Fla. Admin. Code Ann. R. 64J-1.014 - Records and Reports
(1) Each EMS
provider shall be responsible for supervising, preparing, filing and
maintaining records and for submitting reports to the department as requested.
All records shall be handled in such a manner as to ensure reasonable safety
from water and fire damage and to be safeguarded from unauthorized use. Any
records maintained by the provider as required by these rules shall be
accessible to authorized representatives of the department and shall be
retained for a period of at least 5 years except as otherwise specified in this
rule. Each EMS provider shall maintain the following administrative records:
(a) Vehicle registration, copy of past
department inspection reports, proof of current vehicle permit, and proof of
current insurance coverage.
(b)
Personnel records for each employee, to include date of employment, training
records, employee application, documentation of current certification, and
confirmation that each driver is in compliance with Section
401.281, F.S.
(c) Copy of up-to-date department approved
TTPs.
(2) The
transporting vehicle personnel shall at a minimum provide an abbreviated
patient record to the receiving hospital personnel at the time the patient is
transferred that contains all known pertinent incident information as defined
in subsection 64J-1.014(3),
F.A.C. Documentation of known information in an abbreviated patient care record
shall not delay response to requests for emergency medical
assistance.
(3) The abbreviated
patient care record shall include all known information listed below:
(a) Date of call;
(b) Time of call;
(c) The service name;
(d) Incident ID number;
(e) Lead crew signature or identification
number;
(f) Service name for any
other licensed service providing care;
(g) Name for first responder
agency;
(h) The patient's full name
or unique identification number if the name is unknown;
(i) The patient's age;
(j) Patient assessment information (e.g.,
airway, breathing, circulation, pupils, skin and vitals) taken on scene and en
route with times taken for vitals;
(k) The initial vitals taken by a
non-transport service before the arrival of the transport unit;
(l) The patient's medical history, current
medications; allergies, and chief complaint;
(m) Interventions attempted (e.g., airway,
breathing, circulation, and secondary interventions); and,
(n) Medication(s) administered including the
time, medication, dose and route.
(4) Non-transporting vehicle personnel shall
provide an abbreviated patient care record or oral report with known
information pertinent to the patient's identification, patient assessment and
care provided to the patient to the transporting vehicle personnel at the time
the responsibility of the patient is transferred to the transporting
service.
(5) Each EMS provider
shall maintain a copy of the patient care record as defined in subsection
64J-1.001(18),
F.A.C., for a period of at least 5 years. This copy is considered to be the
copy of record, shall contain an original signature by the lead crew member or
an identification number assigned to the lead crew member and is certifiable as
a true copy.
(6) Each licensed EMS
provider is responsible for quality review for completeness and accuracy of
their own patient care records.
(7)
Medication errors and reactions en route shall be reported to the physician who
ordered the medication, the receiving physician, and the ALS medical
director.
(8) Each provider shall
maintain a written plan, available for review by the department, for the proper
handling, storage, and disposal of biohazardous wastes in accordance with
Chapter 64E-16, F.A.C.
(9) Each
provider shall return his license to the department within 15 calendar days
after a change of name or ownership of the service or upon permanently ceasing
to provide service.
(10) Each air
ambulance provider shall maintain documentation describing the service rendered
to the patient and cost as part of the patient's record in accordance with
Section 401.251(4)(c),
F.S.
(11) A fixed wing air
ambulance provider shall have an air medical crew member document the cabin
altitude hourly. The cabin pressure shall be documented on the patient care
record.
(12) Each EMS provider may
document and submit to the department an electronic patient care record in
accordance with the data format specified in the Emergency Medical Services
Tracking and Reporting System (EMSTARS) Data Dictionary Version 1.4.1
(September 1, 2009), and as specified in Florida's Prehospital Emergency
Medical Services Tracking & Reporting System Program Manual for Florida EMS
Data Dictionary version 1.4.1, Version 2 (February 2, 2016), or an EMS provider
may document and submit to the department an electronic patient care record in
accordance with the EMSTARS Data Standards, Version 3 (October 16, 2015). Both
EMSTARS versions and the manual are incorporated by reference and available
from the department at
http://www.floridaemstars.com/docs/FloridaEMSDataDictionary_V_1_4.pdf,
http://www.floridaemstars.com/docs/flemstarsdatastandardsvers3.pdf
and http://www.floridaemstars.com/docs/EMSTARSProgram.pdf;
and also available at
http://www.flrules.org/Gateway/reference.asp?No=Ref-07083,
http://www.flrules.org/Gateway/reference.asp?No=Ref-07084,
and http://www.flrules.org/Gateway/reference.asp?No=Ref-07085,
respectively.
(13) If the provider
fails to submit electronic patient care records in accordance with the format
and time frame specified in the EMSTARS Version 1.4.1 or Version 3, the
provider shall document and submit to the department the information contained
on DH Form 1304, (May 2002), "EMS Aggregate Prehospital Report and Provider
Profile Information Form." Terms in DH Form 1304 are defined and required as
specified in DHP 150-445, (May 2002), "Department of Health, Emergency Medical
Services (EMS) Section Instruction Manual for the: EMS Aggregate Pre-Hospital
and Provider Profile Information Form (DH 1304)." Both documents are
incorporated by reference and available from the department at
http://www.floridahealth.gov/statistics-and-data/prehospital-data-collection-and-reporting-system/_documents/aggregate-pre-hospital-quarterly-report-form-1304.pdf
and http://www.floridaemstars.com/docs/DHP150-445052002.pdf;
and, also available at
http://www.flrules.org/Gateway/reference.asp?No=Ref-07086,
and http://www.flrules.org/Gateway/reference.asp?No=Ref-07087,
respectively.
(a) Reports shall be submitted
in accordance with the format and time frame specified in DHP 150-445. Reports
received after the due date(s) specified in DHP 150-445 or not in the format
specified in DHP 150-445, may not be included in reports published by the
department.
(b) The transporting
unit is required to include counts of all known critical treatments and
interventions that were administered or attempted to be administered to the
patient prior to their arrival as defined and required in DHP 150-445 as part
of their required quarterly submission of DH Form 1304 to the
department.
(14) A
patient care record as defined in subsection
64J-1.001(18),
F.A.C., or an electronic patient care record containing the same information
shall be made available by the EMS provider to the receiving hospital upon
request within 48 hours of the time the vehicle is originally dispatched in
response to the request for emergency medical assistance.
Notes
Rulemaking Authority 381.0011, 395.405, 401.30, 401.35 FS. Law Implemented 381.001, 381.0205, 395.401-.405, 401.23, 401.25, 401.27, 401.30, 401.35, 401.411 FS.
New 11-29-82, Amended 4-26-84, 3-11-85, Formerly 10D-66.60, Amended 11-2-86, 4-12-88, 8-3-88, 12-10-92, 11-30-93, 12-10-95, 1-26-97, Formerly 10D-66.060, Amended 7-14-99, 2-20-00, 4-15-01, 11-3-02, 10-24-05, Formerly 64E-2.013, Amended 7-5-16.
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