Current through Register Vol. 35, No. 18, September 24, 2024
C.
Minimum data elements; general EMS agency information. An EMS agency
shall submit the following general data to the EMS bureau:
(1) EMS agency number;
(2) EMS agency state;
(3) EMS agency county;
(4) level of service;
(5) organizational type;
(6) organization status;
(7) statistical year;
(8) total service size area;
(9) total service area population;
(10) 911 call volume per year;
(11) EMS dispatch volume per year;
(12) EMS transport volume per year;
(13) EMS patient contact volume per
year;
(14) EMS agency time
zone;
(15) national provider
identifier;
(16) EMS agency contact
zip code.
D.
Minimum pre-hospital data elements: An EMS agency shall compile and
submit to the EMS bureau the following minimum pre-hospital data for every
instance that patient care is provided by the EMS agency:
(1) vehicle type;
(2) patient care report number;
(3) software creator;
(4) software name;
(5) software version;
(6) EMS agency number;
(7) incident number;
(8) type of service requested;
(9) primary role of the unit;
(10) type of dispatch delay;
(11) type of response delay;
(12) type of scene delay;
(13) type of transport delay;
(14) type of turn-around delay;
(15) EMS unit call sign (radio
number);
(16) response mode to
scene;
(17) complaint reported by
dispatch;
(18) EMD
performed;
(19) crew member
role;
(20) crew member
level;
(21) PSAP call
date/time;
(22) dispatch notified
date/time;
(23) unit notified by
dispatch date/time;
(24) unit en
route date/time;
(25) unit arrived
on scene date/time;
(26) arrived at
patient date/time;
(27) unit left
scene date/time;
(28) patient
arrived at destination date/time;
(29) unit back in service
date/time;
(30) unit back at home
location date/time;
(31) patient's
last name;
(32) patient's first
name;
(33) patient's home zip
code;
(34) patient's home
country;
(35) patient's social
security number;
(36) patient's
gender;
(37) patient's
race;
(38) patient's
ethnicity;
(39) patient's
age;
(40) patient's age
units;
(41) patient's date of
birth;
(42) patient's primary
method of payment;
(43) patient's
insurance company ID/name;
(44) CMS
service level;
(45) condition code
number;
(46) number of patients at
scene;
(47) mass casualty
incident;
(48) incident location
type;
(49) scene GPS
location;
(50) incident
address;
(51) incident
city;
(52) incident
county;
(53) incident
state;
(54) prior aid;
(55) person who performed prior
aid;
(56) outcome of the prior
aid;
(57) possible
injury;
(58) patient's chief
complaint;
(59) chief complaint
anatomic location;
(60) chief
complaint organ system;
(61)
primary symptom;
(62) other
associated symptoms;
(63)
provider's primary impression;
(64)
provider's secondary impression;
(65) cause of injury;
(66) whether injury was caused
intentionally;
(67) mechanism of
injury;
(68) use of occupant safety
equipment;
(69) airbag
deployment;
(70) height of
fall;
(71) cardiac
arrest;
(72) cardiac arrest
etiology;
(73) resuscitation
attempted;
(74) barriers to patient
care;
(75) alcohol/drug use
indicators;
(76) run report
narrative;
(77) total Glasgow coma
score;
(78) medication
given;
(79) medication
complication;
(80)
procedure;
(81) number of procedure
attempts;
(82) procedure
successful;
(83) procedure
complication;
(84)
destination/transferred to, name;
(85) destination/transferred to,
code;
(86) destination zip
code;
(87) incident/patient
disposition;
(88) transport mode
from scene;
(89) reason for
choosing destination;
(90) type of
destination;
(91) emergency
department disposition;
(92)
hospital disposition.
F.
Location of
records. An EMS agency shall maintain all required records at the
agency's principal place of business within the state of New Mexico. All
required records are subject to inspection by the bureau and shall be
maintained so that they are reasonably accessible. The EMS bureau may, upon a
showing of good cause, allow an EMS agency to maintain required records at a
location outside the state of New Mexico, provided that the EMS agency
demonstrates to the satisfaction of the EMS bureau that the records will be
reasonably accessible for the bureau's inspection.
G.
Completed patient care
records. An EMS agency that transports a patient shall, upon delivery of
the patient to the hospital, deliver a copy of the completed pre-hospital
patient care record to the receiving facility's emergency department for
inclusion in the patient's permanent medical record. In the event that the
transporting unit is dispatched on another call before the pre-hospital patient
care record can be transmitted, the pre-hospital patient care record shall be
delivered to the receiving hospital's emergency department no later than
forty-eight hours after the transportation and treatment of the
patient.
H.
Current records
requirements.
(1)
Current
records for all EMS agencies. An EMS agency shall at all times maintain
current copies of the following records:
(a)
medical protocols signed by the EMS agency's medical director;
(b) operation plans and standard operating
procedures and guidelines for the EMS agency;
(c) rosters of EMS agency
personnel;
(d) applications of EMS
agency employees and other personnel;
(e) copies of certification and licensure
documentation for all EMS agency personnel;
(f) HIPAA documentation for all EMS agency
personnel;
(g) service area maps
with global positioning system (GPS) coordinates of EMS agency
stations;
(h) board of pharmacy
clinic license and pharmacy license, if applicable;
(i) federal drug enforcement administration
(DEA) license, if applicable;
(j)
driver's license and driver certification copies for each employee / volunteer;
and
(k) infection control
policy.
(2)
Additional current records for all medical rescue agencies.
Additionally, a medical rescue agency shall at all times maintain a current,
valid copy of the title for each vehicle owned by the medical rescue
agency.
(3)
Additional
current records for all emergency medical dispatch agencies.
Additionally, an emergency medical dispatch agency shall at all times maintain
current copies of the following documents:
(a)
training records (rosters, course outlines, etc.);
(b) E-911 updates street mapping / maps;
and
(c) a public safety answering
points (PSAP) directory.
I.
Other records required (extended
retention).
(1)
Medical
records. An EMS agency other than special event EMS shall retain all
adult medical records (including patient care reports) for at least ten years.
An EMS agency other than special event EMS shall retain all medical records of
minors (including patient care reports) for at least ten years, or at least one
year after the person reaches the age of majority, whichever period of time is
greater.
(2)
Other
records. An EMS agency shall retain the following records for a period
of not less than seven years:
(a) a copy of
the EMS agency's application for certification from the EMS bureau;
(b) certificate of insurance for the EMS
agency;
(c) business license and
incorporation documents for the EMS agency, as applicable, or documentation
verifying the EMS agency's status as a governmental entity;
(d) all current and expired mutual aid
agreements and memoranda of agreement entered into by the EMS agency;
(e) medical director contract or professional
agreement;
(f) criminal background
check documentation for EMS agency personnel, as applicable;
(g) copies of EMS agency certification
updates; and
(h) quality assurance
documentation.
(3)
Additional medical rescue agency records. Additionally, a medical
rescue agency shall retain the following records for a period of not less than
seven years:
(a) vehicle maintenance
records;
(b) annual safety
inspection certificates for each vehicle operated by the EMS agency;
and
(c) consultant pharmacist
contract or professional agreement.
(4)
Additional emergency medical
dispatch agency records. Additionally, an emergency medical dispatch
agency shall retain the following records for a period of not less than seven
years:
(a) telephone and radio audio
recordings, including magnetic tapes and digital file format recordings (DAT,
CD, DVD, etc.);
(b) 911 system and
call records (printed output, electronic files, etc.);
(c) CAD files; and
(d) hand-written (manual) reports.
J.
Extension of
retention period; contingencies. If at the end of a stated retention
period an EMS agency is involved in or is aware of pending legal obligations
(contractual or otherwise), litigation, administrative action, governmental
investigation, insurance claims, or court orders that relate in whole or in
part to a required record, the EMS agency shall continue to retain the required
record for at least six months after said contingency has been resolved or
concluded.
