If you have successfully downloaded and installed Adobe's Acrobat Reader, you will be able to view and print pdf formatted excerpts from this manual.

2-7-4

PATIENT CARE RECORDS

GENERAL

1. The St. John Ambulance Brigade is often the first link in a chain of health care professionals that will treat an ill or injured person. The continuity of appropriate care for each patient may be determined by the documentation provided on the Patient Care Record (PCR) form. It is essential that this documentation is accurate and concise.

THE PATIENT CARE RECORD (PCR) FORM

2. The primary goals of the Patient Care Record (PCR) are:

a. to document the patient’s condition and treatments and/or actions taken by the patient care provider; and

b. to document information as a means of communication to other health care providers and, therefore, to provide the best possible care for the patient. The PCR is also a legal document.

3. The National Patient Care Record form (see Annex A), developed by National Headquarters, reflects the minimum standard of information required. It has been reviewed by St. John Ambulance medical and nursing professionals, as well as legal counsel to ensure the best possible protection for the patient, the Brigade member, and St. John Ambulance. The National Patient Care Record form should be completed in triplicate. Any other forms developed at other levels must incorporate, as a minimum, all the components of the National Patient Care Record form.

HANDLING THE PATIENT CARE RECORD FORM

4. Adhering to the following guidelines will help ensure accurate patient documentation:

a. complete thorough documentation during and immediately following the intervention;

b. be concise and specific, using lay terms and avoiding short forms;

c. indicate clearly on the form if informed consent was obtained (see StJCI 2-7-2, paragraphs 14 to 16 for details on consent);

d. record to whom responsibility of care is turned over, including the time and the patient’s status at that time;

e. all patients must be advised to seek further treatment from a physician, either immediately or at some time in the future.

5. All PCRs must be treated as confidential documents. The information provided by the patient is in confidence, and is not for divulgence to anyone except those responsible for providing care to the patient. All requests for access to these records must be in writing (see sample Release of Brigade Patient Care Record, Annex B) Only the patient (or parent/guardian for minors) can authorize the release of the PCR or information contained on the form. Unless otherwise directed by court order, only copies of the original PCR should be released. If the original is required to be released, a copy of the original must be retained.

6. The organizer of an event to which St. John Ambulance has been invited does not have the right to confidential patient information, including the PCR. Members should advise event organizers that St. John Ambulance has an absolute obligation to maintain confidentiality to patients, but will provide whatever assistance and information they can (ie. statistical information, or other information that does not reveal the identity of the patient).

9. Patient Care Records should be retained in a safe and secure location (ie. filed alphabetically, by year, in a locked box marked Confidential Patient Care Records) for a minimum of five years. This is the responsibility of the unit Administrative Officer or Superintendent. Some provinces/territories have laws that specifically order the length of time records need to be retained if the patient was treated by a physician or nurse, whether or not they are Brigade members. Determine the governing laws within your province/territory, and comply with them.

 

10. The PCR is the only documentation that offers proof of the type and level of care that was provided by St. John Ambulance to the patient. Be aware that these records may be called upon for use during legal proceedings, a coroner’s inquest, insurance claims, worker’s compensation claims, etc. Timely and accurate completion of the PCR will assist you in answering for your actions in a secure and competent manner if you are called upon to do so.

11. Where a member performs patient care under supervision, the PCR should be completed and signed by the patient caregiver, but should also be reviewed and signed by the patient caregiver’s supervisor.