Collection and Documentation of Patient Care Data

As a member of the St. John Ambulance Brigade you are most often the first link in a long chain of health care professionals that an ill or injured person is treated by. Your initial evaluation and care determines at what level in the health care system your patient receives professional assistance. Your competent judgement means the difference between immediate ambulance transport to hospital or waiting and seeing a family physician or other health care professional. As the primary care provider you are one of the most important members of the health care team.

The position of trust and responsibility placed on you by both the Brigade and your patient, assigns you the "front-line" task of ensuring ongoing professional care. The patient care record is a vital and integral part of your patient's care. The records you make are not only part of your patient s care, they "are" your patient s care. No physician, nurse, ambulance officer, or other Brigade member can determine what has been done for a patient, to what extent it has been done, nor begin planning continuing care until they examine all documentation; including your s.

Legal Implications

Your documentation is the only proof both you and the Brigade have that your patient was cared for properly. It is possible that your records may be required for use during legal proceedings, (ie. a coroner s inquest, insurance claims, worker s compensation claims, etc.) A few simple rules will ensure that if such occurs you will be able to answer for your actions in a secure and competent manner no matter how long after the fact.

Remember:

• complete and thorough documentation at the time is essential, no matter how busy you are or how minor the injury or illness;
• be concise and exact in what you record avoiding short forms, etc.;
• document to whom you turned responsibility of care over to including the time and your patient s status at that time;
• ALL patients must be advised to seek further treatment from a physician, whether immediately or at some time in the future.

The Patient Care Record must be reated as a "confidential" document. The information your patient provided you in trust is not for divulgence to anyone except those responsible for providing care. This is even more important if a health care professional (i.e. Brigade Medical Officer or Nursing Officer) was involved in your patient s care as they have specific legal and professional obligtions to ensure confidentiality of patient care.

All requests for access to these records should be in writing. In Ontario, there is a specific policy and procedure for the retention and release of patient care records. This policy information is available from your Member Services Coordinator.

Patient Care Record

In order to assist you in properly documenting patient care, a form entitled "Patient Care Record" is used. This form guides you through the data collection, care planning, and treatment process. In addition, it provides those Brigade Units involved with the transportation of patients a special section dedicated to the transportation process. As with any form, space is limited. Do not let this intimidate your documentation. If more space is required, use another form and indicate on the first page, in the space provided, that this "Patient Care Record" is made up of more than one page.

Instructions for completing the form are on the reverse side of the form. The use of diagrams depicting body areas and injuries should be avoided. You may well understand today what you meant by an "x" or an arrow, but will you be equally as certain in one, two, or three years time? In some circumstances, however, the use of a diagram may prove useful. Such is the case when trying to describe an accident scene or peculiar position of a limb, joint, etc.

Instructions for Completing Patient Care Records

All documentation must be in ink on this form. If, however, you make an error, put ONE straight line through your mistake and write the word "error" above it. Do not try to erase it or scribble it out. All documentation, with the exception of your signature, must be printed. If more space is required, use another form and indicate on the first page, that this Patient Care record is made up of more than one page.

Section 1: Duty Information

Case Number: The serial number which should be assigned to each patient care record.

Duty: Enter the name and/or number of the duty at which the form was completed.

Section 2: Patient Personal Data

Patient Name: Record the patient s name in full. Use the entire first name, not just initials.

Date of Birth: Record the patient s date of birth (day/month/year).

Mailing Street number and name, P.O. Box, RR #, etc., Address: town, province and postal code are required.

Phone Number: Be sure to include the area code.

Report Date: Record the date this report is written. This should be the date the patient is being treated.

Report Time: Enter the time this report is being completed. This should be the time that the patient was treated at the first aid post or in the field.

Incident Location:Give an accurate description of where the injury/illness occured.

Incident Date: Record the date on which the injury/illness occured.

Incident Time: Record the time at which the injury/illness occured.

Brought in by: Indicate how this patient arrived in your care. If delivered by a police officer, record the officer s badge number. Similiarly, if arrival was by ambulance, record the ambulance number.

Section 3: History

History and Carefully record the specific findings of the Description of specific findings of the presenting injury or illness.

Injury/Illness: The use of diagrams depicting body areas and injuries should be avoided.

Medications: Record any medications that the patient takes and/or has with him/her.

Allergies: Record any allergies which the patient has.

Vital Signs: Record the time and values of vital signs as appropriate.

Section 4: Treatment

Care Rendered: Record in detail all care which is administered. All patients must be advised to seek further treatment from a physician, whether immediately or at some time in the future.

Section 5: Disposition

Disposition: Record the time the patient was discharged from your care. If transported to a hospital, indicate the name of the hospital.

Accompanied Indicate if the patient was accompanied by a by: friend/relative, on their own, ambulance, etc. In the case of an ambulance or police officer, record the vehicle or badge number.

Section 6: Transport

This section is to be completed when a patient is transported in a mobile first aid post.

Section 7: Treated By

PRINT your name. Sign the Patient Care Record. Enter your unit name/number.