Date Published

July 5, 2024

Updated For

ALS PCS Version 5.3



Documentation paints the picture of what happened in a call

  • Patient’s baseline status 
  • Rationale for treatment provided or withheld
  • Changes in condition with treatment rendered 
  • Changes in condition necessitating further interventions or actions 

You May Recall… 

  • As highlighted in a previous SWORBHPTip, in cardiac ischemia the priority of investigations and treatment are important (a 12-lead ECG and consideration for ASA should occur before nitro administration). Your documentation should reflect this temporal sequence and prioritization.
  • Remember, your documentation paints the picture of what happened! 


Some key procedure codes & potential sequence:​

  • 020 Patient Assessment​
  • 010 Vital Signs – Include Pain Scale (Baseline)​
  • 504 ASA 160/162 mg PO​
  • 313 12-Lead – Include Interpretation​
  • 298  Defibrillation – Pads On​
  • 615 Nitroglycerin 0.4 or 0.3 mg SL, q 5 min​
  • 010 Vital Signs –Including Pain Scale (Post medication administration)

Bottom Line:

Documentation is important in all calls to “paint the picture” of what happened.

 In suspected cardiac ischemia calls this should include what assessments, investigations and interventions were performed (and when) as well as any supporting rationale for these decisions.


Additional Resources:

No additional resources available for this #SWORBHPTip.

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