G.4.1 ePCR Completion, Distribution and Retention

PURPOSE

To provide direction for Paramedics to ensure proper completion and distribution of the electronic Patient Call Reports (ePCR).
 

APPLICATION

• Paramedics
• Paramedic Superintendents
   

PROCEDURE

Manitoulin-Sudbury DSB Paramedic Services utilizes the Prehos electronic Patient Care Record system. This software is installed on iPads. Paramedics will complete their patient care record on the assigned iPad.

While the Ontario Ambulance Documentation Standards requires that an ACR/ePCR be completed for each request for ambulance service where care was provided to an individual, the service standard is that an ePCR must be completed any time that Paramedics become mobile enroute to any assigned response (valid T-3 time). 

An ACR/ePCR shall be completed in accordance with the Ambulance Call Report Completion Manual, Basic Life Support Patient Care Standards (BLS PCS), Advanced Life Support Patient Care Standards (ALS PCS) and Paramedic Services Policy & Procedures. All ACR/ePCRs and Incident Reports shall be of a quality and completeness suitable for use as evidence in an investigation or legal proceeding. Both crew members share responsibility to ensure the  documentation is consistent and compliant with legislation and policy. A Paramedic’s signature on any document will serve to formalize their agreement for documentation content. Manitoulin Sudbury DSB records retention policy, and regulations dictate that ACR/ePCRs will be kept for 5 years.

ACR/ePCRs are confidential, subject to the provisions of the Ambulance Act and Personal Health Information Protection Act 2004 (PHIPA) and shall be secured from unauthorized access. Each Paramedic shall comply with all applicable privacy legislation and Departmental confidentiality policies in the handling and processing of the ACR/ePCR.

The Deputy Chief tasked with professional standards shall be responsible for the development, implementation and ongoing management of a quality assurance program focusing on all aspects of service delivery related to documentation and patient care standards, legislation, regulations and policy.

Any diagnostic or assessment information obtained through use of the cardiac monitor shall be uploaded to the Prehos platform for inclusion as part of the permanent record.

The ACR/ePCR shall be completed as soon as possible and no later than the end of the scheduled shift or work assignment during which the call occurred.

Any patient records, or personal patient items transported with the patient shall be identified in the remarks section of the ePCR.

Where there is no patient found, the Paramedics will document their efforts to find the patient and will note who was at the scene including allied agencies.

Where Paramedics are dispatched for a lift assist, an ePCR shall be completed, inclusive of all applicable administrative information, and any other pertinent patient information including details of the incident. Should there be a mechanism suggestive of injury or medical pathology, a full patient assessment shall be performed, and a refusal of service documented.

Should Paramedics encounter any technical difficulties with the Prehos software, they are to contact the 24/7 number at 1-833-977-3467. Inquiries or minor concerns can also be emailed to help@prehos.com.

Paper ACR Completion

1. If a paper ACR is completed, the Paramedic shall input the call data in the electronic ePCR program immediately upon access to a computer, and in all cases, in compliance with this policy.
2.  
3. Patient records and hard copy reports shall be secured in the designated documentation box at each Paramedic Services station.
4. In the event that a paper ACR must be completed, the attending Paramedic shall notify the on-duty Paramedic Superintendent and complete an incident report to document the reason that a paper ACR was necessary (i.e. iPad battery died, technical difficulty, etc…) 

REFERENCE

Ministry of Health, Emergency Services Branch, Documentation Standards, The 
Crown in Right of the Province of Ontario

Ministry of Health, Emergency Services Branch, ACR Completion Manual, The 
Crown in Right of the Province of Ontario

Emergency Health Services Branch, Basic Life Support Patient Care 
Standards 

Ambulance Act, R.S.O. 1990, c. A.19 and Regulations, Queens Printer for 
Ontario