This summary indicates the topics that are to be discussed. At the end of the discussion, you should understand:

Some of the following information contains excerpts from St. John Canada Instructions 2-7-4, Patient Care Records, and the General Orders (Toronto Area) – Duty Scheduling & Management.

The St. John Ambulance Brigade is often the first link in a chain of health care professionals that will treat an ill or injured person. The continuity of appropriate care for each patient may be determined by the documentation provided on the Patient Care Record (PCR) form. It is essential that this documentation is accurate and concise.

The primary goals of the Patient Care Record (PCR) are:

a. to document the patient's condition and treatments and/or actions taken by the patient care provider; and

b. to document information as a means of communication to other health care providers and, therefore, to provide the best possible care for the patient. The PCR is also a legal document.

Adhering to the following guidelines will help ensure accurate patient documentation:

a. complete thorough documentation during and immediately following the intervention;

b. be concise and specific, using lay terms and avoiding short forms if possible;

c. indicate clearly on the form if informed consent was obtained;

d. record to whom responsibility of care is turned over, including the time and the patient's status at that time;

e. all patients must be advised to seek further treatment from a physician, either immediately or at some time in the future.

All PCR's must be treated as confidential documents. The information provided in them is only to be divulged to those who are providing care or are taking over the medical care after St. John has finished. This applies, in particular, to the yellow carbon copy forms attached to the original white copy of the PCR. The yellow form should always be attached when submitted to the duty coordinators unless it is requested by medical personnel only. Event organizers are not entitled to any information which reveals the person's name or personal information. All requests for access to these forms must be made in writing to the Toronto Branch. All members, cadet and adult, participating in any way with the patient’s treatment should record their names on the PCR form.

The PCR is the only documentation that offers proof of the type and level of care that was provided by St. John Ambulance to the patient. Be aware that these records may be called upon for use during legal proceedings, a coroner's inquest, insurance claims, worker's compensation claims, etc. Timely and accurate completion of the PCR will assist you in answering for your actions in a secure and competent manner if you are called upon to do so.

All of the information that is documented should be accurate and concise. However, there should be enough detail to thoroughly explain your actions and the information obtained. If there is not enough room on the front, you can continue to document on the back of the PCR. Short forms are not normally used, but there are a few acceptable (unofficial) abbreviations that are commonly used when documenting:

If you are unsure about the abbreviations, please write the words in full. Please consult one of the officers on using other abbreviations.

The following contains excerpts from The Human Body in Health and Disease, by Gary Thibodeau and Kevin Patton, published by Mosby Year Book, 1992.

Some injuries may require you to specify the exact location of an injury. In these instances, it is often helpful to document the injuries using relative positions (refer to Figure):

1 – Superior and inferior – superior means "toward the head / upper / above"; inferior means "lower / below."

2 – Anterior and posterior – anterior means "front / in front of"; posterior means "back / in back of."

3 – Medial and lateral – medial means "toward the midline of the body"; lateral means "toward the side of the body / away from its midline."

4 – Proximal and distal – proximal means "toward or nearest the trunk of the body / nearest the point of origin of one of its parts"; distal means "away from or farthest from the trunk / or the point of origin of a body part."

5 – Superficial and deep – superficial means nearer the surface; deep means farther away from the body surface.

6 – Supine and prone – supine and prone are terms used to describe the body lying in a horizontal position. In the supine position the body is lying face upward, and in the prone position the body is lying face downward.

Examples: "An abrasion about 10 cm in length, sustained in a direction distal to the knee, located on the anterior side of the lower left leg."; "A suspected closed fracture of the radial bone in the forearm, with swelling and deformity visible on the lateral side of the lower right arm (forearm)."

All of these relative positions are discussed when the body is assumed to be in the anatomical position. In this reference position the body is in an erect or standing posture with the arms at the sides and palms turned forward. The head and feet also point forward. The anatomical position is a reference position that gives meaning to the directional terms used to describe body parts and regions.

An obese male adult was climbing a flight of stairs for a workout in his building, when he felt a sharp pain in his chest. As a result, he fell down about ten steps, ending up on the landing. You happen to be going down the stairs at 4:00pm, November 1^st, 1998, when you find him conscious, with shortness of breath. His skin looks pale, and is sweating profusely. No hazards were found. Unfortunately, it seems that he forgot to wear his deodorant this afternoon.

You identify yourself (somewhat reluctantly) as a first aider and offer to help, to which he gives his consent. He complains of chest pains radiating to his neck and shoulders. He is also complaining of dizziness, nausea and shortness of breath. After the primary assessment, you find no signs of severe bleeding. He does not have any pains in his head or neck (other than the radiating pain), and has no trouble moving them.

It is 4:05pm. The skin is pale, and covered with sweat. The pulse rate is 95 beats per minute, weak and rapid. The respiration rate is 12 breaths per minute, shallow and rapid. The pupils are equal and reactive to light. He is still fully conscious. You decide to call an ambulance at this time, using your handy dandy $300 Digital PCS phone.

Signs and symptoms are listed above. After asking him a few questions, Mr. John Doe reveals that he is allergic to penicillin. He takes nitroglycerine, 1 tablet whenever he experiences chest pains, by placing it underneath his tongue. He says that he has a history of heart conditions, and has experienced one heart attack about one year ago. He also mentions that he never takes Aspirin or Tylenol. He last ate a double cheeseburger with fries at around 3:00pm. Fortunately for you, he mentions that he does not feel the need to vomit at this time. He also explains what happened before you arrived.

Your thorough examination reveals that his right wrist is swollen and he experiences pain when he tries to move it; therefore, you suspect a fracture. No other injuries were found.

The treatment will be left up to you to decide and document. Make assumptions if necessary.

It is 4:17pm. After treatment, you decide to take a second set of vital signs. The skin is pale, and covered with sweat. The pulse rate is 82 beats per minute, weak and regular. The respiration rate is 22 breaths per minute, full and regular. The pupils are equal and reactive to light. He is fully conscious.

Mr. John Doe lives at 46 Wellesley St., Apt. 666, Toronto, M4Y 1G5. He was born on November 1^st, 1950. His telephone number is 416-WOS-I-BIG (416-967-4244).

Toronto Ambulance #917 arrives at 4:20pm to transport the patient to St. Michael’s Hospital. The attendant requests a copy of your Patient Care Record.