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G.4.1 ePCR Completion, Distribution and Retention

 

Paramedic Services Effective Date: April 30, 2019
Topic: Documentation Directives Replaces: April 4, 2013
Subject: ePCR Completion, Distribution and Retention Policy No. G.4.1.

 

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 iMEDIC electronic Patient Care Record system. This software is installed on mobile laptops assigned to each vehicle. Paramedics will complete their patient care record on the assigned laptop.

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 that 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 iMEDIC 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. 

At the completion of each call, all ePCRs shall be uploaded to the server by running Data Mover; this is completed by selecting {Submit} on the ePCR to send it. Paramedics shall also select the Transfer ACR icon on the desktop to send other ACRs that may be residing on the tablet. This shall be completed at the beginning and end of each shift. Paramedics shall always exit the iMEDIC GEN II program following completion of any documentation to ensure ePCRs are not being prepared under an incorrect identification profile. 

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.
 

Paper ACR Completion
  1. In the rare event that a paper Ambulance Call Report is completed, Paramedics shall separate the four-part form and distribute the copies as follows:

  1. White Copy (original) is the patient chart copy and shall be left with the receiving facility. Where no patient was transported the white copy is retained by Paramedic Services.
  2. Blue Copy is the billing copy and shall be left with the receiving facility if it is a billing institution. If no billing institution is involved in the call, then the blue copy is retained by Paramedic Services.
  3. Canary Copy is the Base Hospital copy and shall be forwarded to the Base Hospital according to local Base Hospital procedure.
  4. Pink Copy is the ambulance service copy and shall be retained by Paramedic Services as set out in policy and Legislation.
  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. 

  1. Patient records and hard copy reports shall be secured in the designated documentation box at each Paramedic Service station.

  1. In the event that a paper ACR must be completed, the attending paramedic shall notify the on duty Superintendent and complete an incident report to document the reason that a paper ACR was necessary (i.e. laptop battery died, technical difficulty, etc.)
     

REFERENCE

Ambulance Act/Regulations

Ontario Ambulance Documentation Standard

ACR Completion Manual