37.104.506    EMS AGENCY RECORDS AND REPORTS

(1) Each emergency medical service must maintain a patient care record for every emergency medical service incident. 

(a) In incidents where more than one patient is encountered, one patient care record shall be completed for each patient.

(b) In the event more than one emergency medical service arrives at the scene of an emergency medical service incident, each service having actual contact with a patient is responsible for completing a patient care record on the patient.

(2) Every ambulance service must electronically submit data to the department for each emergency medical service incident within 48 hours of the conclusion of the emergency medical service incident. The department may extend this timeframe in cases of unusual circumstances.

(3) Electronic data submitted to the department must be in the format prescribed by the National Emergency Medical Services Information System (NEMSIS) and include all NEMSIS state and national data elements. The department adopts and incorporates by reference the National Emergency Medical Services Information System (NEMSIS) Uniform Pre-Hospital Emergency Medical Services Dataset, Version 3.5.0 (March 17, 2023) published by the National Highway Traffic Safety Administration (NHTSA). A copy may be obtained at https://nemsis.org/media/nemsis_v3/release-3.5.0/DataDictionary/PDFHTML/EMSDEMSTATE/NEMSISDataDictionary.pdf or from the Department of Public Health and Human Services, Public Health and Safety Division, Emergency Medical Services and Trauma Systems Section, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(a) For ambulance services directly using the reporting system provided by the department, the data is considered submitted to the department as soon as it has been entered or updated in the department-provided system.

(b) For ambulance services using third-party software, the data is considered submitted to the department as soon as it has been uploaded or updated into the department-provided system.

(4) Ambulance services are not required to submit other NEMSIS data elements but may do so. Non-transporting medical units are not required to submit NEMSIS data but may do so.

(5) Other software may be used to submit required data, but agencies must consult with the department before purchasing such software to ensure that the system is capable of submitting data to the Montana EMS Registry.

(6) Patient care reports may be reviewed by the department.

(7) Patient care reports must be maintained by the emergency medical service for a minimum of seven years.

(8) Immediately or as soon as possible upon arrival, but no later than 24 hours after the end of the patient transport, an ambulance service must provide a copy of the patient care report to the health care facility that receives the patient.

(a) If a completed patient care report cannot be left at the health care facility at the end of the patient transfer, an abbreviated patient encounter form containing information essential to continued patient care as set forth under Table 8 of the Emergency Medical Services Rule Appendix shall be provided until a patient care record can be provided to the health care facility.

(b) If an immediate response to another patient is required of an ambulance delivering a patient to a health care facility, a complete oral report on the patient being delivered must be given to the receiving health care facility until an abbreviated patient encounter form or patient care record can be provided.

 

History: 50-6-323, MCA; IMP, 50-6-323, MCA; NEW, 2023 MAR p. 1020, Eff. 9/9/23.