What is the primary purpose of BCEHS clinical documentation?
To provide an accurate, complete record of assessment, treatment and patient response, ensuring continuity of care and medicolegal protection
When should documentation be completed?
As soon as possible after patient care transfer or call completion - no rolling documentation
What must be documented if a protocol is not followed?
Rationale for deviation and any alternative treatments provided
What 6 elements must be included in every PCR?
Assessment findings, treatments, patient response, times, vital signs, clinical reasoning
What is required before providing treatment to a competent adult?
Informed consent
What 3 elements make a patient capable of providing consent?
Ability to understand information, appreciate consequences, and communicate a choice
What is implied consent?
Consent assumed in life-threatening situations when a patient cannot provide consent
Who can provide substitute consent when a patient lacks capacity?
A legally authorized substitute decision maker (representative, guardian, etc.)
