Section 170.345 - RecordsEach service shall prepare and maintain records, in electronic or print format, that are subject to, and shall be available for, inspection by the Department at any time upon request. Records shall be stored in such a manner as to ensure reasonable safety from water and fire damage and from unauthorized use, for a period of not less than seven years. Services shall also store and maintain the records of any service(s) they acquire, in the same manner.
(A) Records for services shall include at a minimum, as applicable, the following: (1) service policies and procedures;(2) EMS personnel training records;(3) EMS personnel and employment files and records;(4) documentation of EMS personnel's current CPR and ACLS training credentials, as applicable for their certification level, EMT or EFR certification and valid motor vehicle operator's license, including when and by whom verification required by 105 CMR 170.285 was completed;(5) all data from cardiac monitors and other equipment used in patient care, downloaded and readily accessible, either in electronic or paper format, for continuous quality improvement as well as Department review upon request;(6) For services licensed at the critical care service level, documentation of compliance with all CAMTS or Department-approved substantially equivalent accreditation standards including, but not limited to, continuous quality improvement (CQI); training and orientation of critical care transport personnel; continuing clinical education, skills maintenance and requirements for ongoing demonstration of clinical competency of its critical care medical crews.(7) preventive maintenance and repair records for ambulances and biomedical equipment and devices;(8) current vehicle registrations;(9) current Federal Aviation Administration (FAA) certifications and licenses for Class IV ambulances and pilots; and(10) Federal Communications Commission (FCC) licenses.(B)Patient Care Report Preparation and Contents. Each service shall maintain dispatch records, in either computer-aided (CAD) or handwritten form, and written patient care reports, for every EMS call including, but not limited to, cases in which no treatment is provided, the patient refuses treatment or there is no transport. Each patient care report shall be accurate, prepared contemporaneously with or as soon as practicable after, the EMS call that it documents. EMS personnel shall provide a verbal report to receiving staff at the time of patient transfer of care. Each written patient care report shall, at a minimum, include the data elements pertaining to the call as specified in administrative requirements of the Department. All EMS personnel on the ambulance or ambulances dispatched to the patient are responsible for the accuracy of the contents of their respective patient care reports, in accordance with their level of certification. In addition, an ambulance service that does not transport must include in the patient care report the reasons for not transporting including, if applicable, the signed informed refusal form from the patient(s). All baseline printouts from equipment used in the care of the patient, and those parts of printouts that correspond to clinical interventions or clinically relevant changes in the patient's condition, shall be available as part of the patient care report(C)Patient Care Reports and Unprotected Exposure Form Submission. (1) EMS personnel at the scene who are not transporting the patient shall keep the original patient care reports, and ensure that a copy of such patient care report is timely delivered to the health care facility to which the patient is transported, in accordance with service zone plan procedures. The receiving health care facility shall keep such patient care reports with the patient's medical record.(2) Each service shall ensure that the EMS personnel on each transporting ambulance shall leave a copy of the patient care reports at the receiving health care facility with the patient at the time of transport. The receiving health care facility shall keep such patient care reports with the patient's medical record.(3) EMS personnel at the scene who are not transporting the patient shall ensure that an unprotected exposure form, as defined in 105 CMR 172.001: Definitions, when appropriate, is timely delivered to the receiving health care facility, in accordance with service zone plan procedures. The EMTs on each transporting ambulance shall also submit an unprotected exposure form, as appropriate, to the receiving health care facility.(D) Personal and medical information, whether oral or written, obtained by EMS personnel or services in the course of carrying out EMS shall be maintained confidentially. Such information contained in communications and records maintained by services pursuant to 105 CMR 170.345 shall be released as required in 105 CMR 170.345(C), and additionally only as follows:(1) To the patient or the patient's attorney or legally authorized representative upon written authorization from the patient or the patient's legally authorized representative;(2) To the Department in connection with a complaint investigation pursuant to 105 CMR 170.795;(3) Upon proper order in connection with a pending judicial or administrative proceeding, and as otherwise required by law; or(4) Pursuant to the requirements of M.G.L. c. 111C, § 3(15).(5)Exceptions: No provision of 105 CMR 170.345(D) shall be construed to:(a) Prevent any third-party reimburser from inspecting and copying, in the ordinary course of determining eligibility for or entitlement to benefits, records relating to treatment, transport or other services provided to any person, including a minor or incompetent, for which coverage, benefit or reimbursement is claimed, so long as the policy or certificate under which the claim is made provides that such access to such records is permitted, or(b) Prevent access to any such records in connection with any peer review procedures applied and implemented in good faith.Amended, Mass Register Issue 1257, eff. 3/28/2014.Amended by Mass Register Issue 1486, eff. 1/6/2023.Amended by Mass Register Issue 1505, eff. 9/29/2023.