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.
The Incident/Patient Assessment Details section:
A minimum of two sets of observations should be documented in this section.
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.
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.
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.