20090304-IR-836080879PRA Amends 836 IAC 1-1-5 to revise the required data elements to conform to specified National Emergency Medical Service Information System data elements. Makes numerous technical changes. Effective 30 d...

TITLE 836 INDIANA EMERGENCY MEDICAL SERVICES COMMISSION

Proposed Rule

LSA Document #08-879

DIGEST

Amends 836 IAC 1-1-5 to revise the required data elements to conform to specified National Emergency Medical Service Information System data elements. Makes numerous technical changes. Effective 30 days after filing with the Publisher.

836 IAC 1-1-5

SECTION 1. 836 IAC 1-1-5 IS AMENDED TO READ AS FOLLOWS:

836 IAC 1-1-5 Reports and records

Authority: IC 16-31-2-7; IC 16-31-3

Affected: IC 4-21.5; IC 16-31-3

Sec. 5. (a) All emergency medical service provider organizations shall comply with this section.

(b) All emergency medical service provider organizations shall participate in the emergency medical service system review by collecting and reporting data elements. The elements shall be submitted to the agency by the fifteenth of the following month by electronic format or submitted on disk in the format and manner specified by the commission. The data elements prescribed by the commission are as follows: the following National Emergency Medical Service Information System (NEMSIS), created by the National Association of EMS Directors in partnership with the federal National Highway Traffic Safety Administration data elements:

(1) Provider organization EMS agency number.

(2) Date of incident. EMS agency state.

(3) Time call received. EMS agency county.

(4) Incident number. Level of service, for example, paramedic, ALS, BLS, etc.

(5) Service Organizational type, for example, county, hospital, fire department, etc.

(6) Time of dispatch. Organization status, for example, volunteer, paid, combination.

(7) Location type. Statistical year (current calendar year).

(8) Patient name. Total service area (in square miles).

(9) Response number. Total service area population.

(10) Patient care record number. 911 call volume per year.

(11) Patient zip code. EMS dispatch volume per year.

(12) Gender. EMS transport per year.

(13) Race. EMS patient contact volume per year.

(14) EMS agency time unit responding. zone.

(15) Time of arrival at scene. National provider identifier (assigned by the National Plan and Provider Enumeration System).

(16) Time unit left scene. Agency contact zip code.

(17) Time available for service. Patient care report number.

(18) Lights and siren to scene. Software creator, that is, company name.

(19) Lights and siren used from scene. Software name.

(20) Level of care provided. Software version.

(21) Provider impression. EMS agency number (in patient record field).

(22) Mode of injury. Incident number.

(23) Incident/patient disposition. EMS unit (vehicle) response number, that is, vehicle number.

(24) Vehicle Type of service requested.

(25) Destination/transferred to. Primary role of the unit.

(26) Destination determination. Type of dispatch delay.

(27) Time of arrival at destination. Type of response delay.

(28) Incident location. Type of scene delay.

(29) Date Type of birth. transport delay.

(30) Medical history. Type of turn-around delay.

(31) Signs and symptoms. EMS unit call sign, that is, radio number.

(32) Injury description. Response mode to scene.

(33) Safety equipment. Complaint reported by dispatch.

(34) Suspected drug/alcohol use. EMD performed.

(35) Pulse rate. EMD card number.

(36) Respiratory rate. Crew member ID (public safety identification number assigned by the Indiana department of homeland security).

(37) Respiratory effort. Incident on onset date and time, that is, the date and time the injury occurred or the symptoms or problem started.

(38) Systolic blood pressure. PSAP call date and time, for example, when call came into 911.

(39) Skin perfusion. Unit notified by dispatch date and time.

(40) Glascow eye opening. Unit en route date and time.

(41) Glascow verbal component. Unit arrived on scene date and time.

(42) Glascow motor component. Unit arrived at patient date and time.

(43) Airway treatment. Unit left scene date and time.

(44) Stabilization treatment. Patient arrived at destination date and time.

(45) Miscellaneous treatment. Unit back in service date and time.

(46) Medication name. Unit canceled date and time.

(47) Research code. Unit back at home location date and time.

(48) Crew member one number. Patient last name.

(49) Crew member two number. Patient's home zip code.

(50) Gender.

(51) Race.

(52) Ethnicity.

(53) Age.

(54) Age units, for example, hours, days, months, or years.

(55) Date of birth (mmddyyyy).

(56) Primary method of payment.

(57) CMS service level.

(58) Condition code number.

(59) Number of patients at scene.

(60) Mass casualty incident (yes or no).

(61) Incident location type, for example, work, residence, retail establishment.

(62) Scene zone number (Indiana homeland security district number).

(63) Incident county.

(64) Incident state of Indiana.

(65) Incident zip code.

(66) Prior aid, that is, aid rendered prior to arrival of unit.

(67) Prior aid performed by.

(68) Outcome of prior aid.

(69) Possible injury.

(70) Chief complaint.

(71) Chief complaint anatomic location.

(72) Chief complaint organ system.

(73) Primary symptom.

(74) Other associated symptoms.

(75) Providers primary impression.

(76) Providers secondary impression.

(77) Cause of injury.

(78) Intent of the injury, for example, self-inflicted.

(79) Mechanism of injury.

(80) Use of occupant safety equipment.

(81) Cardiac arrest.

(82) Cardiac arrest etiology.

(83) Resuscitation attempted.

(84) Barriers to patient care.

(85) Medical and surgical history.

(86) Alcohol and drug use indicators.

(87) Medication given.

(88) Procedure.

(89) Number of procedure attempts.

(90) Procedure successful.

(91) Procedure complication.

(92) Destination/transferred to, name.

(93) Destination/transferred to, code.

(94) Destination zip code.

(95) Destination zone code (Indiana homeland security district number).

(96) Incident/patient disposition.

(97) Transport mode from scene.

(98) Reason for choosing destination.

(99) Type of destination.

(100) Emergency department disposition.

(101) Hospital disposition.

(102) Research survey field.

(103) Medication complication.

Basic life support nontransport provider organizations that are paid or volunteer fire departments that render fire prevention or fire protection services to a political subdivision are not required to submit data under this rule.

(c) Each emergency medical services provider organization shall retain all records required by this rule title for a minimum of three (3) years, except for the following records that shall be retained for a minimum of seven (7) years:

(1) Audit and review records.

(2) Run reports.

(3) Training records.

(4) Maintenance records.

(d) An emergency medical service provider organization that has any certified vehicles involved in any traffic accident investigated by a law enforcement agency shall report that accident to the agency within ten (10) working days on a form provided by the agency.

(e) Each provider organization, except basic life support nontransport provider organization, shall maintain accurate records concerning the assessment, treatment, or transportation of each emergency patient, including a run report form in an electronic or written format as prescribed by the commission as follows:

(1) A run report form shall include, at a minimum, the following:

(A) Name.

(B) Identification number.

(C) Age.

(D) Sex.

(E) Date of birth.

(F) Race.

(G) Address, including zip code.

(H) Location of incident.

(I) Chief complaint.

(J) History, including the following:

(i) Current medical condition and medications.

(ii) Past pertinent medical conditions and allergies.

(K) Physical examination section.

(L) Treatment given section.

(M) Vital signs, including the following:

(i) Blood pressure.

(ii) Pulse.

(iii) Respirations.

(iv) Level of consciousness.

(v) Skin temperature and color.

(vi) Pupillary reactions.

(vii) Ability to move.

(viii) Presence or absence of breath sounds.

(ix) The time of observation and a notation of the quality for each vital sign.

(N) Responsible guardian.

(O) Hospital destination.

(P) Radio contact via UHF or VHF.

(Q) Name of patient attendants, including emergency medical service certification numbers and signatures.

(R) Vehicle certification number.

(S) Safety equipment used by patient.

(T) Date of service.

(U) Service delivery times, including the following:

(i) Time of receipt of call.

(ii) Time dispatched.

(iii) Time arrived on scene.

(iv) Time of departure from scene.

(v) Time arrived at hospital.

(vi) Time departed from hospital.

(vii) Time vehicle available for next response.

(viii) Time vehicle returned to station.

(2) The run report form shall be designed in a manner to provide space for narrative notation of additional medical information.

(3) A copy of the completed run report form shall be provided to the receiving facility when the patient is delivered unless it is not feasible; however, the form shall be provided to the receiving facility no not later than twenty-four (24) hours after the patient is delivered.

(4) When a patient has signed a statement for refusal of treatment or transportation services, or both, that signed statement shall be maintained as part of the run documentation.

(f) Each basic life support nontransport provider organization shall maintain, in a manner prescribed by the commission, accurate records, including a run report form, concerning the assessment and treatment of each emergency patient as follows:

(1) A run report form shall be required by all basic life support nontransport provider organizations, including, at a minimum, the following:

(A) Name.

(B) Identification number.

(C) Age.

(D) Sex.

(E) Race.

(F) Physician of the patient.

(G) Date of birth.

(H) Address, including zip code.

(I) Location of incident.

(J) Chief complaint.

(K) History, including the following:

(i) Current medical condition and medications.

(ii) Past pertinent medical conditions and allergies.

(L) Physical examination section.

(M) Treatment given section.

(N) Vital signs, including the following:

(i) Pulse.

(ii) Blood pressure.

(iii) Respirations.

(iv) Level of consciousness.

(v) Skin temperature and color.

(vi) Pupillary reactions.

(vii) Ability to move.

(viii) Presence or absence of breath sounds.

(ix) The time of observation and a notation of the quality for each vital sign.

(O) Responsible guardian.

(P) Name of patient attendants, including emergency medical services certification numbers and signatures.

(Q) Vehicle emergency medical services certification number.

(R) Responding service delivery times, including the following:

(i) Time of receipt of call.

(ii) Time dispatched.

(iii) Time arrived on scene.

(iv) Time of patient released to transporting emergency medical services.

(v) Time vehicle available for next response.

(S) Date of service.

(T) Safety equipment used by patient.

(2) The report form shall provide space for narrative description of the situation and the care rendered by the nontransport unit.

(3) A signed statement for refusal of treatment or transportation services, or both, shall be maintained as part of the run documentation.

(Indiana Emergency Medical Services Commission; 836 IAC 1-1-5; filed Jun 11, 2004, 1:30 p.m.: 27 IR 3512; filed Jul 31, 2007, 10:01 a.m.: 20070829-IR-836060011FRA)

Posted: 03/04/2009 by Legislative Services Agency

DIN: 20090304-IR-836080879PRA

Composed: Nov 01,2016 12:36:25AM EDT

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