Ontario Ambulance Documentation Standards

Preamble

Preface

The Ontario Ambulance Documentation Standards, as empowered under Ontario Regulation 257/00, Part V, Clause 11.1, is the Ministry of Health (MOH) standard by which Ambulance Service Operators, Paramedics, Emergency Medical Attendants (EMAs) and Regional Base Hospitals are to ensure the timeliness, accuracy, completeness, and distribution of patient care reporting, incident reporting and collision reporting documentation.

The Ontario Ambulance Documentation Standards are organized into 3 sections:

1. Conventions – standards that apply to all documentation completed by a paramedic performing patient care related duties for a certified Ambulance Service Operator. Including, but not limited to call reporting and incident reporting.
2. Patient care – standards applicable to all patient interaction documented on the Call Report.
3. Incident reporting – set out specific requirements of when and how incident reporting shall occur for Paramedics, Certified Land and Air Ambulance Service Operators and Base Hospitals.

This standard applies equally to paper based and electronic documentation.

Definitions

Addendum
When a change is made to a Call Report after the report has been completed (closed).

Ambulance Call Report (ACR)
An essential medical record for documenting information about circumstances and events relevant to the proper provision of ambulance services. Referred to as Call Report in this standard for consistency. (Includes ACR, and electronic versions eACR, ePCR)

Air Ambulance / Critical Care Transfer Unit Paramedic Call Report
The Air Ambulance / Critical Care Transport Unit (CCTU) Paramedic Call Report is an essential document for recording information about circumstances and events that are relevant to a call for ambulance service. Referred to as Call Report in this standard for consistency.

Ambulance Service Operator (ASO)
A person or organization certified to operate an ambulance service.

Regional Base Hospital Program
Same definition as “Base Hospital Program” in Ontario Regulation 257/00.

Biometric data
Refers to all data captured by electronic bio-medical equipment which includes but is not limited to:

• Vital signs
• Electrocardiogram results
• Cardiopulmonary Resuscitation (CPR) metric data
• Percentage of oxygen saturation
• End-tidal carbon dioxide measure
• All captured rhythm strips
• Any and all associated data files containing cardiac monitor date, ECGs, and vitals

Call
Refers to a request for ambulance service.

Call Report
Includes an Ambulance Call Report and an Air Ambulance / Critical Care Transfer Unit Paramedic Call Report.

Communications Centre
Includes Central Ambulance Communications Centres, Ambulance Communication Services, or any dispatch centre authorized by the Ministry to communicate with paramedics.

Canadian Triage and Acuity Scale (CTAS)
Based on the Prehospital CTAS Paramedic Guide as published by the ministry and may be updated from time to time.

Electronic documentation
Refers to a means of documentation, collection and retention of data using an electronic format which shall include all the same information that is included on the paper version of the report being generated.

Electronic service provider
A person or organization who supplies services for the purpose of enabling a person to use electronic means to collect, use, modify, disclose, retain or dispose of personal health information (PHI) or personal information (PI) and who is not an agent of the person.

Field
Refers to a specific location within a section of a Call Report or incident report where a paramedic enters specific types of information.

Harm
Unanticipated, unforeseen accidents (such as patient injuries, care complications, or death) which are a direct result of the care dispensed rather than the patient's underlying disease.

Incident Report
A report that is completed in order to record details of an unusual event that occurs in the provision of ambulance services, such as an injury to a patient. (see Section 3 - Incident reporting)

Investigation
Any review, inquiry, retrospective enquiry, probe or equivalent which is not a common and/or routine practice found within the Ambulance Service Operators Quality Assurance Program.

Ontario Data Dictionary for Paramedic Services (ODDPS)
A companion document to this standard that sets out:

• standard documentation entry fields
• minimum documentation requirements
• definitions
• standard electronic data entry formatting
• other documentation requirements

Paramedic
Paramedic has the same definition as set out in the Ambulance Act and for the purposes of the Standards also includes:

• An Emergency Medical Attendant as defined under the Ambulance Act and Ontario Regulation 257/00, as may be amended from time to time.
• Any other regulated health care provider described in Ontario Regulation 257/00 providing patient care and/or patient transport while engaged or employed by a certified air ambulance service operator.

Patient
Patient refers to 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.

Personal Health Information (PHI)
Personal health information as defined in Personal Health Information Protection Act (PHIPA).

Photography
Capturing a picture using any camera device, live streaming, video recordings, and any other image or audio capture or transmission technology which may be or become available.

Receiving Facility
An authorized hospital or health care facility or appropriate healthcare provider which receives patients from Paramedics.

Report(s)
Reports include:

• any Call Report
• Incident Report (IR)
• collision report

Section
Refers to an area of the Call Report where fields of similar types of information are grouped.

Transfer of Care (TOC) time
When paramedics accountability for patient care has ceased - applicable when the paramedic is transferring care to another person or organization.

Section 1 - Conventions

General requirements

This section applies to all reports as defined by this standard

Ambulance Service Operators and Paramedics shall comply with the following provisions respecting all reports required under the Ontario Ambulance Documentation Standards:

1. all documentation made under this standard shall be:
   • complete
   • accurate
   • legible and in English
   • in chronological order
   • secured from unauthorized access
   • not contain any false or misleading information
2. reports shall be made in either paper or electronic format provided that such reports contain all information required by these Standards and the sections shall follow the same naming/sequence to the report templates published by the ministry, as may be amended from time to time
3. the Ambulance Service Operator is responsible for ensuring:
   • documentation system functionality, redundancy planning and redundancy resources
   • collaboration with system partners to share available data which ensures:
     • seamless patient care
     • continuous quality improvement
     • regulatory oversight
     • system efficiency
4. reports shall be prepared in such a manner as to remain legible and readily accessible for review for a minimum period of 5 years from the date of the documented event.
5. where a report contains information that could identify a person who is a patient, the report and the information contained therein is subject to the confidentiality provisions of the Ambulance Act and the Personal Health Information Protection Act, 2004, and shall be secured from unauthorized access at all times.
6. the 24-hour clock format shall be used when documenting times:
   • dispatch time stamps shall include hours/minutes/seconds (HH:MM:ss) on paramedic documentation
   • dates shall be documented as year/month/day (YYYY:MM:DD)
7. the Ambulance Service Operator shall have and enforce a policy which applies to all front-line staff regarding photography, live streaming, and/or video recording ensuring any image or video captured complies to PHIPA rules.

There may be circumstances and situations in which complying with the Basic Life Support Patient Care Standards (BLS PCS) and/or the Advanced Life Support Patient Care Standards (ALS PCS), as published by the ministry and as may be amended from time to time, is not clinically justified, possible or prudent as a result of extenuating circumstances. Paramedics shall use all knowledge, training, skill and clinical judgment to mitigate any extenuating circumstances. Paramedics shall document any extenuating circumstances in the Call Report that preclude them from following the BLS PCS or ALS PCS.

Report completion

Timely completion and submission of report documentation and delivery is critical.

1. information contained in reports shall be of a quality suitable for use as evidence in an investigation or legal proceeding
2. paramedics shall complete reports as soon as possible following the event and no later than the end of the scheduled shift during which the call occurred
3. not withstanding point 2, an Ambulance Service Operator shall establish a local policy and process to manage report completion for situations when it is not operationally possible for a paramedic to complete a report during a scheduled shift:
   • the Ambulance Service Operator shall have knowledge of all outstanding reports that are not completed during the same shift which the call occurred
   • the Ambulance Service Operator shall have knowledge of when such reports are expected to be completed
   • such a policy shall be made in writing and shall be easy to refer to
   • such a policy shall not apply to patients with a return transport CTAS of 1 or 2

Documentation edits

Paramedics shall ensure all data entered is correct prior to submitting any completed report. Original patient care content or free text narratives made by paramedics shall not be edited, except in accordance with applicable law.

1. Administrative errors pertaining to run/call numbers, dates and times may be revised provided the revision does not affect any patient care details.

Should an error and/or omission or correction related to patient care content be identified after submitting a report:

2. documentation corrections or additions shall be completed only by means of an addendum
3. addendums shall be easily identifiable as additions to the original documentation
4. addendums shall appear in the remarks area of the report or a dedicated section in an electronic form
5. no existing fields within the report shall be altered in any way
6. addendums shall be date / time stamped to reflect when the addendum was added
7. any addendums to a paper form shall be written in the remarks section or a secondary paper form clearly marked “ADDENDUM”
8. reports containing addend shall be redistributed by the Ambulance Service Operator or designate as soon a reasonably possible

Quality assurance

Ambulance Service Operators shall have a Quality Assurance (QA) or Continuous Quality Improvement (CQI) program. A QA/CQI program shall be responsible for overseeing:

• documentation is accurate, and completed
• overall quality of organization/service documentation and records including but not limited to the reports identified in this standard
• ensure that sufficient information is provided in reports to facilitate meaningful review by health care and regulatory partners

Ontario Data Dictionary for Paramedic Services

As a companion to this Standard, the ministry has published a minimum data set for Ontario Ambulance / Paramedic Services (ODDPS). The purpose of the ODDPS is to:

• establish a uniform Minimum Data Set for Emergency Health Services Patient Care and Incident Reporting
• identify, define, and standardize common data elements
• standardize how patient care information resulting from paramedics is documented

The ODDPS outlines minimum Call Report field completion requirements based on call type.

Ambulance Call Report codes

Call Report codes shall align with those published by the MOH, which may be amended from time to time. Ambulance Service Operators shall notify the ministry in the event that there is a delay greater than 10 business days in the implementation of new ACR codes.

Electronic documentation

If an ASO utilizes an electronic version of the Call Report, the ASO shall ensure that the printable version of the Call Report includes all sections and fields of the paper Call Report.

An electronic documentation platform shall:

• conform to Health Language Seven (HL7) version 3 or above (for the purposes of clinical data)
• have the ability to operate in conjunction with a Health Information Exchange system
• have the ability to extract data in accordance with a defined data set
• use reasonable safeguards to protect personal health information from theft, loss, or unauthorized use or disclosure, as required by PHIPA
• allow for two-way electronic call data exchange (where available) between a Computer Aided Dispatch (CAD) system
• support closeout or close call rules as may be described in the ODDPS
• have the capacity to meet/support the requirements:
  • set out in this standard
  • set out in the ODDPS (as mentioned below)
  • to manage all Call Report codes as published by the ministry which may be updated from time to time

Section 2 - Patient care documentation

Paramedic documentation responsibilities

Not withstanding that the Paramedic operates within a system that has its own limitations, there is an inextricable link between the accuracy and thoroughness of information contained within completed documentation and the credibility of a Paramedic who authored said documentation. Accuracy and thoroughness are key to ensuring an effective patient handover and continuous clinical care. Credibility is also an important consideration during calls and during post-call inquiries.

The Paramedic shall:

1. Complete a Call Report for each request for service where paramedic(s) arrive at a location as directed by a Central Ambulance Communications Centre/Ambulance Communication Service (CACC/ACS), including where there is no contact with the individual for whom the request was made.
2. Complete a Call Report with patient health information after making contact with, assessing, and/or providing patient care to a patient. A separate Call Report shall be completed for each patient.
3. Document all assessments, clinical treatments and procedures (including a corresponding result) as required by the Basic Life Support Patient Care Standards (BLS PCS) and/or Advanced Life Support Patient Care Standards (ALS PCS)^{footnote 1[1]}
   • each assessment, treatment and procedure shall include a documented time of initiation
   • each assessment, treatment, and / or procedure that was performed shall indicate the crew member performing by number (1, 2, 3, 4 etc.)
     • The crew member number shall correspond to the crew member’s signature.
     • For any controlled act performed, only the paramedic who performed the actual controlled act, shall be entered as the paramedic performing that procedure.
4. document all factors that impacted the decisions to delay or withhold any specific treatment or procedure that would otherwise be indicated by a ministry patient care standard
5. ensure when a procedure code is used, the documenting paramedic shall provide a brief narrative to describe the procedure and result unless otherwise prescribed by the ODDPS^{footnote 2[2]}
6. ensure if information applicable to a section/field cannot be obtained, document “CNO” (Could Not Obtain) in the section/field. An explanation as to why this information is not available should be documented in the “Remarks” section of the Call Report or equivalent
7. ensure any associated clinically relevant biometric data will be either transferred onto the Call Report or stored in the charting applications database (according to local policy) in format that can be easily reviewed by health care practitioners and/or Call Report auditors
8. ensure if there a considerable time delay in accessing a patient, spent on scene or en route, an explanation of the reason is documented in the remarks section

At Risk Patients flagging

When a paramedic has grounds to believe the patient in their care is at risk^{footnote 3[3]}, the paramedic shall:

• flag (where available) or note on the Call Report remarks section their concerns
• ensure concerns are clearly communicate as part of the transfer of care process

Transfer of care

Where a patient is transported to a receiving facility, the paramedic shall:

1. provide the receiving staff with copies of any associated biometric data monitor print out of the patient (such as ECG / rhythm strips, monitor trends)
2. promptly advise the Communications Centre of Transfer of Care (TOC) time and document the TOC time on the Call Report
3. document on the Call Report where the patient was transferred to and to whom care was transferred to
4. complete the Call Report per ‘Report Completion’ (see Section 1 - Conventions)

Signatures

All paramedics present on a call shall attach their name, ministry identification number and signature on a Call Report when one is required by this standard.

• The attending paramedic shall ensure their signature is contained on a completed Call Report. By attaching their signature to the Call Report, the attending paramedic:
  • affirms the Call Report's content, accuracy, and completeness
  • acknowledges the procedures they are listed as performing
• Any assisting paramedic(s) shall attach their signature(s) to the Call Reports corresponding to the call that they responded to. By signing the Call Report, the assisting paramedic(s):
  • are affirming they were present on the call with the attending paramedic
  • acknowledges procedures they are listed as performing
• Students who are not working/volunteer paramedics shall:
  • be listed and sign the Call Report for all calls that they are present on
  • be listed for any intervention done by them
  • otherwise not participate in the completion of patient care documentation

Guideline – in cases where more than one ambulance resource from the same service arrives at a call, it is acceptable to complete one Call Report provided all paramedics present are listed and additional vehicles present are noted in the remarks section.

Multiple patients

• In instances where more than one patient is assessed, treated, and/or transported, a Call Report shall be completed for each patient assessed by a paramedic assessing said patient.
• The paramedic shall indicate the total number of patients assessed by their respective crew “Patient(s)” field.
• The paramedic shall indicate which of the multiple patients the Call Report information refers to by using the “Sequence” field.
• A separate Return Priority Code and CTAS shall be indicated for each patient assessed, treated and/or transported.
• Patients who are not transported shall be included in the sequencing.
• If triage tags are deployed for initial scene triage, the tag number shall be recorded in the remarks section.

Guideline

• On calls where more than one patient is present, the number of patients on each Call Report pertaining to said call, shall be the same.
• If no individuals were contacted/assessed, enter “0” for “Patient(s)” and “Sequence”.

Refusal of transport

In situations where a patient with capacity is refusing transport:

1. the paramedics shall request the patient/patient’s substitute decision maker (SDM), and any witness^{footnote 4[4]} to sign the appropriate sections of the patient refusal section of the Call Report
   • Note: The patient or SDM may be linguistically or physically unable to, or may refuse to sign the Refusal of Service section of the Call Report. There is no obligation on the patient or SDM to sign the Call Report.
2. if the patient/SDM, or witness refuse to sign the form, the paramedic shall document the circumstances of the refusal in the “Remarks” section of the Call Report
3. if there is only one paramedic attending a call, the paramedic is to make every effort to have a witness sign the form

Consent not given

In situations where a patient does not consent to a required assessment or intervention as per the BLS PCS or ALS PCS, the paramedic shall:

• ensure the patient/SDM has capacity / is capable to refuse consent as detailed in the BLS PCS and ALS PCS^{footnote 5[5]}
• if consent to assessment and/or treatment is not given or is withdrawn at any time, the paramedic shall document as such in the procedure section of the Call Report followed by the reason the patient/SDM did not give such consent

Ambulance Service Operator responsibilities

Notwithstanding that ambulance service operation and delivery occur within a system that has its own limitations, ambulance service operators play an integral role in upholding the Standards for accurate and complete documentation, through their quality assurance and continuous quality improvement activities. Good documentation supports high quality patient care and improves patient care provision within emergency health services and beyond.

Distribution/Transmission

Ambulance Service Operators shall ensure:

1. Call Reports are disclosed as follows:
   • the receiving facility, department or the coroner^{footnote 6[6]}, as applicable^{footnote 7[7]}
     • As a guideline, the design of this copy could/may be a clinical Call Report as set out in the ODDPS.
   • receiving hospital billing office
     • The design of the billing copy shall omit clinical treatment details and be limited to billing-specific information (Billing Section).
   • Base Hospital
   • ambulance service
     • This copy is retained by the Ambulance Service Operator for their records and shall include all biometric data.
2. in conjunction with the area health care facility/facilities, community care partners (where applicable), and/or Regional Base Hospital Programs, establish a transmission process for electronic documentation that allows for timely Call Report routing:
   • completed Call Reports shall be transmitted without delay to the hospital department or health care facility where paramedics brought the patient
   • Ambulance Service Operators shall have a written transmission process for all hospitals/health care facilities in their borders
   • such documents will not be proprietary
3. completed Call Reports and the associated biometric data shall be disclosed to the base hospital for medical oversight within 48 hours of the date on which the Call Report is completed

Clinical Call Report

An Ambulance Service Operator using an electronic documentation system capable of exporting Call Report data into multiple formats, may elect to design an abbreviated clinical Call Report for receiving facility/facilities and community care partners (where applicable). The purpose of this Clinical Call Report is to eliminate non-pertinent operational data.

This standard applies equally to Ambulance Service Operators and Paramedics where a Clinical Call Report is being transmitted to a hospital.

Clinical Call Report content shall include the minimum requirements listed in the ODDPS.

Section 3 - Incident reporting

Incident reporting requirements

Effective incident reporting by all partners involved in the prehospital environment leads to improved patient outcomes and helps drive positive systemic change. Transparency and shared accountability through incident reporting, self reporting and identifying unsafe conditions is crucial to ensure patient safety, system safety and the adaptation of a safety culture though positive and collaborative improvement.

• All Incident Reports and/or Incident reporting required by this standard shall be sent to the ministry as described in this section within 2 business days from the time that the incident first occurred.
• Any incident report sent to the ministry shall include the full Call Report for any instance where a Call Report is required and has been completed.
• All Incident Reports shall follow the format prescribed within the incident report templates. (See Appendix A)
• An Ambulance Service Operator or Regional Base Hospital Program shall send all incident reports via an approved electronic process. (Faxes are not acceptable)

The following 3 sections outline when a Paramedic, Service Operator, or Regional Base Hospital Program shall complete and send an Incident Report to the ministry.

Paramedics

Paramedics shall complete an incident report which will be sent to the ministry for the following incidents:

• harm to a patient while receiving care from paramedic(s)^{footnote 8[8]}
• deviation or omission of a ministry standard, patient care directive, treatment which caused^{footnote 8[8]}
  • harm or deterioration to a patient, or
  • a negative outcome to a patient
• a delay in accessing a patient that caused:
  • harm or deterioration to a patient, or
  • a negative outcome to a patient
• malfunctioned, missing or unavailable:
  • patient care equipment while assigned to a patient call
  • medications (not related to supply shortage) during patient care, or
  • vehicle while assigned to a patient call
• an unresolved incident of missing or unaccounted controlled substances^{footnote 8[8]}

Ambulance Service Operator

A Paramedic/Ambulance Service Operator or designate shall report the following incidents to the ministry:

• at the beginning/initiation of an investigation into any aspect of the Ambulance Act, Regulation or ministry published standard
• any external information request from a coroner
• upon discovering any staff member does not meet any regulatory requirement as required by Ontario Regulation 257/00
• upon the receipt of any complaint related to:
  • the provision of patient care
  • service delivery, or
  • the contravention of any ministry standard
• any unresolved incident of missing or unaccounted controlled substances

A service operator may elect to adopt local policies or processes that use incident reports/reporting for additional purposes not listed in this standard (such as workplace injuries, other unusual occurrences). Such reports are not required to be sent to the ministry provided the aforementioned reporting criteria does not apply.

Regional Base Hospital Program

A Regional Base Hospital Program (RBHP) shall report the following incidents to the ministry:

• any RBHP initiated investigation (or equivalent) related to
  • a major or critical clinical^{footnote 9[9]} error or deviation resulting in RBHP imposed^{footnote 10[10]}
    • a formal remediation plan
    • an education plan
    • increased post review call audits
  • identifying anyone associated with the Regional Base Hospital Program that has falsified documentation or credentials
• any information request or inquiry from a coroner
• any non-administrative paramedic deactivation
• any non-administrative paramedic decertification
• any RBHP imposed paramedic step down (ACP to PCP or CCP to ACP, for example)

On a monthly basis a Regional Base Hospital Program shall notify the following to the ministry:

• any complaint(s) related to patient care received
• patch failure(s) with patient impact

Collision or crash reporting

An Ambulance Service Operator or designate shall report the following incidents to the ministry:

Collisions involving any land ambulance vehicle, including a:

• patient transport vehicle
• emergency response vehicle
• emergency support vehicle/command vehicle
• administrative vehicle

while en route to calls and causing a delay, transporting patient(s) and causing a delay or causing human injury shall be reported to the ministry within 2 business days from the time of occurrence.

The collision report shall include a detailed chronological description including the following information where at a minimum applicable:

• weather conditions
• road conditions
• type of road surface
• posted speed limit
• amount (high/medium/low), type (passenger cars, trucks) and flow (slow, fast) of traffic
• light conditions (day/night)
• significant events before, during and after collision
• approximate speed of vehicle(s) involved
• direction of vehicle(s) involved
• details of human injury (if any)
• vehicle damage
• property/environmental damage
• include a diagram/photo if relevant

Appendices

Appendix A

Generic incident report - Paramedic

Generic incident report – Service

Generic incident report – RBHP