Policy:
Documentation and Submission of ACRs
Owner of Policy:
Professional Standards
SLT Sponsor:
Regional Medical Director, Regional Program Manager
Department/Program:
Southwest Ontario Regional Base Hospital Program
Approval By:
Regional Program Manager
Original Effective Date:
April 2011
Reviewed Date(s):
May 2012, March 2014
Date: April 2011
Revised Date(s):
September 2012
PURPOSE
To ensure that all Ambulance Call Reports (ACRs) are completed in accordance with current Ministry of Health and
Long Term Care (MOHLTC) (Emergency Health Services Branch) ACR Completion Manual and EMS MDS V1.1
Data Dictionary.
PROCEDURE
The Southwest Ontario Regional Base Hospital Program (SWORBHP) will assess compliance to patient care
standards through ACR audits and patch form reviews. The Employer is required to provide all information on the
Ambulance Call Report (ACR) forms in paper and/or electronic format to SWORBHP as soon as possible following
the call. The Employer will ensure that a minimum data set feed is available to SWORBHP from their e-ACR vendor
as indicated in EMS MDS V1.1 Release Jan 2011. A skill inventory may be requested for annual report purposes.
In addition to the ACR Completion Manual, SWORBHP requires the following documentation practices:
1.
2.
3.
4.
5.
Paramedics must complete all ACRs with delegated medical acts immediately or as soon as it is safely
possible, operationally (as required by the Ambulance Act; Ontario Regulation 257/00) documenting all
procedure codes pertaining to the patient care administered.
Paramedics must initial procedures that were initiated by them.
Paramedics must request the “patch number” from the Base Hospital Physician (BHP) during the BHP patch
and document the number on the ACR.
Ambulance Services using paper ACRs, must place all documentation associated with a VSA call in the VSA
envelope provided by your local SWORBHP site.
Ambulance Services using paper ACRs must affix a copy of the rhythm strip (ideally at least ten (10) seconds
long) to the yellow copy of the ACR for all calls involving the use of a cardiac monitor and/or 12 Lead ECG.
Those using electronic ACRs must upload the ECG record to the ACR file and if the ECG cannot be uploaded,
a copy of the ECG must be provided to the Medical Director for review (preferred via e-mail or hard copy).
Documentation requirements for First Response Paramedics
A first response Paramedic who has made patient contact must complete an Ambulance Call Report (ACR)
according to currently acceptable documentation standards.
Ambulance Services Utilizing Field Electronic ACR’s
The Employer, in conjunction with their electronic ACR provider, will ensure that ACR data streams regularly to
SWORBHP. In addition to ACR data streaming to SWORBHP, all ECG data should be uploaded with the respective
electronic ACR.
Ambulance Services Utilizing Field Paper ACR’s
The Employer is required to forward (at minimum once weekly) the yellow copy of all ACRs to their local
SWORBHP site.
Reference
EMS MDS V1.1 Data Dictionary
MOHLTC ACR Completion Manual