A correspondent writes:

I am a paramedic working for the Queensland Ambulance Service (QAS). When we attend a patient we are required to complete an electronic ambulance report form (aERF). This document contains patient details, our assessment findings, and subsequent management including medication administered and interventions performed. It includes past medical history, current medications, and importantly allergies.

The transition of a patient from our care, to that of the hospital includes the following the steps: providing verbal handover at triage, verbal bedside handover, then delivery of our printed records to the bedside. The electronic version is stored and may be downloaded for clinical governance purposes. This documentation may also be requested by external organisations including the police, the Office of the Coroner, OHO, and the patient.

Due to “operational demands” it has become an increasing occurrence that paramedics are being dispatched to other cases prior to their immediate completion of the eARF. In regions of high workload it may be many hours, and several other cases, before this documentation is completed. This means hospitals do not receive immediate, and sometimes never, documentation relating to the prior care of the patient. It also means that there are likely to be inaccuracies and potential omissions from the documentation.

As treating paramedics, what are our legal obligations when it comes to completing and providing timely documentation on a patient we have verbally handed over to hospital staff?  Without considering internal QAS policy on this matter, would a paramedic have a legal stance to refuse an order to attend a new case based on their belief they needed to complete important elements of their care of their current patient (such as medications administered and allergies)?

My concerns come from the findings of Coroner David O’Connell in the inquest into the death of Marcia Joyce Loveday (28 October 2013). The coroner seems to indicate his trust on the attending paramedic’s word based on their eARF completed prior to the paramedic’s knowledge a clinical incident had occurred. If we provide a verbal handover it seems we have no supporting evidence unless we also provide timely paperwork.

Without going into specifics, I am also aware of a situation where a hospital in our region placed a high degree of blame onto not identifying a rupturing Aortic Aneurysm on what they claimed was an insufficient verbal handover from the treating paramedic. My understanding is the paramedic’s documentation was used to support their version of events.

I appreciate if you are able to provide some clarity on this. I am concerned that operational needs or KPI’s, are overtaking the reason for our existence of providing a high standard of clinical care.

The Inquest into the death of Marcia Joy Loveday was held on 9-10 September 2013. The coroner’s findings were handed down on 28 October 2013.   Mrs Loveday was 74 years old. She had an extensive history with the Bundaberg base hospital.   In July 2010 she was taken to Bundaberg hospital by ambulance.   There she was given a penicillin injection even though she was allergic to penicillin. Her allergy was noted in the hospital records and she wore a medic-alert bracelet that also recorded her allergy (see ‘Ignoring a medic-alert bracelet’ July 19, 2015)). According to the coroner it was ‘… unclear whether she died as a result of the alleged anaphylaxis or her underlying conditions which caused her to present to the hospital’ [3]. The coroner’s task was to

… determine how and what caused her to die.

Central to these issues are the questions of how Mrs Loveday’s known allergy to penicillin was not made known to, or enquired about by, medical personnel in the Accident & Emergency Department … ([4]-[5])

On the day Mrs Loveday was taken to hospital she had rung 000 complaining of breathing difficulties.   The ambulance officers completed their eARF and it was noted that Mrs Loveday was allergic to ‘Penicillin; >> CECLOR, MINOMYCIN, KEFLEX’ [20].   The Emergency Department Clinical Record recorded under allergies – ‘CECLOR, MINAMYCIN, KEFLEX. Significantly, there is no reference to penicillin in this document’ [29].

An issue arose as to whether or not the paramedics had communicated that Mrs Loveday was allergic to penicillin. The triage nurse said that if they had said that it would have been recorded. The paramedic responsible for the hand over said that she did say it during the oral handover.   The patient was ‘handed over’ at 10.15am. The eARF was finished at 10.52am and ‘included penicillin in the known allergies’ [32]. The coroner said (at [34] emphasis added):

After viewing the ambulance officer and the nurse when giving evidence, I have formed a view that I accept the evidence of the ambulance officer that she told RN Blunt of the allergy to penicillin. I do this because the ambulance officer presented as a person who gave very straightforward evidence, could recall what occurred, and completed the reference to penicillin in her electronic report at about 10:52am that morning before she left the hospital. Of significance is that when the ambulance officer completed the electronic report (essentially as a contemporaneous note), she had no knowledge that Mrs Loveday had suffered a reaction due to her penicillin allergy.

A digression to the rules of evidence

Generally an out of court statement, like an eARF recorded, cannot be used to prove the truth of what it says because it is ‘hearsay’; that is evidence that someone said something is true is not proof that it is true. They have to come to court to give direct evidence of what they saw or heard. There are however exceptions to the hearsay rule. One exception is for business records (Evidence Act 1977 (Qld) s 92).   Business records are admissible on the assumption that they are created in the course of the undertaking in order to record the truth. They would not help the business if they are not accurate so it may be assumed or inferred that they are. Accordingly if the record records that something happened, that is evidence that it did happen; and if there is no record where one would expect one, that is evidence that the thing did not happen.

A patient case sheet is completed for a variety of reasons (see ‘First aid patient records – who and what are they for?’ (January 31, 2015)). The most important reason, in this context, is to ensure continuity of care.   The records would be useless if not correct so one can infer that they are intended to accurately record what happens. If the eARF records some action then that is evidence that the action occurred.

Putting the issue of admissibility aside, where a person has made a contemporaneous note of events they can, when giving evidence, use that note to remind themselves of what happened.   Here the note cannot be given in evidence but it can be used to refresh the witnesses memory. How close in time the writing has to be to be ‘contemporaneous’ would depend on all the circumstances.

These rules are important. It may mean that a paramedic may not need to go to court to given evidence as to what they saw or did as the court could just rely on the patient record. If they are required to give evidence they can use the record to refresh their memory as to what happened which will be important given the delay between the event and the day in court.

None of that is really relevant to my correspondent’s question other than to show that the court places faith in documents produced by ‘an undertaking’ (which would include a health service – see Albrighton v Royal Prince Alfred Hospital [1979] 2 NSWLR 165) and particularly when the notes are ‘contemporaneous’.

Further, it shows that regardless of the issues for continuity of care, accurate records completed at the time may well work in the paramedics own best interests.  As the coroner found, a report completed at the time and before anyone knows there is an adverse event is likely to be accepted over someone’s recollection of what was said or done.

Back to the question

As treating paramedics, what are our legal obligations when it comes to completing and providing timely documentation on a patient we have verbally handed over to hospital staff?  Without considering internal QAS policy on this matter, would a paramedic have a legal stance to refuse an order to attend a new case based on their belief they needed to complete important elements of their care of their current patient (such as medications administered and allergies)?

Paramedics and all health professionals have to act reasonably and in their patient’s best interests.   Current debates around paramedic professionalism include questions of whether paramedics need to transport everyone and whether or not they can leave patients at a hospital. For discussion on these issues see:

The issue in all these cases is a risk assessment. As I said in Paramedics leaving patients in casualty (January 24, 2015):

The question is always about duty and what does one’s duty require. A paramedic owes a duty of care to the person in their care, the ambulance service may owe a duty of care to a person that then rings triple zero but individual paramedics do not. How the reasonable ambulance service responds to that call requires consideration of the resources available, no emergency service can be resourced to meet every contingency so there will be occasions where demand exceeds supply. What this means is that there is a certain amount of ‘first come first served’.   Where a person is being treated by a paramedic that paramedic has a duty to act in their interest. They cannot just leave them because other people are ringing for an ambulance. There is no way of knowing whether the next patient is in a worse, or better, condition than the patient already being treated.

Because of that I would suggest that a blanket rule – leave your patient after 45 minutes, could not be reasonable. But a rule that says ‘you can leave your patient at the hospital if there is no value in staying in order to reasonably free up resources for others’ would be fine.

I would think the same applies with respect to the eARF. To use an example for that earlier post:

If … the person fell during sport and has been transported as there is a question mark over whether they have sprained or fractured their ankle, then one might make a clinical decision that they could wait on the waiting room chairs as well as on the stretcher and they don’t need a paramedic to talk to them and bring them a cup of tea, when other patients who have made their own way to hospital do not get such a service. In that case it may be reasonable to put the patient on the chair, let the triage nurse know and go.

And if there was no significant treatment to record on the eARF there may be little risk in leaving it if the paramedics are being asked to clear for an urgent task. On the other hand, if the patient has a life threatening condition and has received extensive treatment, including drug treatment from the paramedics, then ensuring that is recorded and handed over with the patient to allow their ongoing care is critical.   As noted above the ambulance service may owe a duty to get to other 000 callers as soon as possible, but the individual paramedic has a duty to continue to care for the person who is in their care.   Driving off without completing the eARF may be a remiss as simply dropping the patient at the door of A&E and driving away.

From a lawyer’s perspective, and ‘[w]ithout considering internal QAS policy on this matter’ I would suggest a paramedic has not only a ‘legal stance to refuse an order to attend a new case based on their belief they needed to complete important elements of their care of their current patient (such as medications administered and allergies)’ but an obligation to do so. Failure to do so would be a failure to properly care for his or her patient.

If that causes a delay for some other patient that would be an issue for the ambulance service. If it has a duty, it is a duty to take reasonable steps to manage its resources to provide appropriate patient care and if it fails to do that then any liability would belong to the service, not to a paramedic that was providing care to a patient. (It should be noted however that a person who has to wait for an ambulance cannot sue either the service or the government on the basis that more resources should be diverted to ambulance services and away from some other government priority (Civil Liability Act 2003 (Qld) s 35). The issue will always be did the service make reasonable use of the resources it had, not that the service should have had more resources).

If the paramedic thinks they can safely leave the person without finishing the eARF then they could do that and complete it later. That however creates a further risk. Assume that there is an adverse event – if the record is not ‘contemporaneous’ it will have less value and if there is a disagreement as to what happened, a court is not going to put much faith in a record completed at the end of a shift when a paramedic has seen multiple patients and is likely to forget details of those earlier cases. In that case omissions from the record may also be used to infer that there were omissions in patient care.

What if paramedics are registered?

One of the benefits of paramedic registration would be that paramedics would owe professional duties to their patients and their profession. These duties are independent of the duties they owe their employer. If paramedics were registered they would be in a stronger position to argue that they are not able to ‘clear’ for the next job as they have an independent, professional duty to complete the care for their current patient which must include ensuring an appropriate transfer of care. Part of that transfer must include accurate and complete documentation so that the treating health team have a complete picture of the patient’s history and treatment prior to arriving in hospital.


Paramedics are, or should be, regarded as health professionals. Their duty is not just to taxi people to hospital or provide a service their employer can charge for. Their duty is to provide care for the people they are called to treat as part of the complete health care team. To ensure that others can continue to provide the care that they start, they need to communicate with the health care team what they observed and the treatment already provided. In some cases an oral handover may be sufficient, in others detailed records will be required. It would be my view that a paramedic has a duty not to clear for a job until the handover, including the paperwork is complete, and their employer has a duty to allow them time to complete the paperwork.