37.104.212 RECORDS AND REPORTS

(1) Each emergency medical service must maintain a patient care record for every EMS 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 EMS incident, each service having actual contact with a patient is responsible for completing a patient care record on the patient.

(2) Ambulance services and non-transporting units must provide data as identified by the department in this rule.

(3) Electronic data submitted to the department must be in the format prescribed by the National Emergency Medical Services Information System (NEMSIS).

(a) For emergency medical 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 emergency medical 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) For ambulance services using NEMSIS version 3.4 software, the data elements designated as national requisite fields must be reported for each incident.

(5) Emergency medical services must provide patient care report data to the department at least quarterly based on a calendar year or on a schedule submitted to and approved by the department.

(a) These quarterly data must be submitted to the department within 60 days of the end of the quarter as follows:

(i) data for EMS responses occurring in January through March must be submitted by June 1;

(ii) for responses in April through June by September 1;

(iii) for responses in July through September by December 1; and

(iv) for responses in October through December by March 1.

(b) The data may be submitted more frequently than quarterly.

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

(7) Other software may be used to submit required data, but agencies must consult with the department before purchasing such software.

(8) The department adopts and incorporates by reference the National Emergency Medical Services Information System (NEMSIS) Uniform Pre-Hospital Emergency Medical Services Dataset, Version 3.4 (7/13/2016) published by the National Highway Traffic Safety Administration (NHTSA). A copy may be obtained at https://nemsis.org/media/nemsis_v3/release-3.4.0/DataDictionary/PDFHTML/DEMEMS/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.

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

(10) Copies of patient care reports must be maintained by the service for a minimum of seven years.

(11) Immediately or as soon as possible upon arrival at a receiving facility, 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 hospital that receives the patient.

(a) If a completed patient care report cannot be left at the facility at the end of the patient transfer to the licensed hospital, an abbreviated patient encounter form containing information essential to continued patient care shall be provided until a patient care record can be left.

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

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; AMD, 2012 MAR p. 187, Eff. 4/1/12; AMD, 2018 MAR p. 1884, Eff. 9/22/18.