Fla. Admin. Code R. 64J-1.014

Current through Reg. 50, No. 244; December 17, 2024

Section 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.

Fla. Admin. Code Ann. R. 64J-1.014

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 by Florida Register Volume 42, Number 120, June 21, 2016 effective 7/5/2016.