A senior St John Ambulance officer has written to me and given permission to put this question on my blog.  My correspondent says:

It appears that there are no legislative requirements that prevent under 18 members of St John from signing Patient Record Forms that are not countersigned. Would this be correct? And if so, do you think it is still good risk mitigation to have under 18s completing PRFs to have them countersigned by an adult member? Appreciate any advice you can offer and happy if you want to use this question for your blog.

A patient record form is a record of what was done.   It forms a business record for the purposes of evidence law which means that it can be used in court to prove that what is recorded on the form is true.  That is if you write on a patient form that you gave two panadol, that is evidence that in fact you gave two panadol even though, strictly speaking, the record is ‘hearsay’ (which I won’t explain in detail here).  To fall within the business record exemption to the hearsay rule the document must be produced in the normal course of operations and without anticipation of litigation, so a record filled in after someone has started court proceedings is not admissible as it is likely to be self serving.  But a system that is designed to record the truth whether it’s recording how many widgets were delivered in order to prepare the bill, or what treatment was given in order to keep a record of numbers treated and to provide continuity of care when a person is delivered to further medical aid, is admissible on the assumption that it does in fact record the truth (see Evidence Act 1995 (Cth) s 69; Evidence Act 2011 (ACT) s 69; Evidence Act 1995 (NSW) s 69; Evidence (Business Records) Interim Arrangements Act 1984 (NT); Evidence Act 1977 (Qld) ss 92 and 93; Evidence Act 1929 (SA) s 45a; Evidence Act 2001 (Tas) s 69; Evidence Act 2008 (Vic) s 69; Evidence Act 1906 (WA) s 79c).

There is indeed no legislative requirement that documents must be signed by a person over the age of 18.  Is it ‘good risk mitigation to have under 18s completing PRFs to have them countersigned by an adult member?’ It depends on what the purpose of the document is and what risk you have in mind.   Let us assume that the Patient Record Form is to record the patient’s details and the details of the treatment given.

If the only person treating the patient was aged under 18, then he or she must, of necessity, sign it and by signing it they are by implication verifying the truth.  What risk is there in them signing it?  None at all.   There may be a risk in letting under 18 year olds treat unsupervised (and of course there’s  a risk in letting anyone treat another unsupervised, but that does not mean it is a risk that cannot be taken).   What is recorded on the form won’t affect that risk.

Having someone sign off the form, after the event, does not affect the risk that the person will have provided inappropriate treatment.  Having someone else ‘sign off’ the form may be a process to say ‘we checked what the member did and were satisfied that it was appropriate’.   That’s only meaningful if the person over the age of 18 did in fact check it and was in fact so satisfied and if not so satisfied took some steps to contact the person involved and tell them eg that they should not go home but should seek medical care or take the ice pack off after 20 minutes or just counsel the under 18 member of what they should have done.  But that’s equally true whether the treating member is or is not over the age of 18.  19 year olds, and 40 year olds, can all make mistakes too, and having someone check the forms to make sure the treatment looked appropriate and that the form was completed properly (had all the necessary details recorded) could be a useful step, regardless of the member’s age.

Where one member is doing the treating and the younger member is in effect ‘the scribe’ recording what’s going on, then the form should be signed by the person who actually did the treatment to confirm that what has been recorded is accurate.  Equally the name of the scribe should be on it and their signature would also, by implication, verify that it is accurate.  Again the issue here is making sure what is recorded is accurate and that should be the same regardless of the member’s age, so if a 20 year old is the scribe, the treating member should still sign it. 

Finally where there are two members are working in a team and the younger member is actively involved in the treatment then yes, both people who were involved in the treatment should sign the form to confirm that it is accurate. That would be particularly important if the person under 18 is taking the primary role in the treatment but under the active supervision of the more experienced member in which case that more experienced, and presumably older member is taking responsibility for the treatment even though he or she was supervising rather than actively treating; but again it makes no difference whether one or both of the members are under or over 18 if one is supervising or working with the other. 

So if members under the age of 18 are treating patients without supervision by members over the age of 18, then what is the purpose of ‘countersigning’ the form?  In that case it can only be to say ‘we checked it’ and then that raises the issue of whether you think under 18s pose an extra risk to the people they treat.  If the answer to that question is ‘yes’ why are they allowed to do it?  In that case the answer is not ‘get someone to counter sign the patient record form’ it’s ‘don’t let under 18s treat without adult supervision’.     If, on the other hand, persons under 18 (assuming they hold all the relevant qualifications) are no less competent than persons over the age of 18 then having another member review the treatment and countersign if satisfied that it all looks appropriate may be useful quality assurance but there is no reason to limit that to persons under the age of 18.