I’m asked if I would

‘…  be so kind as to address this situation with the legal obligations and correct practice with regard to a “PCR” (patient care report)?

A paramedic working alone, on day shift, assesses and treats a high acuity pt. On the handwritten detailed PCR document which contains the patient’s personal details, condition, history, age, address, and phone number, etc. The ph number has the last 2 digits 5&1 joined at the top.

The next shift with the next paramedic takes over for the night shift, 5 hours after the patient was transported to the hospital. The oncoming paramedic goes through the PCR during their shift and doesn’t like the way the phone number is written, so crosses it out and writes it below.

Is this legal?’

Whether it’s ‘legal’ or not depends on why it was done. If it was simply to make it more legible, and if it was clear that there was a change then it’s not ‘illegal’ but one would wonder why anyone would bother.  In the unlikely event that the record is ever subject to forensic analysis (ie is the subject of examination and cross-examination) it may lead to unnecessary questions, but it’s not illegal per se. And if one paramedic gets into the habit of editing another paramedics case sheet it will make the case sheets irrelevant if they don’t record the treating paramedics observations and actions; but there is not law that I’m aware of that says that such an action would be an offence.

If the motivation was some sort of fraud or other improper purpose then it’s the purpose rather than the actual annotation that is the problem.

Having said that, Peter (in a comment below) makes the important point that it is important to know how and why the second paramedic had access to the record. If he or she had a supervisory role and it was part of their duty to review the record, fair enough. But if the records were simply left unsecured in the station and the second paramedic was reading them for fun, or for interest, then that does raise serious issues of privacy and document control – and there the issue is not so much about the addition but about how and why the second paramedic had access to the documents in the first place.