Tenn. Comp. R. & Regs. 1200-12-01-.15 - AMBULANCE SERVICE RECORDS

Each ambulance service and invalid vehicle operator, licensed or permitted by the Tennessee Department of Health and Environment shall maintain records that include, but are not limited to, the following information:

(1) Each ambulance service shall maintain the following records and provide information to the Division office at the request of any authorized representative of the Division relative to ambulance service personnel, including, but not limited to the following:

(a) Records indicating the individual's driver's license type and number, emergency medical technician license number, training or expiration date of CPR courses, the date of the individual's last physical examination, and the status of the individual's EMS telecommunication training, defensive driving courses, emergency vehicle operation courses, and other in-service training.

(b) Time cards, time sheets, call rosters, or shift schedules accurately indicating the availability of ambulance service personnel and the crews assigned on each date for each staffed ambulance within a specified county or jurisdiction.

(2) Dispatch and Run Records shall be provided for every call to which an ambulance responds or when a patient is evaluated, treated, or transported; including information in accordance with the following requirements:

(a) A dispatch log shall be maintained to record the assignment of all units, including the date, the time the call is received, time and unit dispatched, time of arrival on scene, time of arrival at the destination, and time available for return to service. The dispatch log will specify responding or attending personnel by name and level of licensure, and cross-reference any ambulance run report number. Calls will be logged to reflect immediate emergency or non-emergency response or scheduled transfers. Compliance may be demonstrated by a single log, or such combination of records that can confirm the required information. Ambulance dispatch logs will be retained for a period of at least ten (10) years.

(b) Ambulance service run reports shall be filed with the Division of Emergency Medical Services to include all information in required data fields and such other information as may be detailed in the Board approved prehospital care data set. This information shall be transmitted in an approved format using Tennessee subset schema definitions (XSD) in Extensible Markup Language (XML) in compliance with information systems procedures adopted by the State of Tennessee. Each service shall submit reports, either web based or via compiled form, to the Division of Emergency Medical Services within sixty (60) days. Notices shall be sent to the service within fifteen (15) days for non-compliance or citing deficiencies in the reported data elements or required information.

(c) For each patient transported to a hospital emergency department or transferred between medical facilities, emergency medical services personnel shall submit a report to the emergency department or hospital personnel in a written or electronic format or method approved by the Division or the Board. This report shall provide brief information identifying the patient by name (if known), age, and gender; the location from which the patient was transported; the approximate times of the medical incident, initiation of transport, and arrival at the hospital; the chief complaint or description of the illness or injuries, with appropriate notation of vital signs and patient condition; and shall describe the care and treatment provided at the scene or during transport. This report shall identify the name(s) and professional license level of the attending personnel , ambulance unit, and ambulance service. The receiving facility should receive any records or copies of physicians' orders for scope of treatment (POST) that may accompany the patient. Should circumstances or other emergencies preclude the submission of the report at the time of arrival at the emergency department, the report shall be submitted in not less than twenty-four hours from time of transport. If circumstances or other emergencies preclude the submission of the report at the time of arrival at the emergency department, the attending personnel must give a verbal report of above information to receiving personnel at health care facility with that individual signing for receipt of verbal report before attending personnel leave the health care facility. This report, while classified as confidential, shall be deemed as an essential element for continuity of care.

(d) Each licensed service shall file a written report with the Division within five (5) business days from the discovery by the service of any incident that results in serious injury to a patient that could not reasonably be expected as a result of the patient's condition. A serious injury is one that results in exacerbation, complication or other deterioration of a patient's condition. Such reportable incidents include, but are not limited to, the following:

1. Medication errors resulting in serious injury;

2. The failure to provide treatment in accordance with the service treatment protocols resulting in serious injury; or

3. A major medical or communications device failure or other equipment failure or user error resulting in serious injury or delay in response or treatment.

(3) Vehicle and Equipment Records - Records regarding the acquisition and maintenance of all vehicles and equipment shall be retained by each service, which shall include the following:

(a) Registration and title certificates or notarized copies of such documents for each vehicle.

(b) Maintenance records shall be maintained on each vehicle, detailing all mechanical work.

(c) Copies of orders, invoices or other documents asserting title or ownership of medical equipment, including contracts or agreements pertaining to state-issued equipment consigned to the service.

(4) Ambulance equipment inventory - An ambulance equipment inventory shall be recorded not less than every three (3) days for each vehicle reflecting an accurate status of patient care equipment, safety devices, and supplies. Each service shall adopt forms or procedures appropriate to this purpose which shall be available for inspection reflecting status of a period of at least three (3) months.

(5) Each ambulance service shall maintain a file of FCC-related records in accordance with 47 C.F.R., Part 90.443. Such records shall include that of any transmitter maintenance, base or mobile, which affects frequency, modulation or power output tolerance of the transmitter, and those periodic reports of inspection of antenna support structures which are required to be illuminated.

(6) All records detailed herein shall be made available when requested for inspection by a duly authorized representative of the department.

Notes

Tenn. Comp. R. & Regs. 1200-12-01-.15

Original rule filed November 30, 1984; effective February 12, 1985. Amendment filed October 22, 1987; effective December 6, 1987. Amendment filed August 11, 1993; effective October 25, 1993. Amendment filed October 21, 1993; effective January 4, 1994. Amendment filed June 5, 1998; effective August 19, 1998. Amendment filed December 16, 2005; effective March 1, 2006. Amendment filed May 26, 2010; effective August 24, 2010. Amendment filed May 5, 2014; effective 8/3/2014.

Authority: T.C.A. §§ 4-5-202, 4-5-203, 4-5-204, 68-140-502, 68-140-304, 68-140-306, 68-140-307, 68-140-504, 68-140-505, 68-140-507, 68-140-508, 68-140-509, and 68-140-519.