement of Multi-select resucitation was not attempt-
Death (POD) ed, select criteria that patient
met to be included in POD
protocol.
Police Officer’s
Free type --
Name

39
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Police Officer Badge Number Free type --
Police Report Number Free type --
If patient was moved at all
Was Patient moved from during resuscitation at-
Yes/No
original position? tempts/to pronounce death,
select “Yes.”
If Patient was moved, De-
scribe location where Patient
was found, appearance of Provide as much detail as
Free type
Patient (highlighting any- possible in this section.
thing unusual) and position
of Patient
Unknown or body was left
No in posession of police or the
Confirmed release by police/
medical examiner.
medical examiner of the
Police/medical examiner
body to the family
Yes released body to patient’s
family.
If Released to Family, Name
Free type --
of Family or Bystander
Was Living Legacy (410-
242-3822) or Washington
Regional Transplant Com- Multi-select --
munity (703-641-0100)
contacted?

Airway (ALS) Field Response Format/ Options Explanations

Adequate Airway Reflexes/
Effort, Potential for Compro-
mise
Airway Reflex Compromised their own airway with natu-
Indications for Apnea or Agonal Respira-
Invasive Airway tions
Illness Involving Airway
Injury Involving Airway
Other
Ventilatory Effort Compro- Patient unable to breathe on
mised
Patient able to control own
airway and breath unassist-
ed, but there is an imminent
threat to the airway.
Patient unable to protect
ral body responses.
No breathing or ineffective
breathing.
Patient’s airway is compro-
mised due to illness.
An injury has compromised
a patient’s airway.
--
their own.

40
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
Airway Confirmation Pop-up dialogue box See below. ➊
Airway Complications En-
Multi-select Select all that apply.
countered
Suspected Reasons for
Multi-select Select all that apply.
Failed Airway Management
Date/Time Invasive Airway
Time when last intubation
Placement Attempts Aban- Date/time
attempt was avandoned.
doned
➊ Airway Confirmation Pop-up Dialogue Box
Field Response Format/ Explanations
Options
Select device used in success-
Device Being Confirmed Multi-select
ful attempt.
Date/Time Airway Device Time when airway placement
Date/Time
Confirmation was confirmed.
Preoxygenation Done Yes/No --
Provider Tube Placement Select all methods provider
Multi-select
Verification used to verify success.
Tube Depth Free type --
Chest Rise-Left; Chest Is chest rise observed upon
Yes/No
Rise-Right ventilation of patient?
Can air be heard in the abdo-
Abdominal Sounds Yes/No
men during ventilation?
Grade corresponding to air-
Airway Grade Multi-select
way prior to intubation.
Complication Encoun-
Free type --
tered-Other
Type of Individual Con- Classification of person verify-
Multi-select
firming Device Placement ing successful intubation.
Name of MD/Provider
Free type --
Confirming
No X-Ray available to confirm
Chest X-Ray Not
tube placement after transfer
Available
to hospital bed.
X-Ray confirmed tube place-
Chest X-Ray
ment after patient was moved
Verified
to hospital bed.
Verify Tube Placement Displaced-Tube Re- Tube displaced during transfer
moved and was removed.
NA-Patient Not Patient not moved once intu-
Moved bated.
Visualized Tube Tube placement confirmed
passed through Vocal visually after patient transfer
Cords. to hospital bed.
41
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Downloaded A pop-up dialogue that will prefill all information once it has been uploaded from
the monitor.
EKG

TRANSPORT


This section is only required when you transport a patient. If you did
not transport a patient, but it is still in red, go back to Call Info Dis-
position and verify that your responses are correct.

Destination Field Response Format/Options Explanations

Info The question refers to how
patient was primarily moved
from the position in which
How Patient was they were initially found to
Moved to the Ambu- Multi-select ambulance (i.e. if patient
lance was placed on a Reeves then
moved the the stretcher
waiting outside of the mabu-
lance, select “Reeves.”
Hospital to which patient
Destination Name W Multi-select
was transported.
Patient was transported to
Hospital-ER Dept any hospital (including spe-
cialty centers).
Type of Destination Your crew transported the
 Only options
Other EMS Responder patient and then handed
utilized by BCoFD are
listed. (ground) care off to another EMS unit
(generally BLS to ALS).
Other EMS Responder Your crew transported the
(Air)-Landing Zone patient to the LZ.

42
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Hospital Capability If patient was transproted to

with Patient Condi- a hospital for a designated
Multi-select
tion ➊ specialty, select that special-
ty here.
Reason for Choosing Either patient had no pref-
Destination ➊ Closest Facility erence or patient required
care at the nearest ER.
A closer hospital was on a
Diversion
color.
Medical control gave ex-
On-Line/On-Scene Medical plicit orders for patient to
Direction be transported to a specific
hospital.
Patient met criteria to be
Protocol-When NOT closest transported to a designated
Hospital/Specialty Center hospital in accordance with
MIEMSS protocols.
Patient required care that
State Specialty Center could only be provided by a
state specialty center.
Patient requested transport
Patient’s Choice to a specific hospital, and
EMS felt it was appropriate.
Patient’s physician request-
ed transport to a specific
Patient’s Physician’s Choice
hospital, and EMS felt it was
appropriate.
Patient’s family request-
ed transport to a specific
Family Choice
hospital, and EMS felt it was
appropriate.
Law enforcement requested
to have patient transported
Law Enforcement Choice
to a specific hospital, and
EMS felt it was appropriate.
Patient’s insurance only
Insurance Status/Require-
permits them to be seen at
ment
certain hospitals. ➋
Other --
Hospital Team Activation/Alerts
Date/Time of Alert Time when hospital was
Date/Time
Activation consulted to adivse of alert.
Pre-Arrival Alert or
Multi-select Type of alert called.
Activation
43
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

W Ensure hospital selection is correct. Incorrect selection will result in

hospital to which the patient was transproted not receiving the report.
➊ Hospital capability and reason for choosing hospital must be consistent with
one-another (i.e. if patient is transported to Union Memorial for a hand injury,
select "State Specialty Center" and not "Protocol"). If patient requires a specialty ser-
vice and the appropriate hospital happens to also be the closest, select "State Special-
ty Center" and not "Closest Hospital."

➋ Insurance requirements never take precedence over what is best for a patient’s
health.

Transport Field Response Format/Options Explanations

Mode Type of Transport Almost exclusively
Multi-select
Vehicle “Ground-Ambulance.”
Entire transport done
No Lights/Sirens
non-emergency.
Began transport non-emer-
No Lights/Sirens UPGRAD-
gency, but changed to emer-
ED
Transport Mode gency en route to hospital.
From Scene Entire transport done emer-
Lights/Sirens
gency.
Began transport emer-
Lights/Sirens DOWN-
gency, but downgraded to
GRADED
non-emergency en route.
Triage Tag/Medical
Record/Tracking Pop-up Dialogue Not used by BCoFD.
Number
Patient transported either
in their own carseat or in a
Car Seat
child safety device carried by
the unit.

Position of Patient Fowlers

During Transport

Lateral Left

44
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

Lateral Right

Prone
W Patients should never
be transported face down.

Semi-Fowlers

Patient seated in captain’s chair

Sitting
or other seat.

Supine

Trendelenburg

Other --

Patient Field Response Format/Options Explanations

Condition Priority 1 Critical
Priority 2 Potentially life threatening
Priority 3 Non-emergent
Final Patient Medical attention not re-
Priority Priority 4
quired
Patient DOA, and EMS did
Dead without Resuscitation
not make any resucitation
Effors
attempts.
Select all belongings trans-
ported with the patient and
Patient Belongings Multi-select then specify where belong-
ings were left one patient
care was transferred.
45
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

NARRATIVE

For a detailed guide to writing the narrative portion of the PCR, see “Narrative
Writing” on page XX.

Narrative
Response
Field Explanations
Format/Options
Crew member writing the
narrative. This is particularly
Crew Member Completing
Multi-select important if the narrative author
this Report
is someone other than the user
that is logged in.
See narrative guidelines on page
Narrative Free type
46.
What TYPE of documentation
Multi-select —
was left at the facility?

Unless the patient is

unconscious/unresponsive, you
Is this patient a resident of
Multi-select must answer this question with
Baltimore County, MD?
Yes/No. This information is
required for billing.

Which EMS District Officer is

Multi-select —
your unit assigned to?

EMS supervisor provided ALS

Was your unit upgraded
from BLS to ALS by an EMS
District Officer?
Yes
care to a BLS unit’s patient.
ALS provider other than EMS
No supervisor provided ALS care
to a BLS unit’s patient.
Not Applicable Patient only received BLS care.

46
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services
ALS provider other than a
Yes supervisor provided ALS
Was your unit upgraded care to a BLS unit’s patient.
from BLS to ALS by a unit EMS supervisor provided
other than an EMS District No ALS care to a BLS unit’s
Officer? patient.
Patient only received BLS
Not Applicable
care.

Exceptional If this call presented abnormal conditions in the care of a patient

Call -OR-
If you were required to act outside of your normal scope of practice
-OR-
Something was done that did not comply with MIEMSS protocols
-OR-
You believe that report should be reviewed further
Select “Yes” to this question.

Crew This section should be utilized any time a crew member has an accidental exposure
or is injured in the course of doing his/her job. This section should be filled out as
Exposures/ completely as possible and with as much detail as possible.
Injury

SIGNATURES

The layout of the signatures dialogue in eMEDS Elite is significantly changed from
the previous version of eMEDS. Use this table to guide you in ensuring you obtain
all of teh required signatures from the necesarry persons.

 You should click all applicated signature reasons in the designated field for
which the signer is signing such that only one signature from each party

47
 Signatures Required
Patient Hospital
Patient EMS Provider
Call Type Representative W Representative W
1. HIPAA acknowl-
Regular Transport to edgement/Release
-- Report Author Transfer of Patient Care
ER 2. Authorization/Re-
lease for Billing
PARENT/GUARDIAN:
1. Report Author
Regular 1. HIPAA acknowledge-

Transport to ER, ment/Release Transfer of Patient Care
2. Patient/Medical Ne-
BALTIMORE COUNTY FIRE DEPARTMENT

PEDIATRIC 2. Authorization/Re-
cessity Unable to Sign.
lease for Billing
1. HIPAA acknowled- 1. Report Author
Emergency Medical Services

Transport to ER, Pa- ment/Release 

-- Transfer of Patient Care
tient unable to sign 2. Patient/Medical Ne- 2. Patient/Medical Ne-
cessity Unable to Sign. cessity Unable to Sign.
Patient Refusal Refusal of Services -- Report Author --

48
Patient Refusal, PARENT/GUARDIAN:
-- Report Author --
PEDIATRIC Refusal of Services
PHYSICIAN:
If possible:
1. Report Author Airway Verification
1. HIPAA acknowledge-
Patient 
-- ment/Release
Intubation 2. Patient/Medical Ne-
2. Patient/Medical Ne- Physician/RN:
cessity Unable to Sign.
cessity Unable to Sign. Transfer of Patient Care

Patient Representative: Anytime an authorized representative signs in place of Providers only need to
W the patient, the provider must obtain their full name and specify their relation-
ship to the patient using the corresponding drop down menu.
sign for “Patient/Medical
Necessity Unable to Sign”
when there is no eligible,
Hospital Representative: Since providers must transfer patient care to someone authorized represen-
of their level of care or higher, the hospital representative must be a nurse or phy- tative/parent guardian
sician. present to sign.
 BALTIMORE COUNTY FIRE DEPARTMENT
Emergency Medical Services

BILLING Not utilized by BCoFD.

OPIOID
CRISIS
#

OOCC This section should be filled out anytime Narcan is administered and/or there is rea-
son to suspect a narcotic overdose. Accurate responses are critical to ensure ade-
quate response to the opioid epidemic.
It has become commonplace to administer Narcan to patients in

 cardiac arrest; unless you adminsitered the Narcan with reasonable

suspicion of a narcotic overdose, you do not need to fill out this page
for cardiac arrest patients.
Response Format/
Field Explanations
Options
If Narcan was adminsitered
due to reasonable suspicion
Do you suspect this patient
of opioid overdose which
is suffering from an opioid
Yes/No you document in your
[heroin, fentanyl, or narcot-
narrative, even if the patient
ic] overdose?
did not respond to Narcan,
select “Yes.”

Was a “Leave Behind” Nal-

oxone Overdose Kit left at
this scene?
 BCoFD does not gen-
erally leave Narcan with a
patient/patient’s family. It is No
preferable to refer patients
to a R.E.A.C.H. advocate
whenever possible.
Did the patient report
having a previous opioid
overdose?
Have you (the provider)
previously encountered this
patient as a suspected opioid
overdose?
A Naloxone Overdose Kit
Yes
was left at this scene.
No kit was left at this scene
and a R.E.A.C.H. advocate
was not contacted.
A R.E.A.C.H advocate was
Not Applicable
contacted.
If the patient was uncon-
Yes/No/Unknown scious/unresponsive, select
“Unknown.”
Yes/No/Unknown --

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PATIENT
REFUSAL
#

Ensure your responses in this section match what you’ve reported in

W other places of the PCR (i.e. if pulse was 58, do not select no for “5.
Adult. a. Abnormal vital signs for adult: Pulse greater than 120 or less
than 60?”). Select the correct answer and add any necesarry explana-
tions in the narrative.

Sect 1: Medi- Field

Response Format/
Explanations
Options
cal Capacity
1. a. Disoriented to Person? Yes/No

1. b. Disoriented to Place? Yes/No

1. c. Disoriented to Time? Yes/No

1. d. Disoriented to Situation? Yes/No

2. Altered level of conscious- If yes to any of these ques-

Yes/No
ness? tions, patient may not refuse
3. a. Alcohol or drug inges- transport
tion by history or exam with Yes/No
slurred speech?
3. b. Alcohol or drug inges-
tion by history or exam with Yes/No
unsteady gait?
Yes/No
4. Patient does not under-
 If patient does
stand the nature of illness and
understand the
potential bad outcome?
risks, select “No.”
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Sect 1: At Field Response Format/Options Explanations

Risk 5. Adult a. Abnormal vital
signs for adult: Pulse greater Yes/No
Criteria than 120 or less than 60?
5. Adult. b. Abnormal vital
signs for adult: systolic BP Yes/No
less than 90?
5. Adult. c. Abnormal vital
signs for adult: Respirations
Yes/No
greater than 30 or less than
10?
5. Peds. a. Abnormal vital
signs for minor/pediatric: Yes/No
Age inappropriate HR?
5. Peds. b. Abnormal vital If yes to any of
signs for minor/pediatric: Yes/No these questions,
Age inappropriate RR? provider must
5. Peds. c. Abnormal vital consult with a
signs for minor/pediatric: Yes/No physician prior to
Age inappropriate BP? allowing patient to
refuse.
6. Serious chief complaint
Yes/No
(chest pain, SOB, syncope)?
7. Head injury with history of
Yes/No
loss of consciousness?
8. Significant NOI or high
Yes/No
suspicion of injury?
9. For minor/pediatric pa-
tients: ALTE, significant past
Yes/No
medical history, or suspected
intentional injury?
10. Provider impression is
that patient requires hospital Yes/No
evaluation

Sect 2: For Field Response Format/Options Explanations

Providers 1. Did you perform an as-
sessment (including exam) Yes/No --
on this patient?
2. If unable to examine, did
Yes/No --
you attempt vital signs?

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3. Did you attempt to con- The answer to this question

vince the patient or guardian Yes/No should almost always be
to accept transport? “Yes.”
4. Did you contact medical
direction for patient still Yes/No --
refusing service?

Sect 3: Field Response Format/Options Explanations

Situation Initial Disposition Multi-select Select all that apply.

Interventions Multi-select Select all that apply.

Facility Contacted for
Free type --
Medical Direction
Final Disposition Multi-select Select all that apply.

Sect 4: Pa- In the patient’s own words, explain why they do not want to go to the hospital (i.e. I
don’t think it’s serious enough.”)
tient’s State-
ment

Power Tools
The power tools are the icons located on the right side of the screen. They are
quick access tools to common procedures that allow you to access a means of
documentation without having to find the proper category and subcategory.
Clicking the “All” icon at the bottom will display the full list of power tools available
to you.
Once you have utilized a power tool to enter information, should you need to
change that information, you will have to navigate to its location in the main tabs
on the left side of the screen (i.e. if you used the PROCS power tool to document
a procedure, once you’ve clicked “OK,” to change information about the procedure
you must navigate to Provider ActionsàProcedures.
Many of the assessment tools are straightforward requiring you to enter only
the date/time of the given event and your findings. A few of the power tools are
highlighted below:

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Timeline The timeline shows all events in chronological order on a single page.

(Information The timeline highlights any events with validation errors in red allowing
Tool)  you to click on the event and be taken directly to its corresponding page.
Entries highlighted in red at the bottom of the timeline require a time to
be entered for them.

Situations The Situations icon on the right side of the window provides a list NOIs. Clicking on
a specific entry in the list will bring up a set of guidelines consistent with the MIEMSS
(Information protocols for handling a given emergency.
Tool)
W Providers should always refer to the most up-to-date MIEMSS protocols
for questions concerning patient care.

Cardiac Unlike other power tools that allow for comprehensive reporting, think of this power
tool as a quick list. It is designed specifically for cardiac arrests and allows you to select
all interventions, medications, etc. that were done. However, rather than having to
click OK and reopen the window to add a new entry, clicking each item will add it
to the timeline and leave the Cardiac power tool open to allow you to select another
without leaving the screen. This means that at some point, you must go back and
report a time for each event. Selecting certain events, namely procedures, will bring
up a new dialogue that asks for more details. Clicking okay on that dialogue will bring
you back to the Cardiac power tool.

 If you wish to return to the cardiac power tool without entering the requested
information, simply click “OK” on the top left of the screen. You will be
required to enter the information later, but this will allow you to continue
building the list of interventions provided.

Rapid Exam The Rapid Exam power tool allows you to document findings of a rapid, head-to-toe
trauma assessment on a single page. It give you the ability to select findings for each
portion of the body beginning at the head and ending at the feet.

Assessment The assessment power tool is accessed by clicking the “All” button along the right side
of the window at the bottom. Clicking on “Assessment” in the window that opens
will open the assessment power tool. Using the power tool will give the provider
greater flexibility in detailing their assessments. Clicking on an icon corresponding
to a portion of the body brings up a dialogue in which the provider can select various
findings and respond to other prompts based on the portion of the body being

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 At the bottom of these dialogue boxes, there is a “NP Tag Mode” button.
This button is used to document pertinent negatives. For example, a
provider might click this button under the abdomen tab and then click
on rebound tenderness. This would convey that the provider assessed for
rebound tenderness, did not find any, and recognizes that not finding it is
still pertinent.

 The power tool allows providers to select multiple body areas at once and
mark them all as normal. To do so, the provider that either select “< All
Normals” from the top toolbar, or select “< Tag Normals” from the bottom
toolbar and then indicate which areas of the body he/she would like to
mark as normal.

Vital This power tool allows you to document all of the major vitals (BP, pulse, airway
status, respiratory rate, mental status, and lung sounds) on a single, easily laid out
page without the other fields in the Vitals subcategory under the Provider Actions tab.

Narrative Writing
Introduction In an effort to maximize data collection abilities, information that traditionally
belonged in the narrative now has a specific field with designated response options
embedded in a variety of sections of the PCR (P. X-XX of this guide). This is
particularly relevant when it comes to documenting the patient assessment. As
such, the narrative should be used to document information that does not have a
specific field in the PCR. More generally, the narrative is the place where a provider
builds a visual of their patient and any other pertinent information depending on the
circumstances.
Ever provider has their own way of formulating their narrative, and the most
important thing is that each provider does what works for that individual. As long as
the narrative is logical and includes all required information, the actual format of it
is less important. Below are a few common techniques that you may find helpful in
guiding your narrative writing, even if you do not follow them exactly.
A variety of formats exist to guide providers in completing their narrative. Two of the
most common are the SOAP note and CHART (or ICHART). The basic principles of
the two formats are described below:
S.O.A.P. S (subjective)
Description of patient including age, gender, etc. Information on
their chief complaint, OPQRST, pertinent medical history, etc.
Your impression of the patient; visible signs, findings from
O (objective) assessments, pertinent environmental observations, scene
description if appropriate.
Findings that guide your assessment and help you formulate a
A (assessment) plan (i.e. patient’s current presentation is consistent with their
description of previous asthma attacks).
What you did—medications, procedures, etc., and how the
patient responded to them. How your transported the patient,
P (plan)
where you left the patient at the hospital, and who you transferred
care to.
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I.C.H.A.R.T. I (incident)
Description of the incident including the scene, how the
patient was found, etc.
C (chief complaint) Patient’s age, gender, reason EMS was called today.

H (history) Relevant findings from SAMPLE history.

A (assessment) OPQRST, pertinent findings from physical exam, etc.
What you did, why you did it, and how the patient
R (Rx-treatment)
responded to your interventions.
How was patient transported (did they walk to ambo,
were they on the stretcher or in the captain’s chair, etc.)?
T (transport)
Where the patient was left at the hospital and who care
was transferred to.
Format SOAP ICHART
S I, C
Equivalencies O H, A
A A
P R, T

General Some providers will utilize each letter in the aforementioned formats as a bullet point,
writing each section as a separate paragraph of their narrative. Other providers will
Strategies use these pneumonics as a guide to ensure they convey all information necessary in a
logical manner but will not actually separate each portion of the narrative.
Yet other providers chose to use the name of the section as a guide: the narrative.
They will write this section as a story conveying what happened while the patient was
under their care in a chronological order. Since we’re humans, the care we provide
general occurs in a logical progression, so accurately capturing the story in the order
that it occurred will reflect that.
As a general rule, the following information, when applicable, should always be in the
narrative:
1. Other units on scene and their unit numbers
2. How you found the patient
• Patient position (seated, standing, on ground, etc.)
• Patient location (in a chair, on the sidewalk, etc.)
• Bystanders present (son, mother, etc.)
3. How the patient looked when you found him/her (i.e. visible respiratory distress,
obvious trauma, etc.)
4. Any pertinent information about the patient’s surroundings/environment
5. Patient’s explanation of current condition/circumstances that caused the injury (i.e. I fell).

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6. Specific details of assessments and findings not covered in other areas of the PCR (i.e.
c-sine was assessed visually and via plapation; neither stepp-off nor pain was observed).
7. Explanation of decision making (i.e. Patient was not placed in a collar since no stepp off
or pain were noted).
8. Further details on information entered in specific fields (i.e. patient reported feeling
“weird” after administration of Zofran).
• Specific details of any interventions (i.e. bleeding controlled with a pressure dress-
ing using 2 4x4s and roller gauze).
9. Specific details of how patient was moved if necessary (i.e. patient rolled onto Reeves
without any further pain, carried out of house, and placed on stretcher).
10. Any extraordinary cicumstances and what was done in response.
11. Where patinet was transported with explanation of reasoning if necessary.
12. Documentation of consult if one was done.
13. Which bed patient was moved to.
14. Name of nurse to whome patient care was transferred.
15. Explanation for any requried information that could not be obtained (i.e. “EMS could not
obtain a SSN because patient could not remember it”).

 You can use the MIEMSS protocols as a guide of what needs to be documented
for a specific type of call.

Examples This guide purposefully does not list specific call types and what information belongs in
the narrative for each one in the hopes that doing so will encourage providers to formulate
their own way of approaching this section of the report. However, it is recognized that many
providers have already developed their own method for completing this section of the PCR.
In the following portion of the guide, we provide examples of complete narratives for the
same call but in a variety of common formats:

S.O.A.P S: AOS to find a 78 YO female supine on the ground with no visible trauma. PT reports she
lost her balance and fell, but was able to brace the fall with her right hand. PT does not believe
she hit her head. No LOC. No nausea or vomiting, and PT reports no abnormalities with her
vision. Pt does take Warfarin, and she took it this morning.
O: PT is AOx3 and does not appear to be in significant distress. VS as noted in Vitals section
of PCR; remained stable throughout EMS care. Right wrist appears slightly swollen but no
deformity or bruising was observed. PT reports pain is a 6/10 and describes it as “dull.”
+CMS in right hand. PT reports generalized pain in the center of her back. No step-off was
found. PT reports pain as 4/10 and also “dull.” PT reports no deficits and no tingling in any
extremities. CMS present in all four extremities. Lungs clear and equal bilaterally.
A: Injuries consistent with fall, and PT reports that the pain began immediately after the
fall. Since PT does not have any new deficits, she does not meet the full spinal protection
protocol.
P: PT placed in C-collar as a precaution. PT was assisted from the ground to the stretcher,
and the head of the stretcher was raised to 30°. PT reported that she was in slightly less
pain after being moved from the ground. PT was moved to the ambo on the stretcher.
During transport, VS remained stable and PT noted no further changes in pain. PT was
transported to 218, moved to bed 18, and care was transferred to RN Josephine.

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(I).C.H.A.R.T I: EMS dispatched for a fall patient. AOS to find a female supine on the ground
with no visible trauma, AOx3.
C: 78 YO female reports pain in her back and right wrist.
H: PT reports she lost her balance and fell, but was able to brace the fall with her
right hand. PT does not believe she hit her head. No LOC. No nausea or vomiting,
and PT reports no abnormalities with her vision. Pt does take Warfarin, and states
she took it this morning.
A: Right wrist is slightly swollen. No deformity or bruising. Pain is a 6/10, and
PT describes it as “dull.” +CMS in right hand. PT reports generalized pain in the
center of her back. No step-off was found. PT reports pain as 4/10 and also “dull.”
No deficits and no tingling in any extremities. CMS present in all four extremities.
Lungs clear and equal bilaterally.
R: Due to pain in back, EMS placed a C-collar on the patient as a precaution. Since
PT had no deficits, PT was not given full spinal immobilization. PT was assisted
from the ground to the stretcher, and the head of the stretcher was raised to 30°. PT
reported that she was in slightly less pain after being moved from the ground.
T: PT was moved to the ambo on the stretcher. During transport, VS remained
stable and PT noted no further changes in pain. PT was transported to 218, moved
to bed 18, and care was transferred to RN Josephine.

Chronological AOS to find a 78 YO female supine on the ground, AOx3, with no visible trauma.
PT lost her balance and fell but braced herself with her right hand. PT did not hit
Paragraph her head and had no LOC. PT reports no nausea or vomiting and no abnormalities
in her vision. PT reports pain in her right wrist and the center of her back. Slight
swelling was noted in the right wrist, but no deformity was observed. PT reports
pain as 6/10 and “dull.” No step-off observed in back. PT reports back pain as
generalized, 4/10, and also “dull.” CMS present in all extremities. Lungs clear and
equal bilaterally. PT does report taking Warfarin and did take it this morning.
EMS placed PT in a C-collar as a precaution, but since PT had no new deficits,
full spinal immobilization was not indicated. PT was assisted from the ground to
the stretcher, and the head of the stretcher was raised to 30°. PT reported that she
was in slightly less pain after being moved from the ground. PT was moved to the
ambo on the stretcher. During transport, VS remained stable and PT noted no
further changes in pain. PT was transported to 218, moved to bed 18, and care was
transferred to RN Josephine.

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Narrative
Tips  Ø Don’t try to write the narrative before transfer of care; looking at the
call in hindsight may help you formulate your report.
o You can avoid this temptation by using the narrative section
of eMEDS to jot down quick notes (i.e. direct quotes from the
patient that you may choose to include in the narrative).
Ø On that note, quotes from the patient are useful in building a better
picture of the situation.
Ø Take a minute to reread your report or have someone else do so
before you upload it.
Ø It’s always better to include too much information than not enough;
if you’re not sure whether or not something belongs in the narrative,
just put it in.
Ø Just because you’ve documented something in a different place does
not mean you cannot say it in your narrative; use the narrative as a
place to highlight pertinent findings.
o This is especially important when talking about a patient’s

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