Documentation Definitions:
Know Your Paramedic Lingo
Know Your Paramedic Lingo
An individual for whom a request for ambulance service was made and who a paramedic has made contact with for the purpose of assessment, patient care and/or transport, regardless of whether or not an assessment is conducted, patient care is provided, or the patient is transported by ambulance
What is a patient
All times shall be documented in this fashion
What is the 24 hour clock (HH:MM:SS)
By signing the form, this paramedic affirms the call reports content, accuracy, and completeness and acknowledges the procedures they are listed as performing
What is the attending paramedic
In instances where more than one patient is assessed, treated, and/or transported the paramedic shall complete this piece of documentation for each patient they assess.
What is a (n) ACR (call report)
An incident report will be completed in addition to the completion of this document.
What is a(n) ACR
Essential medical record for documenting information about circumstances and events relevant to the proper provision of ambulance services
What is a(n) ACR (ePCR)
All dates shall be documented in this fashion
What is year/month/day
By signing the form, this paramedic affirms they were present on the call with their partner, and acknowledges procedures they are listed as performing
Secondary paramedic (assisting paramedic)
A paramedic shall indicate the total number of patients assessed by their respective crew in this field on the ACR.
What is the patient(s) field
A crew has delayed patient contact due to a locked residence requiring PD entry. Patient was initially verbal through door, later found VSA upon access. An incident report will be expected from this medic prior to completion of shift.
What is both paramedics
A report that is completed in order to record details of an unusual event that occurs in the provision of ambulance service, such as an injury to a patient
What is a(n) incident report
According to the Documentation Standards, paramedics must complete reports in the following time frame
What is no later than the end of the scheduled shift during which the call occurred
This ‘category’ of errors, including run/call number, dates, and times, may be revised provided the revision does not affect any patient care details
What is administrative errors
A paramedic shall indicate which of the multiple patients the call report information refers to by filling out this field.
What is the sequence field
Oxford County's Incident Report Policy states paramedics shall complete the incident report within this time frame.
What is 24 hours
Unanticipated, unforseen accidents (e.g., patient injuries, care complications, or death) which are a direct result of the care dispensed rather than the patient’s underlying disease
What is harm
When CNO is documented on the ACR an explanation as to why this information is not available should be documented in the following section
What is the remarks section
Comments regarding reasoning for addendum must be filled in the following section
What is the remarks section
The paramedic shall indicate a separate ________ & ________ for each patient that is assessed, treated and/or transported.
Return Priority & CTAS
Once completed, incident reports are submitted to this organization.
What is the ministry of health
A companion document to this standard that sets out: standard documentation entry fields, minimum documentation requirements, definitions, standard electronic data entry formatting and other documentation requirements
What is the Ontario Data Dictionary for Paramedic Services (ODDPS)
This program is used by SWORBHP to deliver required quality assurance audits under Ontario Ambulance Documentation Standards, ensuring reports are accurate, complete, and detailed enough for meaningful review by healthcare and regulatory partners.
What is CARES
Should an error and/or omission or correction related to patient care content be identified after submitting a report, the paramedic would request for the following
What is an addendum
If triage tags are deployed for initial scene triage, this item shall be recorded in the remarks sections of the ACR
What is the triage tag number
In the past this type of call used to require an incident report, however this is not current practice.
What is (1) an obvious death, (2) a TOR (medical OR trauma), (3) multiple ambulances on scene