New Jersey Administrative Code
Title 8 - HEALTH
Chapter 41 - ADVANCED LIFE SUPPORT SERVICES; MOBILE INTENSIVE CARE PROGRAMS, SPECIALTY CARE TRANSPORT SERVICES AND AIR MEDICAL SERVICES
Subchapter 3 - GENERAL ADMINISTRATIVE, CREWMEMBER AND VEHICLE REQUIREMENTS
Section 8:41-3.8 - Patient care reports
Current through Register Vol. 56, No. 6, March 18, 2024
(a) The provider shall develop a patient care report to be utilized each time a crewmember makes physical or verbal contact with a patient.
(b) Each patient care report shall be multi-copy, shall be typed, printed or written in ink and shall contain the following information:
(c) If a patient refuses care, the refusal shall be documented on the patient care report and an attempt shall be made to obtain the signature of the patient (or guardian) on a "Refusal of Care" statement.
(d) A copy of the patient care report shall be delivered to an authorized representative of the receiving health care facility. This shall be done no later than 24 hours after completion of the call. Additions to the original report shall not be made once a copy has been delivered to the receiving health care facility, unless such changes are initialed and dated by the person making the change and the receiving health care facility is provided with a copy of the changes.
(e) The provider shall keep a record of all calls answered or transports provided, as applicable, and shall track the destination, diagnosis and disposition of each patient evaluated by the crewmembers. The receiving health care facility shall supply the provider with the information needed to comply with this section.
(f) Every provider of mobile intensive care and air medical services shall develop and maintain a means for recording cancelled or recalled calls, missed calls, and other activity that does not result in patient contact, but did result in a dispatch.
(g) The provider shall keep all patient care reports in accordance with the provisions for the retention of medical records set forth at 8:41-3.11.