The purpose of this rule development and workshop is to gather input regarding a possible mandatory requirement of electronic patient care record submission from emergency medical services providers.

 

DEPARTMENT OF HEALTH

Division of Emergency Medical Operations

RULE NO.:RULE TITLE:

64J-1.014Records and Reports

PURPOSE AND EFFECT: The purpose of this rule development and workshop is to gather input regarding a possible mandatory requirement of electronic patient care record submission from emergency medical services providers.

SUBJECT AREA TO BE ADDRESSED: Electronic submission of prehospital patient care records.

RULEMAKING AUTHORITY: 401.30 FS.

LAW IMPLEMENTED: 401.30 FS.

A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: TBD

PLACE: TBD/Broward County

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Steve McCoy at [phone], ext. 2727 or via email at [e-mail] If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT IS: Steve McCoy at [phone], ext. 2727 or via email at [e-mail]

 

The meeting agenda, Draft Emergency Medical Services Tracking and Reporting System Data Dictionaries 1.4 and 3.0, and additional meeting materials will available by close of business, seven days prior to the meeting.

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

 

64J-1.014 Records and Reports.

(1) Each provider shall be responsible for supervising, preparing, filing and maintaining records and for submitting reports to the department as requested. All records shall be handled in such a manner as to ensure reasonable safety from water and fire damage and to be safeguarded from unauthorized use. Any records maintained by the provider as required by these rules shall be accessible to authorized representatives of the department and shall be retained for a period of at least 5 years except as otherwise specified in this rule. Each provider shall maintain the following administrative records:

(a) Vehicle registration, copy of past department inspection reports, proof of current vehicle permit, and proof of current insurance coverage.

(b) Personnel records for each employee, to include date of employment, training records, employee application, documentation of current certification, and confirmation that each driver is in compliance with Section 401.281, F.S.

(c) Copy of up-to-date department approved TTPs.

(2) Each EMS provider shall ensure that a written abbreviated an accurate and complete patient care record or a complete patient care record was prepared for each instance in which a patient was transported to a hospital and . The transporting EMS provider shall provide the abreviated complete and accurate patient care record as defined in subsection 64J-1.014(3) 64J-1.001(18), F.A.C., to the receiving hospital personnel at the time the patient is transported and required in Rule 64J-1.014, F.A.C. upon request within 24 hours of the time the vehicle was originally dispatched in response to the request for emergency medical assistance.

(3) The abbreviated accurate and complete patient care record shall include all known information listed below and the known information defined under subsection 64J-1.001(18), F.A.C.;

(a) Date of call;

(b) Time of call;

(c) The service name;

(d) Incident ID number;

(e) Lead crew signature or identification number;

(f) Service name for any other licensed service providing care;

(g) Name for first responder agency;

(g)(h) The patient’s full name or unique identification number if the name is unknown;

(h)(i) The patient’s age;

(i)(j) Patient assessment information (e.g., airway, breathing, circulation, pupils, skin and vitals) taken on scene and en route with times taken for vitals;

(j)(k) The initial vitals taken by a non-transport service before the arrival of the transport unit;

(k)(l) The patient’s medical history, current medications; allergies, and chief complaint;

(l)(m) Interventions attempted (e.g., airway, breathing, circulation, and secondary interventions); and

(m)(n) Medication(s) administered including the time, medication, dose and route.

(4) Non-transporting vehicle personnel shall provide an abbreviated patient care record information pertinent to the patient’s identification, patient assessment and care provided to the patient to the transporting vehicle personnel at the time the responsibility of the patient is transferred to the transporting service.

(5) Documentation of known information in an abbreviated patient care record shall not delay response to requests for emergency medical assistance. Transporting vehicle personnel shall provide recorded information to the receiving hospital personnel at the time the patient is transferred that contains all known pertinent incident, patient identification and patient care information.

(6) Each EMS provider shall maintain a copy of the complete patient care record as defined in subsection 64J-1.001(18), F.A.C., for a period of at least 5 years. This copy is considered to be the copy of record, shall contain an original signature by the lead crew member or an identification number assigned to the lead crew member and is certifiable as a true copy.

(7) Each licensed EMS provider is responsible for quality review for completeness and accuracy of their own patient care records.

(8) Medication errors and reactions en route shall be reported to the physician who ordered the medication, the receiving physician, and the ALS medical director.

(9) Each provider shall maintain a written plan, available for review by the department, for the proper handling, storage, and disposal of biohazardous wastes in accordance with Chapter 64E-16, F.A.C.

(10) Each provider shall return his license to the department within 15 calendar days after a change of name or ownership of the service or upon permanently ceasing to provide service.

(11) Each air ambulance provider shall maintain documentation describing the service rendered to the patient and cost as part of the patient’s record in accordance with Section 401.251(4)(c), F.S.

(12) A fixed wing air ambulance provider shall have an air medical crew member document the cabin altitude hourly. The cabin pressure shall be documented on the patient care record.

(13) Each provider shall document and submit to the department a complete patient care record in accordance with the format and time frame specified in the Emergency Medical Services Tracking and System Data Dictionary Version 1.4 or 3.0 by January 1, 2016, the information contained on DH Form 1304, May 02, “EMS Aggregate Prehospital Report and Provider Profile Information Form”, which are is incorporated by reference and available from the department and available at www.XXXXXX.gov as defined and required in DHP 150-445, May 02, “Florida Department of Health, Bureau of Emergency Medical Oversight Instruction Manual for the: EMS Aggregate Pre-hospital and Provider Profile Information Form (DH 1304)”, which is incorporated by reference and available from the department. A complete patient care record shall be delivered to the receiving hospital within 24 hours from the time the vehicle was originally dispatched in response to the request for emergency medical assistance.

(a) Each provider transitioning to the Emergency Medical Services Tracking and Reporting System (EMSTARS) Data Dictionary Version 1.4 or 3.0 shall document and submit to the department, the information contained on DH Form 1304, May 02, “EMS Aggregate Prehospital Report and Provider Profile Information Form”, which is incorporated by reference and available from the department as defined and required in DHP 150-445, May 02, “Florida Department of Health, Bureau of Emergency Medical Oversight Instruction Manual for the: EMS Aggregate Pre-hospital and Provider Profile Information Form (DH 1304)”, which is incorporated by reference and available from the department. Providers transitioning to EMSTARS shall submit DH Form 1304 within thirty days after the close of the quarter until all requests for emergency medical assistance are documented and submitted through the EMSTARS. Quarter 1 closing date is March 31st, Quarter 2 closing date is June 30th, Quarter 3 closing date is September 30th, and Quarter 4 closing date is December 31st. Reports shall be submitted in accordance with the format and time frame specified in DHP 150-445. Reports received after the due date(s) specified in DHP 150-445 or not in the format specified in DHP 150-445, may not be included in reports published by the department.

(b) The non-transporting unit is responsible for providing critical treatment and intervention information as defined in subsection 64J-1.014(3) DHP 150-445 to the transporting unit at the time that the responsibility for the patient’s care is transferred to the transporting unit. The transporting unit is required to include counts of all known critical treatments and interventions that were administered or attempted to be administered to the patient prior to their arrival as defined and required in DHP 150-445 as part of their required quarterly submission of DH Form 1304 to the department.

Rulemaking Authority 381.0011, 395.405, 401.30, 401.35 FS. Law Implemented 381.001, 381.0205, 395.401-.405, 401.23, 401.25, 401.27, 401.30, 401.35, 401.411 FS. History–New 11-29-82, Amended 4-26-84, 3-11-85, Formerly 10D-66.60, Amended 11-2-86, 4-12-88, 8-3-88, 12-10-92, 11-30-93, 12-10-95, 1-26-97, Formerly 10D-66.060, Amended 7-14-99, 2-20-00, 4-15-01, 11-3-02, 10-24-05, Formerly 64E-2.013, Amended_________.