Patient Care Record

A clinical record documenting the assessments & interventions of every patient attended by St John WA.

Documentation of patient care must provide an accurate description of each patient contact with St John. All Officers have a responsibility to complete an electronic patient care record (ePCR) with accurate, clear and precise information that provides a record of any relevant history, assessment, treatment, advice and outcomes of any patient you had primary contact with. When an ePCR cannot be completed, a paper-based care record is required.

The patient care record is considered by St John to be a medico-legal document that should reflect all relevant information of the case as set out by this guideline. The case sheet should be completed during the call, or shortly afterwards. The patient care record must be completed prior to leaving the receiving facility and a copy must be provided to the hospital during, or shortly after handover.

An individual record should be filled in for every patient attended to by St John. An ePCR must also be completed when attending as a backup and must provide a contemporaneous record of your involvement in the patient care.

Where possible, tick boxes should be used to record information. Use the free text narrative section to add additional information, explanation or justifications.

Section 1 – Case Information

• Ensure that the prefilled crew and location information is correct and valid. Adjust times if necessary to accurately reflect actual situation.
• Select the appropriate problem urgency and problem code that best describes your patient’s condition after your assessment. Should more than one option be available, select the one you spend most of your time treating, or that has the most severe consequences to the patient.
• Complete as much of the information as available. Should health insurance details, pension numbers or vehicle number plates be available, they must be recorded. This reduces unnecessary duress caused by contacting patients for this information after the event.

Section 2 – Patient Information

• Ensure that all prefilled information is true, correct and accurate, and complete any blanks.
• Where available, the patient’s phone number must be completed.
• Complete the medical history section as thoroughly as possible. List or scan medication packets/lists of all the appropriate medication that your patient is taking. Do not document – “See list” or “See attached”, this is not acceptable.
• Pre-Ambulance care should be completed if any treatment was done prior to our arrival to confirm if our pre- arrival instructions were effective. Documentation of any bystander CPR prior to arrival is mandatory. If a Doctor is on scene, and has provided care for the patient, please record their details accurately.

Patient Not Transported

• Select the appropriate PnT form and complete ALL relevant sections.
• A PnT form should be completed for each patient assessed by St John WA who is not transported to further care.
• Ensure that the rationale and reasons are recorded for the decision, as well as any safety netting advice given to the patient or family.
• All patients aged 12 years or younger are excluded from the PnT process. Unless the patient’s legal guardian refuse ambulance transportation of the child, transport should be advocated. Parental refusal must be documented and signed for by the legal guardian.
• Where possible, the patient and witnesses must sign the form. Document any concerns or refusals to sign appropriately.
• It is important to remember that patients with capacity have the right to refuse treatment and transport. By honouring the decision, officers might not necessarily agree with the patient, but agree that all appropriate avenues have been exhausted to convince the patient to be transported. Potential foreseeable consequences should be explained to the patient to enable an informed decision (Refer to the ‘Patient Not Transported’ guideline).
• A minimum of 2 sets of full vital signs must be recorded to establish a trend. If this is not possible, a robust explanation should be recorded in the narrative.

Patient Refusal of Treatment or Transportation

• Select appropriate drop-down boxes describing your patient’s signs, condition and position.
• The Incident/Patient Assessment Details section – optional templates can be selected from the drop-down menu on the right of the narrative
• This free text section should include all relevant information regarding the call that cannot be captured by using the specific tick boxes.
• This can include background information, pertinent facts and negatives, supporting evidence for clinical decision making, or any mitigating circumstances for omissions or not following recommended procedures.
• Clearly document any refusals by the patient, as well as any alternative treatment options discussed or considered.
• All adverse events should be noted and described in this section, including patient’s condition post event
  and reporting line used.
• It is also appropriate to report challenges/barriers to providing appropriate care, as well as extrication difficulties faced.
• This section should not be used to detail complaints or information that is not pertinent or part of a patient’s medical care record. Care is required to ensure information is accurate and objective. Personal opinion and subjective information should be not be included

Section 3 – On Examination

• Select appropriate drop-down boxes describing your patient’s signs, condition and position.

The Incident/Patient Assessment Details section:

• Optional templates can be selected from the drop-down menu on the right of the narrative.
• This free text section should include all relevant information regarding the call that cannot be captured by using the specific tick boxes.
• This can include background information, pertinent facts and negatives, supporting evidence for clinical decision making, or any mitigating circumstances for omissions or not following recommended procedures.
• Clearly document any refusals by patient, as well as any alternative treatment options discussed or considered.
• The use of prefilled templates is not recommended as it might erroneously reflect treatment that did not actual occur.
• All adverse events should be noted and described in this section, as well as the reporting line used, and patient’s condition post event.
• It is also appropriate to report challenges/barriers to provide appropriate care, as well as extrication difficulties faced.

Section 4 – Observation

A minimum of two sets of observations should be documented in this section. 

• As a minimum requirement, Glasgow Coma Scale (GCS), Respiration Rate (RR), Pulse (HR) Blood Pressure (BP), Oxygen Saturation (SpO₂) and pain scores. It should also include, where appropriate, any of the other parameters including pupils, ECG, end tidal Carbon Dioxide (etCO₂), Blood Glucose Levels (BGL), temperature, dyspnoea and weight.
• Patient observations should be performed and documented every 20 minutes, and more frequently if clinically indicated. If this is not possible or is deemed clinically unnecessary the rationale should be documented.
• For PTS undertaking dual transfers, observations are taken at the point of pick up, and the second upon reaching the destination. Should there be any clinical deterioration of the patient, more frequent observations are also required, in addition to calling for Paramedic backup. 

Section 5 – Intervention

• Select appropriate drop-down boxes.
• Record the intervention and time of intervention.
• It is important that the service number of the officer administering the medication or providing the skill or intervention is recorded accurately. If it is left blank it will be assumed the documenting officer has provided the care.
• Disposal of part used medications must be completed for all Schedule 4R, Schedule 5A and Schedule 8 medications.
  Medication disposal must be witnessed by both officers, and signed in the appropriate space provided.

Section 6 – ePCR returns and addendums

• Crews are reminded to complete the ePCR as accurately as possible and review all documentation prior to submission. In rare instances, the ePCR may be returned to the completing officer to amend the record where a major omission has been identified or an addendum may be requested to make changes retrospectively. This can be amended on ePCR; if the amendment potentially affects patient safety, the hospital should be notified of the new information so that records can be updated.

ePCR returns

• If the crew are still at the receiving hospital, the ePCR may be returned.
• Officers may request a return of a case sheet through the on duty Clinical Support Paramedic.
• The completing officer is responsible for notifying the receiving hospital of the amendments made and ensuring a single source of truth exists. This should involve the appropriate disposal of a previously printed patient care record.
  

ePCR Addendums

• If crews have departed hospital, and changes need to be made retrospectively, an addendum can be requested.
• Case sheet addendum requests should be submitted via email to the Clinical Support Paramedic (SOC) mailbox. Requests should:
  • Provide the patient care record number the addendum relates to
  • Clearly identify the addendum to be made
  • Note the justification for the addendum
• Only the original case sheet submission will be available to the hospital. It is the responsibility of the requesting officer to notify the hospital if the amendment potentially affects patient safety.
• Once an addendum has been added, it cannot be edited or removed.

Key Terms & Links

Patient Care Record (PCR):
The patient care record is a confidential, legal document that can be used in a court of law to provide evidence of care provided to a patient. Patients have the right to request and to be provided a copy of this record. All patient care records must be completed in a clear and legible way. Either an electronic or paper-based care record should be completed by the documenting officer.

Documenting Officer
The officer providing the majority of the patient treatment, and completion of the patient care record. Skills and/or medications can be administered/performed by another officer, however this must be clearly documented on the care record.

Patient not Transported (PnT)
Refers to the document required when attending a scene and a patient is provided treatment, but transport is not indicated or needed.

Officers
Employees and volunteers working in the name of St John WA in the delivery of healthcare inclusive of but not limited to; Metropolitan and Country Ambulance Services, Transport Services, Volunteer First Aid Services, Event Health Services, and Medical Services.