Current through Register 1531, September 27, 2024
Each service shall prepare and maintain records, in electronic
or print format, that are subject to, and shall be available for, inspection by
the Department at any time upon request. Records shall be stored in such a
manner as to ensure reasonable safety from water and fire damage and from
unauthorized use, for a period of not less than seven years. Services shall
also store and maintain the records of any service(s) they acquire, in the same
manner.
(A) Records for services shall
include at a minimum, as applicable, the following:
(1) service policies and
procedures;
(2) EMS personnel
training records;
(3) EMS personnel
and employment files and records;
(4) documentation of EMS personnel's current
CPR and ACLS training credentials, as applicable for their certification level,
EMT or EFR certification and valid motor vehicle operator's license, including
when and by whom verification required by
105
CMR 170.285 was completed;
(5) all data from cardiac monitors and other
equipment used in patient care, downloaded and readily accessible, either in
electronic or paper format, for continuous quality improvement as well as
Department review upon request;
(6)
For services licensed at the critical care service level, documentation of
compliance with all CAMTS or Department-approved substantially equivalent
accreditation standards including, but not limited to, continuous quality
improvement (CQI); training and orientation of critical care transport
personnel; continuing clinical education, skills maintenance and requirements
for ongoing demonstration of clinical competency of its critical care medical
crews.
(7) preventive maintenance
and repair records for ambulances and biomedical equipment and
devices;
(8) current vehicle
registrations;
(9) current Federal
Aviation Administration (FAA) certifications and licenses for Class IV
ambulances and pilots; and
(10)
Federal Communications Commission (FCC) licenses.
(B)
Patient Care Report
Preparation and Contents. Each service shall maintain dispatch
records, in either computer-aided (CAD) or handwritten form, and written
patient care reports, for every EMS call including, but not limited to, cases
in which no treatment is provided, the patient refuses treatment or there is no
transport. Each patient care report shall be accurate, prepared
contemporaneously with or as soon as practicable after, the EMS call that it
documents. EMS personnel shall provide a verbal report to receiving staff at
the time of patient transfer of care. Each written patient care report shall,
at a minimum, include the data elements pertaining to the call as specified in
administrative requirements of the Department. All EMS personnel on the
ambulance or ambulances dispatched to the patient are responsible for the
accuracy of the contents of their respective patient care reports, in
accordance with their level of certification. In addition, an ambulance service
that does not transport must include in the patient care report the reasons for
not transporting including, if applicable, the signed informed refusal form
from the patient(s). All baseline printouts from equipment used in the care of
the patient, and those parts of printouts that correspond to clinical
interventions or clinically relevant changes in the patient's condition, shall
be available as part of the patient care report
(C)
Patient Care Reports and
Unprotected Exposure Form Submission.
(1) EMS personnel at the scene who are not
transporting the patient shall keep the original patient care reports, and
ensure that a copy of such patient care report is timely delivered to the
health care facility to which the patient is transported, in accordance with
service zone plan procedures. The receiving health care facility shall keep
such patient care reports with the patient's medical record.
(2) Each service shall ensure that the EMS
personnel on each transporting ambulance shall leave a copy of the patient care
reports at the receiving health care facility with the patient at the time of
transport. The receiving health care facility shall keep such patient care
reports with the patient's medical record.
(3) EMS personnel at the scene who are not
transporting the patient shall ensure that an unprotected exposure form, as
defined in
105
CMR 172.001: Definitions,
when appropriate, is timely delivered to the receiving health care facility, in
accordance with service zone plan procedures. The EMTs on each transporting
ambulance shall also submit an unprotected exposure form, as appropriate, to
the receiving health care facility.
(D) Personal and medical information, whether
oral or written, obtained by EMS personnel or services in the course of
carrying out EMS shall be maintained confidentially. Such information contained
in communications and records maintained by services pursuant to
105
CMR 170.345 shall be released as required in
105
CMR 170.345(C), and
additionally only as follows:
(1) To the
patient or the patient's attorney or legally authorized representative upon
written authorization from the patient or the patient's legally authorized
representative;
(2) To the
Department in connection with a complaint investigation pursuant to
105
CMR 170.795;
(3) Upon proper order in connection with a
pending judicial or administrative proceeding, and as otherwise required by
law; or
(4) Pursuant to the
requirements of M.G.L. c. 111C, § 3(15).
(5)
Exceptions: No
provision of
105
CMR 170.345(D) shall be
construed to:
(a) Prevent any third-party
reimburser from inspecting and copying, in the ordinary course of determining
eligibility for or entitlement to benefits, records relating to treatment,
transport or other services provided to any person, including a minor or
incompetent, for which coverage, benefit or reimbursement is claimed, so long
as the policy or certificate under which the claim is made provides that such
access to such records is permitted, or
(b) Prevent access to any such records in
connection with any peer review procedures applied and implemented in good
faith.
