G.6.10 Patient Care Records Audit

PURPOSE

To monitor compliance to all applicable standards during emergency and non-emergency Paramedic responses and provision of patient care.
 

APPLICATION

• Paramedics
• Paramedic Superintendents
• Senior Managers
   

PROCEDURE

Manitoulin-Sudbury DSB, Paramedic Services will, through Interdev Technologies, compare Ambulance Dispatch Reporting System data with electronic Patient Care Records (ePCR), housed within the iMedic application to ensure that an ePCR is completed for each request for ambulance service where there is a valid T-4 time (Arrive Scene).

Paramedic Services will ensure that completed and uploaded electronic Patient Care Records will be distributed through iMedic within 48 hours of completion of the call to:

• Receiving hospital staff
• Base hospital
• Billing
• Manitoulin-Sudbury DSB, Paramedic Services

In addition to the established audits performed by the Base Hospital, the Deputy Chief assigned to the Professional Standards portfolio will oversee the audit of ePCRs including the following call cohorts:

• 100% of SCA Calls
• 100% of CTAS 1 Transports
• 25% of CTAS 2 Transports, including 100% where RTS not met.
• 15% of CTAS 3 Transports, including 100% where RTS not met.
• 10% of CTAS 4/5 Transports, including 100% where RTS not met. 

ePCR audits will consider accurate completion of the following fields:

• Administration – Surname, Given Name, Address, DOB, Date, Call #, CACC, Warning System, Service Name, Service #, Station #, Status, Vehicle #, Mileages, UTM Code, Pickup Location, Pickup Code, Dispatch Problem Code, Dispatch Sent Code, Return Code, Patient #, Sequence, Event Times, Driver #, Driver Name, Driver Signature, Attendant #, Attendant Name, Attendant Signature, No Patient Carried name and signatures, No Patient Carried witnesses and signature, travel conditions, Offload Delay, Personal Effects.
   
• Patient Care –Chief Complaint, Primary and Secondary Problem Codes, , Time of Occurrence, Incident History, Past History, Traumatic Injury Site/Type, Medications, Allergies, Treatment prior to ambulance arrival, Cardiac Arrest Information, Age, Gender, Weight, CTAS, General Appearance, Physical Findings, Vital Signs, Procedures, Remarks, Final Primary Problem, Final Status, Receiving Location, Receiving Signature.

Audited ePCRs that reveal findings that are outside of the standards will be returned to the Paramedic, with an Ambulance Call Evaluation (ACE) document in order to allow for resolution/clarification. The ACE is part of a remedial plan. Additionally, auditors may request a written Paramedic response that includes corrective actions to resolve exceptions to the standards.  This documentation shall be placed on the employees’ personnel file.  All remedial training shall be documented in accordance to the training policy.

While the focus for ePCR auditing is to ensure quality service delivery, and focus on remediation through education, habitual/significantly egregious documentation errors may be managed through the progressive disciplinary process.
 

REFERENCE

Ambulance Act

Ontario Regulations 257/00 (General Regulation)

Patient Care and Transportation Standards

Communicable Disease Standards

Basic Life Support Patient Care Standards v 3.0.1

Advanced Life Support Patient Care Standards v 4.5

MSDSB Policy C.4.06