Addendums to ePCR

Making Addendums (or changes) to completed ePCR: An addendum is the addition of any information to a patient care record (ePCR) outside of the immediate patient care period. This can be minutes to hours or even days after the initial interaction with the patient and is no longer considered contemporaneous not taking. An addendum can only be made to the Narrative section of the ePCR as it is easy to identify where the addendum was made, and no other section can be altered. Any supplemental content like ECGs can be added, but it must be clearly stated in the addendum what was added with time and date. We want to encourage employees to please make an addendum if you feel important information was initially missed.

Instructions for Making Addendums

1. Finalized ePCR Submitted to Hospital: If you realize after hours or days that you need to add information to an ePCR that was finalized and submitted to the hospital, follow these steps:
   • Contact your UC or OCUC to request that the ePCR be unfinalized in Siren Web. The report will then reappear in your dashboard as unfinalized.
   • Only add an addendum in the narrative section, do NOT add to any other section.
   • At bottom of the original narrative, draw a line with dashes or symbols and write ADDENDUM (all caps) with date and time of the addendum.

     • ---

                                        ADDENDUM - dd/mm/yyyy - time
     • Only write below this line and nowhere else in the ePCR.
   • Add the addendum to the patient's chart at the hospital where the patient is currently located or last located if the patient is discharged.
   • It is the original author’s responsibility to ensure the addendum is put into the patient hospital chart.
   • Supervisors and managers must support these efforts within reason.
   • If for any reason, it is not possible to have the addendum put into the patient’s chart, record this in the narrative section of the addendum. Then write an occurrence report and inform the hospital.
2. Alternative if access to Siren Web is limited or the ePCR cannot be sent back to Siren dashboard for any reason.Your UC or OCUC can alternatively instruct you to create a new ePCR but MUST include the original report number (R-number).
   • After including the original Event number, ensure all patient identifiers are also included if available.
   • Again, only use the narrative, and clearly label as ADDENDUM with date and time and provide the information you wish to add below this.
   • Use the manual override function to bypass any mandatory fields.
   • Add the addendum to the patient's chart at the hospital where the patient is currently located or last located if the patient is discharged.
   • If for any reason, it is not possible to have the addendum put into the patient’s chart, record this in the narrative section of the addendum. Then write an occurrence report and inform the hospital.
3. Adding Information Before Submitting ePCR to Hospital Staff: If you have just handed over the patient and accidentally finalized your ePCR before completing it:
   • Contact your UC or OCUC, explain you are still patient side, you have not handed in the original copy and request that the ePCR be unfinalized.
   • Submit your corrected ePCR to the hospital. This is not considered an addendum and is still considered contemporaneous notetaking.
   • Securely destroy original copies in an approved shredding container.