07/14/2014 REVIEWED/REVISED: DATE TO BE REVIEWED: 01/31/2016 EMERGENCY MEDICAL SERVICES ELECTRONIC PATIENT CARE REPORT DOCUMENTATION - EPCR

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1 POLICY NO: 701 DATE ISSUED: 08/2000 DATE 07/14/2014 REVIEWED/REVISED: DATE TO BE REVIEWED: 01/31/2016 EMERGENCY MEDICAL SERVICES I. PURPOSE: To define the use of standardized records to be used by Emergency Medical Services providers for documentation of pre-hospital care. II. AUTHORITY: California Health & Safety Code, Sections & 1798; California Code of Regulations, Title 22, Section III. DEFINITIONS: A. Incident: An incident is any response involving EMS personnel to any event in which there is an actual victim or the potential for a victim, regardless of whether or not the responding unit was cancelled en route. This includes all emergency responses, non-emergency responses, walk-in responses, responses that are cancelled before scene arrival, any pre-arranged ambulance stand-bys and any ambulance transfers originating in Santa Barbara County. B. Patient Contact: A patient contact is defined as any contact between an EMT or Paramedic and a potential patient, is considered a patient contact and requires completion of an epcr. IV. POLICY: EMS response and all patient care provided by EMS personnel will be accurately and completely documented using the appropriate method, within the specified time frame. PROCEDURE: A. Provision of Access The EMS Agency will provide access to the approved Santa Barbara County Electronic Patient Care Report (epcr) system and software to EMS system participants required to enter, edit, or analyze data. Santa Barbara County EMS provider agencies are to utilize only the EMS Agency approved electronic patient care data system. This system is able to be modified to meet the needs of the EMS Agency Medical Director. B. Documentation 1. Complete documentation on all medical response and care is essential to ensure proper continuity of patient care. The epcr will be used to document all care provided APPROVED: John H. Eaglesham, EMS Director Angelo Salvucci, MD, EMS Medical Director

2 PAGE 2 OF 5 POLICY NO. 701 by pre-hospital personnel for every patient contact or incident to which a unit or provider goes enroute with the Dispatch Center. Documentation will be completed on any person with obvious illness, injury or significant mechanism, regardless of consent. C. Transfer of Care a. If a First Responder EMT-I or paramedic initiates care of the patient, the First Responder personnel will document all care provided to the patient on epcr. b. If care is turned over to another ALS agency, an epcr will be completed by all pre-hospital provider agencies who delivered patient care or transport. c. The appropriate Level of Service (ALS vs BLS) provided to the patient will be documented on the epcr. 1) If an ALS provider determines a patient to only require basic level care, the ALS level of service drop down choice will be utilized. 2) If a unit or provider is attached to an incident, but cancelled en route, an epcr will be completed by selecting Cancelled in the Response Disposition box. 3) A brief narrative will include any additional information as necessary to provide accurate continuity of patient care. d. At a minimum all required mandatory fields indicated in red in the epcr will be collected. A validation score of 95 will be required for every epcr prior to completion and locking of the document. e. Patient side documentation is encouraged and should be practiced whenever patient care will not be negatively affected. f. In the event of multiple patients, documentation will be accomplished as follows: 1) Level 1 MCI: The care of each patient will be documented using the approved epcr. 2) Level 2 and 3 MCI: Triage tags may be used in lieu of a patient care report (PCR) if necessary due to large number of patients. Any care provided will be documented on the triage tag. 1. Transfer of care between two field provider teams and between field provider and hospital will be documented on the approved epcr, including the specific time of transfer. The first providing agency will post to the server and perform a coordinated electronic transfer of information to the unit to which care is transferred. The unit receiving the electronic transfer will download the correct corresponding report prior to completion of the epcr. This includes intra-agency units and inter-agency units. 2. The time that patient care is transferred to hospital staff will be documented by the EMS responder in the role of primary patient care provider at the time of that transfer.

3 PAGE 3 OF 5 POLICY NO. 701 D. ECG Monitor A. In the event a 12-Lead ECG is obtained according to EMS Policy, a complete ECG will be attached to the corresponding epcr. ECG data will be downloaded by each provider agency involved in that incident and attached to the corresponding epcr. An original 12 lead ECG will also be printed and submitted upon transfer of care to hospital staff. B. During patient monitoring when transfer of patient care occurs from one agency to another the accepting agency will connect their ECG monitor to the patient to ensure all data from time of transfer forward is documented in the accepting agencies epcr. E. epcr Completion Requirements 1. In the following circumstances, a final epcr will be completed and posted by any transporting unit, and by any First Responder personnel either retaining or transferring care, within thirty (30) minutes of arrival at the destination hospital: a. Any patient that falls into Step 1 or Step 2 ( ) of the Santa Barbara County Field Trauma Triage decision scheme. b. Any patient that is in cardiac arrest, or had a cardiac arrest with ROSC. c. Any patient with a positive result of STEMI upon completion of a 12 lead ECG. d. Any patient with a positive Cincinnati Stroke Scale (CSS +). e. Any patient that is unable to accurately communicate information regarding present or past medical history. An exception to this requirement would be during times of EMS system overload where a delay in a unit returning to service will pose significant delays in response times. In this situation, the report shall be completed as soon as possible and no later than 2 hours from the time of transfer of care. The reason for delay must be reported to a supervisor. 2. For circumstances not listed above, in which the patient was transported to a hospital, the entire data subset found on the epcr REPORT tab will be completed and electronically posted to the server by transporting agencies, and by First Responder ALS personnel retaining care, within thirty (30) minutes of arrival at destination. a. An exception to this requirement would be during times of EMS system overload where a delay in a unit returning to service will pose significant delays in response times. In this situation, the report shall be completed as soon as possible and no later than 2 hours from the time of transfer of care. The reason for delay must be reported to a supervisor..

4 PAGE 4 OF 5 POLICY NO. 701 F. Dry Run/Against Medical Advice 1. Every patient contact resulting in refusal of medical care or transport must be documented with the following information; the reason dispatched and/or chief complaint, assessment and vital signs, base hospital contact documenting the physician authorizing AMA, patient advised to seek medical attention and completion of AMA. 2. The AMA checklist as well as patient signatures will be captured whenever possible by each applicable agency at the time of patient contact/refusal. If a signature is not obtained an explanation will be documented in the narrative section of the epcr. G. ALS Inter-facility Transfers (Acute Care Facility to Acute Care Facility) Documentation will be completed on all interfacility transfers. Documentation will include, but not be limited to, names of both sending and receiving physician, baseline assessment, medications administered, reason for transfer, any procedures utilized in providing patient care, vital signs and any changes from baseline assessment. If the transferring facility sends staff to accompany the patient, the staff member(s) name(s) will be documented on the epcr. H. The completion of an epcr should not delay patient transport to the hospital. I. Patient Medical Record The epcr will be considered a legal document and part of the patient s medical record. The first responder agency, transport agency, and hospital are custodians of record. Printing should only be performed as needed, and an electronic copy of the epcr should be utilized and referred to whenever feasible. A print log and reason for printing will be monitored regularly to help ensure security of protected health information within the system. 1. A completed epcr shall not be altered or changed except by the individual who completed the epcr, upon approval and permission of a Service Administrator. Upon consultation the change may be either a data change or an addendum as determined to be appropriate. J. Technical Problems / Recovery Procedures: 1. Device Failure - In the event of a device failure, contact your agency support person, document all pertinent information on paper and enter the epcr in Rescue Bridge as soon as you return to your station. Electronic documentation system failure is NOT an exception for providing the required PCR documentation. Device failure will be resolved within 48 hours. 2. Connectivity Failure If there is connectivity failure document all patient information on your device and save. Post your call to the server as soon as connectivity returns. 3. System Failure In the event of system failure document all patient information on your device and save. Post to the server as soon as the system is rebooted or document on paper and enter into Rescue Bridge when the system is back up.

5 PAGE 5 OF 5 POLICY NO The EMS Agency shall be notified of downtime or transmission difficulties lasting more than 24 hours. 5. Any system upgrades or system maintenance must be reviewed and approved in writing by the EMS Agency prior to implementation. Any planned issue that could cause a delay in data transmission will be notified to the EMS Agency at least 24 hours in advance. K. General Instructions: L. Privacy: 1. The epcr is a part of the patient s permanent medical record and is used for but not limited to the following purposes: a. Transfer of information to other healthcare providers b. Medical legal documentation c. Billing for services d. Development of aggregate data reports for Continuous Quality Improvement (CQI) including specific quality indicators and identification of educational needs e. EMS Agency case investigation 2. Reference to an EMS Unusual Occurrence form or similar record should not be included in the epcr. 3. The EMS Medical Director is the final authority for determination of all aggregate data reports that are to be maintained confidential or distributed. 4. Willful omission, misuse, tampering or falsification of documentation of patient care records is cause for formal investigative action under section of the California Health and Safety Code. 1. Maintaining confidentiality is an essential part of all health care, including prehospital care. The confidentiality of personal health information (PHI) is covered by numerous state and federal statutes, Policies, Rules and Regulations, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA), California Civil Code Section 56.36;Division 109; Section and California Health and Safety Code Sections , and a. Providing epcr copies to receiving hospitals and other providers giving care in an EMS response system and to the EMS Agency for CQI does not constitute a violation of the above regulations. b. Provider agencies are responsible for training their employees in the initiation, completion and distribution of patient care records, HIPAA and State Health Information Privacy statutes and regulations.

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