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37.104.212    RECORDS AND REPORTS

(1) Each emergency medical service must maintain a trip report for every run in which patient care was offered or provided, which contains at least the following information:

(a) identification of the emergency medical services provider;

(b) date of the call;

(c) patient's name and address;

(d) type of run;

(e) identification of all emergency medical services providers, riders, trainees, or service personnel officially responding to the call;

(f) the time:

(i) the dispatcher was notified;

(ii) the emergency medical service was notified;

(iii) the emergency medical service was enroute;

(iv) of arrival on the scene;

(v) the service departed the scene or turned over the patient to an ambulance service; and

(vi) of arrival at receiving hospital, if applicable;

(g) history of the patient's illness or injury, including the findings of the physical examination;

(h) treatment provided or offered by the emergency medical services personnel, including, when appropriate, a record of all medication administered, the dose, and the time administered;

(i) record of the patient's vital signs, including the time taken, if applicable;

(j) utilization of online medical control, if applicable; and

(k) destination of the patient, if applicable.

(2) Trip reports may be reviewed by the department.

(3) Copies of trip reports must be maintained by the service for a minimum of seven years.

(4) Each emergency medical service must provide the department with a quarterly report, on a form provided by the department, that specifies the number and types of runs occurring during the quarter, the type of emergency, and the average response times.

(5) Immediately or as soon as possible upon arrival at a receiving facility, but no later than 48 hours after the end of the patient transport, an ambulance service must provide a copy of the trip report to the hospital that receives the patient.

History: 50-6-323, MCA; IMP, 50-6-323, MCA; NEW, 1989 MAR p. 2212, Eff. 1/1/90; AMD, 1997 MAR p. 1201, Eff. 7/8/97; TRANS, from DHES, 2001 MAR p. 2305; AMD, 2005 MAR p. 2681, Eff. 12/23/05.

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