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.
In response to “legal obligations and correct practice” it is also necessary to take a step back and ask under what circumstances or for what purpose did the second paramedic have access to the PCR. Does the custodian have appropriate security procedures for dealing with PCR’s that meet the privacy requirements in their jurisdiction? Was the record not secured appropriately by the first paramedic? Was the second paramedic approved by the custodian to access the records (i.e. to audit them or some other purpose)? Was the purpose for accessing the PCR within the privacy principles or relevant legislation for the jurisdiction? Unless that paramedic was involved in the continuum of care, had some form of sanctioned purpose or consent, they perhaps were not complying with the privacy legislation or the professions code of conduct when they accessed the record in the first place. The oncoming paramedic should not just go looking out of interest through identifiable PCR’s completed in the previous shift.
They are good points that I hadn’t considered.
The PCRs are kept in the clinic’s safe. Where all Paramedics onsite have access.
Case notes are kept along with the PCR which is photocopied, in files on the computer for us to access. This practice is done so we can follow up the pt for post incident care for Return To Work purposes. I do not see the need to change the PCR. There are numerous ways to find the pt’s ph number including on the case notes.
This has brought up some contention between us. She is not my senior.
Presumably you are working in industry not in a jurisdictional ambulance service. I do think changing the PCR may be problematic and is probably unnecessary but I can’t see that it’s illegal.
…and thank you for addressing this querie. 🙂