Q: How soon do I have to leave a patient care report (PCR) at the hospital?
A: Under 105 CMR 170.345(B): Each trip record shall be prepared contemporaneously with or as soon as practicable after, the EMS call that it documents. Under 105 CMR 170.345 (C) of the EMS regulations, EMTs who transport a patient to the hospital must deliver the trip record at the time of transport. Approved Service Zone Plans for each town also stipulate the trip record procedure that must be followed for all services operating within the town.
Q: Are the signatures of EMTs required on an electronic patient care report (PCR)?
A: The signature is not technically required by the state, but an ambulance service can require it as part of its own policies. It’s also wise for an EMT to sign the PCR after reviewing it so s/he knows what’s documented since each crew member is responsible for patient care up to his/her certification level as limited to the level of the ambulance service license. The state does require the names of the EMTs, certification numbers and levels as well as the role each had on the call.
Q: How long does our service have to store patient care reports?
A: 105 CMR 170.345 requires that “each service shall prepare and maintain records 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.”
Q: You respond to a call for a motor vehicle collision. You arrive on scene and the occupants of the vehicles all report they are not injured. Are EMTs required to obtain patient refusals for all parties in all vehicles, even if no one is claiming injuries, or do they obtain refusals for only those who report an injury, but do not wish transport?
A: An example of a "no EMS" call is getting dispatched for an "unresponsive in a car" only to learn that a gentleman was taking a pleasant nap until awakened by EMTs rapping on the window. Clearly, the call to 911 was good intentioned, but unwarranted (there was no emergency). You get into murky waters when the call is for an MVA, and those involved were actually in the MVA; no matter how minor. Failure to obtain a refusal may cause a legal issue if an individual involved in the MVA decides to pursue legal action against everyone on scene. It will be difficult to defend your actions when an attorney subpoenas the patient care report and finds there is nothing documenting what happened except "no EMS" (hard to justify when you were dispatched to an MVA). OEMS strongly advises each ambulance service to have its legal counsel review and approve its patient refusal policies, procedures and forms.
Related: References: 105 CMR 170.345(B) and OEMS/MDPH AR 5-610 Responding to Scenes Involving Minors Refusing Treatment or Transport and advisory from 2002
Q: When will ambulance services be required to submit data in compliance with MATRIS(Massachusetts Ambulance Trip Record Information System)?
A: As of December 15, 2010, each trip record (aka “patient care report”) must include the data elements indicated in Administrative Requirement 5-403 Statewide EMS Minimum Dataset and be uploaded or directly entered into the MATRIS website within 14 days of the call at: https://matris.dph.state.ma.us
Q: My Ambulance Service has a document to assist new EMTs and students to gather all the information needed for a PCR including patient name, address, DOB, medical history, and medications. After transport, the EMT (or student) uses this document to help write the PCR. Once all of the information is transferred and the PCR is completed, should this document be destroyed, or how should this document be handled as it does contain confidential patient information?
A: The HIPAA Privacy Rule requires that covered entities implement reasonable safeguards to limit incidental uses or disclosures of protected health information. See 45 CFR 164.530(c)(2). Although the regulation does not dictate specific means or provide guidance on acceptability of methods of destruction for confidential materials, shredding (and subsequent recycling) is convenient, effective, and has minimal environmental impact.
Q: Can First Responders (not certified EMTs) obtain a signed patient care refusal from patients at an emergency scene? (Example: a fire department running a Class 5 ambulance not fully staffed by EMTs, but required to document every EMS run, including patient refusals not obtained by the private EMS provider.)
A: First Responders may cancel an incoming ambulance for “no EMS” calls (e.g., 9-1-1 call for an MVA which is then determined to be just a disabled motorist). First Responders are not prohibited from obtaining a patient refusal but there should be a policy in place between the First Responder service (e.g., police or fire department) and the ambulance service, since ultimately; the ambulance crew is responsible for the response to the patient. First Responders should receive the appropriate training in dealing with patient refusals and continue ambulance response for any patient that a refusal of care may not be prudent.
Q: Is it within a minor's right to refuse ambulance transport?
A: Refer to Administrative Requirement 5-610 "Responding to Scenes Involving Minors Refusing Treatment or Transport"
Q: If a competent patient initially refuses care but goes unconscious while crew is in process of informing patient of possible consequences of refusing care: does the crew then operate under implied consent?
A: Yes they do !
Minors Refusing Treatment or Transport
Administrative Requirement 5-403
Administrative Requirement 5-610
