N.M. Admin. Code § 18.3.14.22 - QUALITY ASSURANCE
Each ambulance service shall have a written quality assurance program, which shall provide for.
A.
patient care records retention: an ambulance service shall retain
pre-hospital patient care records for seven years, as approved by local medical
protocol;
B.
reporting: ambulance services shall complete a patient run
report for each patient contacted during an emergency response or
inter-facility transport; the minimum data elements from these reports, as
identified by the EMS bureau, shall be compiled to the extent possible and
submitted to the pre- hospital data collection system at the EMS bureau as
prescribed in 7.27.4 NMAC, Emergency Medical Services Fund Act;
C.
minimum patient information required
upon patient delivery to the destination facility: pursuant to ambulance
service protocol, an ambulance service shall communicate, electronically or in
writing, clinical patient information to the intercepting ambulance or
receiving facility at the time of patient transfer or delivery, if available:
(1) ambulance unit number, EMT name and level
of licensure;
(2) patient age and
sex;
(3) patient's chief complaint
or EMT's primary impression;
(4) a
brief history of the present illness, including scene assessment and mechanism
of injury;
(5) major past
illnesses;
(6) patient's mental
status;
(7) patient's baseline
vital signs;
(8) pertinent findings
of the physical examination;
(9)
description of emergency medical care that has been provided for the patient,
including that provided by any first response units; and
(10) the patient's response to the emergency
medical care received.
D.
completed patient care
records: an ambulance service shall deliver an electronic or written
copy of the completed pre-hospital patient care record to the receiving
facility emergency department for inclusion in the patient's permanent medical
record upon delivery of the patient to the hospital; in the event the unit is
dispatched on another call, the patient care record shall be delivered as soon
as possible after that call, but not later than the end of a shift or twenty
four (24) hours after the transportation and treatment of the
patient;
E.
medical protocols
and operational guidelines: the ambulance service medical director shall
develop and approve medical protocols and operational guidelines which should
include procedures for obtaining on-line medical direction; service medical
protocols shall not exceed the New Mexico EMS scope of practice, unless a
special skill has been granted; medical protocols and operational guidelines
should be developed in collaboration with receiving hospitals and EMS agencies
within the territory or patient catchment area; adult and pediatric patient
protocols shall be on the unit at all times, in electronic or hard copy
form;
F.
medical director
review of patient care: an ambulance service medical director shall
review patient care records at least quarterly to determine whether appropriate
medical care is being provided; the medical director shall document the steps
taken during the review; subsequent reviews will include an evaluation of
whether appropriate follow-up has been accomplished; receiving hospitals and
other EMS agencies within the patient catchment area should be invited to
participate in these reviews when appropriate;
G.
confidentiality of medical
records: an ambulance service may only release patient care records as
provided by state and federal law, including but not limited to the Health
Insurance Portability and Accountability Act (HIPAA).
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.