Md. Code Regs. 30.03.04.04 - Maryland Ambulance Information System

A. Each EMS operational program shall, within 24 hours of a call's dispatch, ensure the completion of an EMS patient care report for each unit:
(1) That responds to a call within the State;
(2) That responds to a call from within the State;
(3) That provides EMS care;
(4) That provides EMS transport; or
(5) That applies the Maryland Medical Protocols for Emergency Medical Services Providers.
B. The EMS provider-in-charge of each unit shall ensure the accurate and timely completion of the patient care report.
C. The patient care report shall be complete without reference to any other documentation.
D. EMS Documentation Delivered to the Receiving Facility.
(1) If a patient is transported to a health care facility, a completed patient care report shall, if possible, be left at the receiving facility before the EMS unit leaves the facility.
(2) If a completed patient care report is not left at the health care facility, the transporting unit shall:
(a) Provide documentation of the patient's prehospital care on a template and in a format provided or approved by MIEMSS for inclusion in the patient care record before leaving the facility; and
(b) After May 31, 2011, deliver the completed patient care report for the patient to the receiving facility not later than in 24 hours after transfer of care.
E. EMS Data Submitted to MIEMSS.
(1) If the EMS operational program uses MAIS or CMAIS forms, EMS data shall be submitted to MIEMSS monthly by delivery of a copy of the form, or in some other form acceptable to MIEMSS, provided the EMS operational program retains the ribbon copy of each MAIS or CMAIS form as the official record of the data contained therein.
(2) If the EMS operational program uses EMAIS-®, all EMS data shall be submitted to MIEMSS electronically via EMAIS-®.
(3) If the EMS operational program records health care data electronically in a form other than EMAIS®:
(a) All EMS data shall be delivered electronically to MIEMSS with content and format acceptable to MIEMSS; and
(b) After May 31, 2011, the EMS data shall be submitted to MIEMSS at least once every 24 hours to include all newly completed patient care reports.
(4) Changes to a completed patient care report or dataset after it has been submitted to MIEMSS shall be managed as an amendment to the original record or dataset and will not overwrite the original file. No amendments will be accepted after 30 days.
F. After December 31, 2010, all EMS operational programs shall only submit EMS data to MIEMSS through EMAIS-® or electronically with content and format acceptable to MIEMSS.
G. All electronic EMS data reports shall prominently display on each patient care report a unique 11-character report identifier in which:
(1) The first three characters shall show the unique identifier assigned to the EMS operational program by MIEMSS;
(2) The fourth and fifth characters shall show the year of the event reported on; and
(3) The remaining 6 characters shall show the EMS operational program sequential report number which shall be reset to zero for the first event reported in each calendar year.
H. EMAIS-® patient care report data will be made available to an EMS operational program by MIEMSS in accordance with the Maryland Confidentiality of Medical Records Act, Health-General Article, §4-301 et seq., Annotated Code of Maryland, and, if applicable, the federal Health Insurance Portability and Accountability Act (HIPAA) privacy regulations, 45 CFR § 164.500 et seq., for treatment, quality assurance, and billing, if requested by the EMS operational program and pursuant to the terms of a memorandum of understanding with MIEMSS.
I. Compliance with this regulation shall be required for an EMS Operational Program to meet the requirements for funding under Public Safety Article, § 8-103(b)(7), Annotated Code of Maryland, (Amoss Fund) with respect to the Maryland Ambulance Information System and to be eligible for MIEMSS grants.

Notes

Md. Code Regs. 30.03.04.04
Regulations .04 and new Regulation .04 adopted effective November 1, 2010 (37:21 Md. R. 1437)

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