Deleting Electronic Patient Care Records

***Every Patient Contact Requires an ePCR***

Brief patient encounter: If you made patient contact and the interaction is brief, you MUST open an ePCR and document the interaction. For example, you attend a call from a 3^rd-party-caller, you approach the patient, and they refuse to allow any assessment. In this case you would document the encounter, observations and any attempts at respectfully offering help in the narrative section of the ePCR. This is also true if you assist another crew with a lift assist and had a brief patient encounter. You may not be involved in the treatment or assessment of this patient, but an explanation of the encounter should still be documented in the narrative section of the ePCR. Deleting an ePCR when patient contact has been made, even if brief, is never acceptable.

• ALL deleted ePCR’s are tracked and are permanently attached to your profile in Siren.
• An ePCR must be completed for every patient interaction, regardless of the outcome (transport, referral, or refusal).
• Not documenting your patient encounter and deleting an ePCR, even if the encounter is brief violates:
  • BCEHS and PHSA policies.
  • Emergency Medical Assistant Regulation, Schedule 3 (a), (d), and (g).
  • Freedom of Information and Privacy Act Chapter 165.
  • Having no documentation of a patient’s encounter is indefensible in court and exposing the employee and organization to unnecessary risk if investigated for any reason.
• Case law - The Supreme court of Canada is clear that what is not written did not occur. Therefore, a detailed and accurate ePCR may be your only defense if you find yourself in court