Legal obligation

There are several legal obligations that inform documentation standards and policy in PHSA and BCEHS.

Provincial Law

I. Regulatory Compliance: Emergency Medical Assistants Regulation

      (i) Under the Emergency Health Services Act and associated regulations, paramedics are legally obligated to carry out professional responsibilities with integrity – thorough documentation upholds integrity. EMA Regulations Schedule 3.

II. Freedom of Information and protection of Privacy Act (FIPPA):

      (i) The ePCR is a legal document and is part of the patient’s medical record and therefore subject to the Freedom of Information and Protection of Privacy Act (FIPPA) Chapter 165, 1996.

      (ii) Paramedics are legally required to document every patient encounter, and any unauthorized deletion of a patient care record is a violation of FIPPA.

      (iii) Any mishandling and/or breach of patient confidential information is a violation of FIPPA. The information within the patient care record ultimately belongs to the patient and we are merely custodians of this information.

Lessons from a recent case

A recent ruling by the Ontario Court of Appeal (2024 ONCA 537) highlighted the importance of accurate documentation. In this case, paramedics were convicted of failing to adhere to standard care protocols and for incomplete records that could not support their claims. This serves as a powerful reminder of the critical role documentation plays in uplifting Indigenous people’s truths as well as honoring your professional actions. 

Common Law, Indigenous Law and Civil Law

I. Declaration Of the Rights of Indigenous Peoples ACT (DRIPA) Ch44.

• DRIPA was brought into BC law in November 2019, and section 3 and 4 of the Act mandate the government to bring BC laws into alignment with the UN declaration (UNDRIP). DRIPA establishes the United Nations Declaration on the Rights of Indigenous Peoples as the province’s framework for reconciliation, as called for by the Truth and Reconciliation Commission’s Calls to Action. The BC government has committed to a 5-year action plan to be completed in 2027, with 89 actions organized around themes: self-determination and self-government; Indigenous title & rights; ending Indigenous-specific racism and discrimination; social, cultural, and economic well-being.

II. Bill C-15-UN Declaration of Right of Indigenous Peoples (UNDRIP)

Free and Prior Informed Consent is a right specific to Indigenous Peoples that is articulated in UNDRIP and put into Canadian law in 2020. Within this context, it addresses the importance of ensuring that Indigenous Peoples have agreed to decisions related to their Health Care as informed by the following components:

• Free, meaning that Consent is given voluntarily and without coercion, intimidation or any form of manipulation.
• Prior, meaning that Consent for proposed Health Care decisions are obtained in advance of the decision being made and includes the time necessary to allow Indigenous Peoples to undertake their own decision-making processes.
• Informed, meaning that when Indigenous People make a decision about a proposed Health Care option, they have been provided with objective and accurate information that has been presented in a manner and form understandable to them

III. Article 24 of the UN Declaration (UNDRIP)

• Indigenous Peoples have the right to traditional medicines and to maintain health practices, including the conservation of vital medicinal plants, animals and minerals. Indigenous Peoples have the right to access, without any discrimination, all social and health services.
• Indigenous Peoples have an equal right to the enjoyment of the highest attainable standard of physical and mental health. States shall take the necessary steps with a view to achieving progressively the full realization of this right

Statement from the Indigenous Law Research Unit, BC Law Institute: ‘Indigenous laws’ are the principles and processes that Indigenous Peoples and communities use and have always used to govern themselves. While it is often used interchangeably with ‘Aboriginal law’ (which is Canadian law about Indigenous issues), it is distinct and should be understood as deriving from Indigenous Peoples’ societies and histories.

Indigenous Laws – BCLI

IV. Tripartite Agreement

The British Columbia Tripartite Framework Agreement on First Nations Health Governance (often simply called the “Tripartite Agreement”) is a collaborative accord between three parties: First Nations Health Council (representing First Nations in British Columbia), the Government of Canada and the Government of British Columbia. It was negotiated to give legislative and operational shape to the broader vision set out in earlier policy documents (like the Tripartite First Nations Health Plan from 2007) and aims to improve health outcomes for First Nations peoples in B.C. by shifting greater planning, design, management and delivery of health programs to Indigenous-led institutions.

Under the agreement:

• The parties commit to the transfer of designated federal health programs for First Nations in B.C. to the First Nations Health Authority (FNHA), enabling it to design and deliver services in ways that better reflect First Nations’ cultures, priorities and governance.
• The agreement affirms that it does not create new treaty rights or self-government rights, nor does it purport to alter underlying constitutional law. Instead, it provides a framework for collaboration, governance change and program transition.
• The parties agree to a joint evaluation regime (every five years) to assess health indicators and implementation outcomes, and to manage the transition so that services continue without interruption.

V: Remembering Keegan

Please visit First Nations Health Authority (FNHA) for the entire case study.

Keegan Combes, a gifted young man from Skwah First Nation, was known as an accomplished chess player and pianist, a trades student, and someone who moved through the world with gentleness and depth. He lived with developmental disabilities and communicated in ways that reflected his own agency and comfort. In 2015, Keegan died at just 29 after an accidental poisoning and a delayed diagnosis, a loss that exposed the profound consequences of systemic and cultural racism within the health-care system. In the years since, his family and community have generously shared his story as a teaching gift to health-care providers across British Columbia. Remembering Keegan has become a catalyst for cultural safety and humility, inspiring reflection, accountability, and transformative change. His legacy—honored in ceremony, artwork, and learning—continues to guide the shift from a system rooted in sickness to one grounded in wellness.

Culturally unsafe encounters surrounding Kegans death:

Direct quote from Remembering Keegan: A BC First Nations Case Study Reflection |FNHA

Keegan’s story also demonstrates that his death was not a result of one mistake by “a bad apple,” but rather the result of a series of culturally unsafe and harmful encounters with a team of registered Canadian health professionals working in an urban setting that impacted their ability to provide high quality care and save his life. When responsibility cannot be put on a single person, it indicates that there is something wrong with the culture of the system. Systemic racism can therefore be understood, “not as a set of individually held beliefs or actions…but as a structure of indifference” affecting the likelihood of a good outcome. The important thing is not just how to keep bad health providers from harming patients, but also how to keep good providers from harming patients.

VI. Protecting your livelihood and organization

An ePCR is the definitive account of your clinical actions. Incomplete or absent documentation weakens your ability to defend your practice in the event of complaints or litigation.  The law in Canada states that absent evidence to the contrary, if there is no documentation regarding care provided there is an assumption that nothing was done.  Koziol v Joseph Brant Memorial Hospital SCC, (1978)

VII. What is not written did not occur

The Supreme Court of Canada has established that written notes, when taken contemporaneously (taken in the moment), by individuals trained to do so as part of their job should be received as prima facie evidence (or proof) of the facts stated therein (what is written is taken as fact). This also means that a court is open to decide that what is not written did not occur. Ares v Venner (1970). In the context of paramedics and EMRs completing documentation, the only witnesses to the event might be you, your partner and your documentation. If you find yourself giving testimony in court for any reason, what was documented is taken as fact and what was not documented did not happen despite your testimony. 

VIII. Contemporaneous notes are taken as fact

Contemporaneous means notes taken while the event is occurring or immediately after the event. This means late entry of information (several hours to days later) may not be seen by a court to hold as much weight.

IX. Ownership of Documentation

BCEHS are merely custodians of the patient care record (ePCR), the owner of the information within the ePCR belongs to the patients. Paramedics and EMR have a professional responsibility to the patient to document all assessments, treatments and responses to those treatments. Paramedics and EMR’s have a fiduciary responsibility (legal position of trust) to act in the patient’s best interest and protect this information (Supreme Court of Canada ruling, McInerney vs MacDonald 1992). https://decisions.scc-csc.ca/scc-csc/scc-csc/en/item/884/index.do

If you make patient contact, then an ePCR MUST be done! Unauthorized deletion of an ePCR is NEVER acceptable, and violates BCHES policy, PHSA policy, The Emergency Health Services Act (EMA regulations reg 243/2024), and provincial law.