All BCEHS employees responsible for providing out-of-hospital care in, what is now known as, British Columbia must complete an electronic patient care record (ePCR) for each patient encounter. The ePCR plays a crucial role in the patient’s healthcare journey. It is the responsibility of every BCEHS employee to ensure that for every patient contact, documentation is completed promptly, diligently, and comprehensively. Documentation should be clear and include relevant patient information, factual findings, the management plan, and outcomes. It should be concise and free from subjective opinions. Additionally, 'documentation' may encompass materials or data generated outside of the ePCR, such as reports from monitors, defibrillators, and data downloads.
This Documentation Standard borrows heavily from provincial laws and BCEHS policy but does not encompass the entirety of every policy. BCEHS invites employees to uphold their responsibility to read, fully understand and adhere to this Documentation Standard, any BCEHS policy, PHSA policy, and Provincial law regarding documentation. Any question regarding documentation or BCEHS OPS 010 Patient Care Report policy should be directed to your direct supervisor or manager.