Importance of Documentation in Paramedic Practice

These flashcards cover key concepts related to the importance of documentation for paramedics, including legal and procedural requirements, definitions, and standards for accurate record-keeping in patient care.

Documentation

The process of recording patient care and treatment as per established standards.

ACR

Ambulance Call Report; a legal medical document that details patient care and must be completed for every call.

ePCR

Electronic Patient Care Report; a digital version of an ACR.

Legal Medical Document

A document that becomes part of a patient’s medical chart and can be used in legal proceedings.

Confidentiality

The obligation to protect patient information and ensure it is not disclosed to unauthorized individuals.

Procedures

Actions taken during patient care that must be documented in the ACR with details and results.

Patient

An individual who has requested ambulance service and made contact with a paramedic for assessment or care.

CNO

Cannot Obtain; a documentation term indicating when information cannot be obtained from the patient.

Factual Information

Records that are objective and based on evidence, avoiding personal opinions.

ACR Sections

The different parts of the ACR, which include demographics, clinical information, and treatment procedures.

Incident Report (IR)

A document used to report unusual circumstances or events, which can include opinions and non-medical details.

Aid to Capacity

A section of the ACR that must be completed to assess a patient's ability to make informed decisions.

Remarks Section

A part of the ACR where additional information can be documented if space runs out.

Biometric Data

Patient information such as vital signs and ECG results that must be included in the ACR.

Omission

Failure to document an action that was performed during patient care.

Commission

Documenting incorrect information or actions taken during patient care.

Patient Refusal of Service (ROS)

When a patient chooses not to be transported to a hospital, necessitating specific documentation to ensure their capacity to make that decision.

Sketches in IRs

Visual representations that can accompany an incident report, although not expected to be artistic.

General Documentation Guidelines

Standards that state documentation must be clear, concise, relevant, accurate, and must maintain patient confidentiality.

Approved Abbreviations

Specific abbreviations that are permitted for use in documentation, found in the ALS PCS and BLS PCS.

CTAS

Canadian Triage Acuity Scale; levels that must be recorded regarding a patient's triage status.

Central Ambulance Communication Centre (CACC)

The service that directs paramedics to scene locations and issues call numbers.