Patient Complaints & History
This field is mandatory and documents when the patient's complaint occurred.
Time of occurrence
This section should describe the patient's initial presentation, including where they were found and their level of consciousness.
General appearance
At minimum, vital signs should be reassessed at this interval.
Every 30 minutes
(Or more frequently according to patient presentation)
When applicable, this section of the ACR is mandatory for cardiac arrest documentation.
Cardiac Arrest Information
When a patient refuses care, the paramedic must determine whether the patient has this.
Capacity
This type of information belongs in the Incident History rather than the Chief Complaint when documenting why a patient became ill or injured.
Mechanism of injury
Name two situations in which a physical reassessment is required according to the BLS-PCS
After a critical intervention; after a series of interventions; when patient status changes
Name five of the seven required baseline vital signs required when the patient does not require immediate intervention or meet Load and Go criteria.
HR, RR, BP, SpO₂, GCS, pupils, skin colour/condition
This time must be documented for the beginning of resuscitation efforts.
Approximate date/time of initial CPR
Name two of the five required areas the paramedic should communicate to a patient who is refusing treatment or transport.
Inform the patient treatment/transport is recommended; communicate specific risks; determine capacity; advise to call 911; obtain signatures
If the patient is unable to provide the history, this is one of the things the Incident History should identify.
The source of the information
This information should be included when documenting the patient's General Appearance (list 3)
where the patient was found,
level of consciousness,
mental status,
level of distress,
obvious wounds or deformities,
colour and skin condition
How many vital signs are required according to the BLS PCS Patient Assessment Standard.
Two full sets of vital signs
During a cardiac arrest, paramedics must document their rhythm interpretation at this interval—even when the patient's rhythm has remained unchanged throughout the entire patient contact.
Every 2 minutes
On the Aid to Capacity section, “Responsible adult on scene” refers to someone other than the patient. If no responsible adult is present, this answer may be selected, and the patient may still be left on scene when the appropriate capacity and refusal requirements have been met.
No
Name three things that should be included in the incident history narrative.
Patient's current condition
Source of information
How/ where the patient was found
Events leading to illness/ injury
Pertinent negatives
How many full physical assessments are required in the physical assessment area per ePCR?
One full physical assessment
In what order should vital signs and interventions generally be documented?
In sequential order, according to when they occurred
The ACR asks who first initiated CPR, who first applied the AED and who first did this.
Defibrillated the patient
If a paramedic is unable to obtain a patient's signature, this person should be contacted immediately.
Paramedic Superintendent
A patient is involved in an MVC but tells the paramedic they are experiencing severe chest pain. What should be documented as the Chief Complaint?
Chest pain
A patient's condition changes after the initial physical assessment, the paramedic does not need to repeat the entire physical assessment. At minimum, the reassessment must address these four areas:
Airway, breathing, circulation, and level of consciousness
A paramedic documents a medication administration with all required dosages, routes and times, is there anything else that should be documented?
The result of the administration.
After insertion of an advanced airway during cardiac arrest, this is when the paramedic must document reassessment of the airway: after initial insertion, after each move, and before this event.
Handover
Police tell the paramedic crew to “clear the scene” because they believe there is no medical issue requiring assessment. Before leaving, the paramedics should do this and document the outcome.
Attempt to make patient contact and document the patient encounter/outcome