Patient care record policy – changes from recent incidents

The patient care record (PCR) policy is currently under review, to take into account learning from incidents and complaints and will be re-published shortly.

Following two serious incidents, staff are advised to note the following points in the interim and ensure future practice adheres to;

• ECG summary print outs must be secured to the shift log summary sheet at the end of the shift. These should be monitored by duty locality officers prior to submission to their locality office. Under no circumstances should they be submitted loose or attached to the care record when a paper one is completed, as these records cannot be reconciled following scanning and archiving processes. 
• Cardiac arrest patients - all relevant information must be recorded for any patient who has an airway inserted as part of their care, including; oxygen saturation, end tidal CO2 and any times that the patient is moved e.g. transfer from scene to vehicle.

Published 9th January 2015