First Aid Records: What Employers Must Document

Last updated: March 2026

Someone on your crew cuts their hand. Your first aider cleans and bandages it. Everyone goes back to work. Three months later, an OHS officer asks to see your first aid records for the past year. You open a drawer and find nothing. No log, no form, no documentation that the treatment ever happened.

At Safety Evolution, we see this gap constantly when onboarding new clients. The first aid treatment happens. The record doesn't. It's the simplest documentation requirement in your entire safety program, and it's the one most contractors forget because nobody teaches them what to write down.

First aid records are written documentation of every first aid treatment provided to a worker at your workplace. Both BC (OHS Regulation s.3.19) and Alberta (OHS Code Part 11) require employers to maintain these records, keep them for at least 3 years, and restrict access to protect worker privacy. These records are not just a compliance checkbox; they're the starting point for incident reporting, trend analysis, and COR audit documentation.

For the full picture of employer first aid obligations, see our workplace first aid requirements guide.

What Must Be in a First Aid Record?

Every first aid treatment provided at your workplace needs a record that captures the following:

• Date and time of the injury, illness, or exposure
• Name of the injured worker
• Nature of the injury or illness (what happened, what body part was affected)
• Circumstances (how the injury occurred, where on site, what activity)
• First aid treatment provided (specific care given, not just "treated")
• Name and certification level of the first aid attendant who provided treatment
• Whether the worker was referred for further medical attention
• Follow-up actions taken (if any)

The record doesn't need to be fancy. A dedicated logbook at the first aid station, a standard form, or a digital entry all work. What matters is consistency: every treatment, every time, same information captured.

Most contractors think a first aid record means writing "John cut his finger" on a piece of paper. They're wrong. That's not a record; that's a sticky note. A proper record documents enough detail that someone reviewing it months later can understand what happened, what care was provided, and whether follow-up was needed.

How Long Must Records Be Kept?

Both BC and Alberta require first aid records to be retained for at least 3 years from the date of the injury or illness.

In BC, OHS Regulation s.3.19 specifies this retention period. In Alberta, the OHS Code requires records to be kept for at least 3 years from the reported date of injury or illness.

Three years is the legal minimum. Many safety professionals recommend keeping records longer, especially if:

• The injury led to a WCB claim (claim-related records may need to be kept for the duration of the claim)
• The injury involved an occupational disease with a latency period
• Your company is in active or pending COR certification (auditors may review historical records)

When in doubt, keep records longer than required. Storage is cheap. Producing a record from three years ago during an investigation is valuable. Not having it is costly.

Who Can Access First Aid Records?

First aid records contain personal health information. Access must be restricted to:

• The employer (for compliance, reporting, and safety management purposes)
• The injured worker (their own records)
• Joint health and safety committee members (for trend analysis, with individual names removed where possible)
• Provincial regulators (WorkSafeBC, Alberta OHS) during inspections or investigations
• WCB/WSIB if the injury results in a claim

Do not post first aid records in common areas. Do not discuss specific injuries with other workers unless there's a safety reason (like alerting the crew to a new hazard). Treat these records like the medical information they are.

A 30-person plumbing contractor in Calgary made this mistake: they kept their first aid log open on a clipboard in the lunchroom. Every worker could see who got treated, for what, and when. An OHS inspection flagged it as a privacy violation. The fix was simple: move the log to a locked file in the foreman's office. But the citation could have been avoided entirely.

How Do First Aid Records Connect to Incident Reporting?

First aid records are not the same as incident reports, but they're closely connected. Here's how they fit together:

• First aid record: Documents the immediate treatment provided. Created by the first aid attendant at the time of treatment.
• Incident report: Documents the broader incident, including root causes, contributing factors, and corrective actions. Created by the supervisor or safety coordinator.

Not every first aid treatment triggers a full incident report. A minor cut that's cleaned and bandaged may only require a first aid record. But any treatment that involves:

• Lost time from work
• Medical attention beyond first aid
• A near-miss that could have been more serious
• A hazard that could affect other workers

should also trigger your incident report and investigation process.

The first aid record becomes the starting document for the investigation. It captures the "what happened" and "what care was given" that the investigation builds on.

What Do COR Auditors Look For?

If you're pursuing or maintaining COR certification, auditors will review your first aid records as part of the health and safety management system evaluation. They're checking for:

• Completeness: Are records being created for all treatments, or just the serious ones?
• Consistency: Are the same fields captured every time? Is the format standardized?
• Retention: Can you produce records from the past 3 years?
• Integration: Do first aid records connect to your incident reporting and corrective action systems?
• Trend analysis: Are you reviewing records periodically to identify patterns?

The last point catches contractors off guard. Auditors don't just want to see that you keep records. They want to see that you use them. If your first aid log shows five hand lacerations in six months on the same crew, and you never investigated why, that's a gap in your safety management system.

Setting Up a First Aid Record System

You don't need software to start. Here's a practical system that works for most contractors:

1. Create a standard first aid treatment form. One page with fields for all required information. Keep a stack at every first aid station.
2. Train your first aiders to complete it. Not just how to fill in the fields, but when. The record should be completed immediately after treatment, not the next day from memory.
3. Establish a filing system. Chronological order in a dedicated binder or folder, stored in a locked location with restricted access.
4. Set a monthly review cadence. Someone (the safety coordinator, the owner, or the designated first aider) reviews the past month's records for completeness and patterns.
5. Connect to your incident process. Any first aid record that meets your incident reporting threshold should automatically trigger your investigation procedure.

If you want to go digital, Safety Evolution's training and compliance platform tracks first aid records alongside certifications, inspections, and incident reports in one system.

Common Mistakes With First Aid Records

These are the patterns we see during safety program audits that cost contractors audit points and compliance citations:

1. Recording only serious injuries. The small cuts and tweaked backs get treated but never documented. Regulators and auditors expect records of all treatments, not just the dramatic ones.
2. Vague descriptions. "Hurt hand" is not useful. "Laceration to right index finger from utility knife while cutting drywall" tells the story and supports trend analysis.
3. Missing attendant information. The record doesn't identify who provided the treatment or their certification level. This is a required field.
4. No referral documentation. Worker was sent to the hospital but the first aid record doesn't mention it. The handoff to medical care is part of the record.
5. Records destroyed too early. Moving offices, changing foremen, or clearing out old files sometimes takes first aid records with it. Establish a "do not destroy before" date on every file.

The blunt truth: most first aid record problems aren't about having the wrong form. They're about not using any form at all. Start with a basic template and improve it over time. Any record is better than no record.

For more on building first aid into your broader safety program, see our guides on BC first aid requirements and Alberta first aid requirements. For training your crew on first aid certification, we have a dedicated guide.

Using First Aid Records for Trend Analysis

Keeping records is the legal minimum. Using them is what separates contractors who pass audits from contractors who actually reduce injuries.

Once a quarter, pull your first aid records and look for patterns. You do not need software for this. A spreadsheet or even a manual count on paper works. Ask these questions:

• Are the same body parts showing up repeatedly? Three hand lacerations in two months on the same crew points to a tool issue, a PPE gap, or a training problem. That is a corrective action trigger, not a coincidence.
• Is one crew or one site generating more treatments than others? Uneven distribution of first aid events across crews often reveals differences in supervision quality, tool condition, or task planning.
• Are injuries clustered at certain times? A spike in treatments during the last two hours of a shift may indicate fatigue. A spike on Mondays may reflect weekend rust or inadequate toolbox talks.
• Are minor treatments escalating to medical referrals? If first aid records show a pattern of workers initially treated on site and then sent to the hospital within 24 hours, your first aiders may need refresher training or your threshold for referral may be set too low.

Document your findings. Write a short summary each quarter noting what you found and what action you took. This is exactly the kind of evidence COR auditors want to see: proof that your safety program is not just collecting paper but acting on information.