N.J. Admin. Code § 8:40-3.6

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:40-3.6 - Patient care reports

(a) The provider shall develop a patient care report to be utilized each time a crewmember makes physical or verbal contact with a patient.

1. A separate patient care report shall be prepared for each patient transported in the same vehicle. One patient care report, per person shall be completed. A separate patient care report shall be completed for each leg of a round trip transport.

2. The patient care report shall be signed by all of the crewmembers.

(b) Each patient care report shall be typed, printed or written in ink and shall contain the following information:

1. The patient's name, age, sex and home address;

2. A description of the patient's condition at the scene and in transit, including a description of the patient's chief complaint and at least one set of vital signs and the time that the vital signs were taken (BLS providers) or a description of the patient's condition and any observed changes (MAV providers);

3. A description of care given to the patient at the scene and in transit (BLS providers) or a description of any care and/or assistance given to the patient (MAV providers);

4. The time when, and location where, the patient was picked up and was discharged;

i. For BLS ambulances utilized to provide emergency response, times when the call was received, when the vehicle was dispatched, when the vehicle reported going en route to the call, when the vehicle reported on location, when the vehicle reported en route to a general hospital and when the vehicle arrived at that hospital.

(1) All patients must be screened according to the COVID-19 Triage Protocol for EMS Providers, which is incorporated herein by reference, at N.J.A.C. 8:40-3.6 Appendix A.

(2) If the patient meets the criteria for triaging to home, as set forth in the COVID-19 Triage Protocol for EMS Providers, then the EMT shall consult with their BLS provider's medical director, their pre-designated medical command physician, or otherwise arranged hospital medical command. Any agency that does not have a medical director, a pre-designated medical command physician, or otherwise arranged hospital medical command may not implement this protocol.

(3) If the medical authority agrees that the patient should be triaged to home, then the patient may remain at home and does not have to be transported to an emergency department.

(4) If the medical authority disagrees that the patient should be triaged to home, then the EMT shall transport the patient to the closest, most appropriate emergency department.

(5) The EMT shall document, in the patient's ePCR, the EMT's contact with the medical authority and the medical authority's determination as to whether the patient should be triaged at home.

(6) When triaged to home, the EMT shall provide the patient with the COVID-19 Home Care Guide, which is incorporated herein by reference, at N.J.A.C. 8:40-3.6 Appendix B.

(7) All patient care reports shall be documented electronically.

(8) Complying with this waiver shall not constitute patient abandonment pursuant to N.J.A.C. 8:40A-10.2(b)5.

(9) For all other patients complaining of symptoms not associated with COVID-19, the provisions set forth at N.J.A.C. 8:40-6.4 and in this section shall remain in effect.

(10) The provisions at (b)4i(1) through (9) above shall not apply to calls for emergency medical services initiated by a healthcare provider, such as health providers in long-term care facilities, institutional settings, and assisted living facilities.

(A) For healthcare provider initiated emergency medical services calls, responding EMTs shall transport the patient to the closest, most appropriate acute care hospital and shall not use the COVID-19 Triage Protocol;

5. The vehicle recognition number, date, and full names of each crewmember and their affiliation (including the identification of any responding MICU or AMU, if applicable); and

6. For BLS ambulances utilized to provide emergency response, whether or not emergency warning devices were utilized responding to the scene, at the scene, or in transit to the receiving health care facility.

(c) If a patient refuses care, the refusal shall be documented on the patient care report and an attempt shall be made to obtain the signature of the patient (or guardian) on a "Refusal of Care" statement.

(d) A copy of the patient care report shall be given to an authorized representative at the receiving health care facility. This shall be done no later than 24 hours after completion of the call. Additions to the original report shall not be made once a copy has been delivered to the receiving health care facility, unless such changes are initialed and dated by the person making the change and the receiving health care facility is provided with a copy of the changes.

(e) The provider shall keep all patient care reports in accordance with the provisions for the retention of records set forth at 8:40-3.9.

N.J. Admin. Code § 8:40-3.6

Modified by Executive Order No. 103(2020) 52 N.J.R. 1643(a), effective 4/15/2020