New Mexico Administrative Code
Title 18 - TRANSPORTATION AND HIGHWAYS
Chapter 3 - MOTOR CARRIER GENERAL PROVISIONS
Part 14 - AMBULANCE SERVICES
Section 18.3.14.24 - QUALITY ASSURANCE

A. patient care records retention: an ambulance service shall retain pre-hospital patient care records for seven (7) years, as approved by local medical protocol;

B. reporting: ambulance services shall complete a patient run report for each patient contacted during an emergency response or inter-facility transport; the minimum data elements from these reports, as identified by the EMS bureau, shall be compiled to the extent possible and submitted to the pre- hospital data collection system at the EMS bureau as prescribed in 7.27.4 NMAC, Emergency Medical Services Fund Act;

C. minimum patient information required upon patient delivery to the destination facility: pursuant to ambulance service protocol, an ambulance service shall communicate, electronically or in writing, clinical patient information to the intercepting ambulance or receiving facility at the time of patient transfer or delivery, if available:

D. completed patient care records: an ambulance service shall deliver an electronic or written copy of the completed pre-hospital patient care record to the receiving facility emergency department for inclusion in the patient's permanent medical record upon delivery of the patient to the hospital; in the event the unit is dispatched on another call, the patient care record shall be delivered as soon as possible after that call, but not later than the end of a shift or twenty four (24) hours after the transportation and treatment of the patient;

E. medical protocols and operational guidelines: the ambulance service medical director shall develop and approve medical protocols and operational guidelines which should include procedures for obtaining on-line medical direction; service medical protocols shall not exceed the New Mexico EMS scope of practice, unless a special skill has been granted; medical protocols and operational guidelines should be developed in collaboration with receiving hospitals and EMS agencies within the territory or patient catchment area; adult and pediatric patient protocols shall be on the unit at all times, in electronic or hard copy form;

F. medical director review of patient care: an ambulance service medical director shall review patient care records at least quarterly to determine whether appropriate medical care is being provided; the medical director shall document the steps taken during the review; subsequent reviews will include an evaluation of whether appropriate follow-up has been accomplished; receiving hospitals and other EMS agencies within the patient catchment area should be invited to participate in these reviews when appropriate;

G. confidentiality of medical records: an ambulance service may only release patient care records as provided by state and federal law, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA).