POLICY NO:

701

DATE ISSUED:

8/00

DATE REVIEWED/REVISED:

4/2006

DATE TO BE REVIEWED:

4/2008

EMERGENCY MEDICAL SERVICES PATIENT CARE DOCUMENTATION (MEDS SYSTEM) Purpose: To establish standards for documentation of prehospital care by Santa Barbara County EMS Providers. Authority: Health and Safety Code, Division 2.5, Section 1798. California Code of Regulations, Title 22, Division 9, Section 100175. Policy: A patient care record or report must be completed for all calls where a patient is contacted or assessed by BLS, BLS-Optional Scope, and ALS personnel. The primary system for patient documentation is the Multi-EMS Data System (MEDS), a software program being provided to the EMS System by American Medical Response (AMR). MEDS (Multi-EMS Data System) is an Electronic Pre-Hospital Care data collection system that integrates sending Computer Aided Dispatch (CAD) information to the field and receives patient data back from the field to generate patient billing information, and reports for the EMS Agency, provider CQI coordinators, hospitals, and other approved entities. Selected users of the MEDS system are authorized to create/view sensitive patient information in this environment. All users of the MEDS are also required to be in compliance with AMR policies regarding MEDS, as appropriate. Procedure: General Procedures: 1. All EMS personnel in the System must complete a MEDS training program, as prescribed by AMR and approved by the EPCR Committee. 2. All requests for modification/changes/editing of the MEDS system must be submitted on the MEDS feedback form and forwarded to the EPCR committee for action and approval. 3. MEDS connects to the computer aided dispatch (CAD) system at the Public Safety Dispatch Center and call response data is to be imported from that system when available.

APPROVED:

Nancy A. Lapolla, EMS Director

Angelo Salvucci, MD, EMS Medical Director

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POLICY NO: 701

TITLE: PATIENT CARE DOCUMENTATION (MEDS SYSTEM)

4. An electronic patient care record (EPCR) is to be completed for all EMS calls where patient contact and/or assessment occurs and according to Policy # (pt contact) 5. Required fields are highlighted in magenta and must be completed. Fields in red are strongly recommended. 6. In many cases, data fields are limited to drop down menu and other format controls to standardize data. Where the MEDS system allows for user input with a menu, providers are to utilize either plain text language or accepted abbreviations and symbols. Users and User Accounts: 1. Each provider that will input data into MEDS will have a user account. 2. User accounts will be specific to the individual provider and contain required system permissions. 3. Provider agencies shall complete a User Account Request form to the MEDS administrator and arrange for MEDS training. 4. MEDS users are required to change their passwords every forty-five (45) days. Timeline Requirements for Completing the EPCR: 1. Code 3 patients: For all patients transported code 3 (emergent transport) and for all major trauma patients, the EPCR will be completed and submitted to the MEDS system before the paramedic leaves the hospital. However, if ambulance system status is low, the AMR field supervisor may require the that a paramedic ambulance respond to another code 3 call even know the EPCR has not been completed. 2. Coroner (11-44) cases: First responders and transport paramedics (BLS/ALS) will complete EPCR as soon as feasible upon return to their station (or on mobile device). In no case will the EPCR completion and submittal be delayed beyond four (4) hours. 3. Maximum timeline: The EPCR will be completed and submitted to the MEDS server as soon as possible. In no case will this occur after the end of the provider’s shift, without approval of the provider’ s supervisor. Trailing (attached) documents: 1. The following documents are to be submitted to the MEDS system in support of the EPCR. This is accomplished by faxing copies of the documents using the special fax cover sheet provided by the MEDS system for each specific patient. a. EKG strips - for routine cardiac monitoring: At least one EKG strip (of at least three (3) leads optimally) b. EKG Code Summary – for cardiac arrest: The code summary as well as appropriate other EKG segments including initial rhythm, pre and post shock rhythms, changes in rhythm, and final rhythm. c. 12-lead EKG: All 12-lead EKGs d. End-tidal CO2 (EtCO2) data: For all patients with advanced airway management, if data is not already included on code summary. e. Drug lists: As appropriate, but attaching a drug list does not replace the requirement to complete that data in the MEDS system. f. DNR forms: For patients to whom a DNR has been used to stop or withhold resuscitation. g. Patient Refusal Form: For patients who have signed the hard copy refusal form as outlined in this policy. SANTA BARBARA COUNTY EMERGENCY MEDICAL SERVICES

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POLICY NO: 701

TITLE: PATIENT CARE DOCUMENTATION (MEDS SYSTEM)

2. If the technology becomes available to import cardiac monitor/vital signs/EtCO2 data directly into MEDS, that some or all of the trailing documents process may not be required. Electronically Submitting the EPCR: 1. The competed EPCR is submitted to the MEDS system server. 2. EPCR must be submitted prior to the end of the provider’s shift. In the rare event that it is impossible to electronically submit the EPCR prior to end of the shift (e.g. the MEDS server is “down”) the provider will print out a “Preview PCR” document to provide to the hospital until a final EPCR can be submitted. Receiving Hospital Procedures: 1. When the patient is delivered to the receiving facility (or location). An EPCR will be completed as soon after as possible and in compliance with this policy. 2. The MEDS system id designed to automatically send a completed and submitted EPCR to the receiving emergency department facsimile machine. 3. Each County emergency department is to develop procedures for periodically checking the fax machine for EPCRs. 4. If the fax machine printing process in not functioning, each emergency department is equipped with a MEDS printer as a back up and should be used for completed EPCR printing. Signatures: 1. Patient: The transporting paramedic will obtain the patient’s signature on the EPCR. This signature is important for a variety of reason including consent, HIPAA, and billing. If the patient is unable to sign and the patient’s representative is present, the paramedic will obtain the representative’s signature and the paramedic will document this and will indicate the reason why the patient was unable to sign. The patient and witnesses signatures are required in the Refusal of Care process as outlined below. 2. Providers: All providers are required to sign a completed EPCR prior to submitting and list all members of the crew. 3. Physicians: The receiving physician’s signature is required on the Advanced Airway form, if an advanced airway was used on the patient. Addendums: 1. Once an EPCR has been electronically submitted to the MEDS server, it is unable to be modified. The provider may however, add an addendum to the EPCR. 2. The purpose of the addendum is to permit the provider to add information that was inadvertently missed at the time the provider submitted the EPCR. The addendum is not intended as a mechanism to simply create a PCR. 3. The provider will notify the receiving hospital pre-hospital coordinator anytime an addendum is completed to supplement a previously submitted EPCR. Refusal of Care and/or Transportation: 1. All EPCR fields pertaining to non-transport of patients must be completed in all instances where patient contact is made, but the patient is not transported. 2. If the paramedic is utilizing a wireless laptop computer, the patient or responsible party will read the Patient Refusal Form on the computer screen and sign it (unless SANTA BARBARA COUNTY EMERGENCY MEDICAL SERVICES

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POLICY NO: 701

TITLE: PATIENT CARE DOCUMENTATION (MEDS SYSTEM)

precluded by standard precautions). The paramedic will provide the patient written instructions on how to obtain a written copy of the Refusal Report. 3. If the paramedic is not utilizing a wireless laptop computer, the paramedic will have the patient or responsible sign a hard copy of the Patient refusal form and attach using the trailing documents process as outlined in this policy. Multicasuality Incidents (MCI): 1. An EPCR record will be submitted for each patient unless this requirement is waived by the EMS Agency. 2. ??Other procedure here?? Technical Problems: 1. MEDS System Down (server not functional) a. AMR will notify the Public Safety Dispatch center to notify field providers that the MEDS system is “down”. b. AMR will notify the on-call EMS Agency duty officer. c. Providers will continue to enter the EPCRs on the computers, which will retain records until the system is functioning normally again; at which time providers will submit EPCRs. d. Providers will provide a written preliminary (Preview) EPCR record at the receiving emergency department until the system is functionally normally again. 2. First Responder PC Problems: a. Hardware problem: Providers should contact their agency’s IT contact to resolve the issue. b. Internet Connectivity: Providers should contact their agency’s IT contact to resolve the issue. c. MEDS Software problem: Providers should contact the MEDS Administrator or AMR duty supervisor during non business hours. 3. Ambulance Laptop Problems: a. The paramedic will contact the MEDS Administrator or AMR duty supervisor immediately. b. The supervisor may elect to contact the Itronix Help Desk at (866) 665-7559 for further assistance. c. Depending on the status of the problem, the AMR supervisor will bring a replacement laptop to the ambulance crew impact by the problem. 4. Reverting to paper PCR: a. If there is complete system failure (both MEDS server and laptop without replacement) providers should revert to completing a paper PCR. b. It is the responsibility of the provider’s agency to reenter any paper PCR’s data into MEDS once the system is functioning normally again. 5. Lost or Stolen equipment: a. The responsible crew will immediately notify the AMR duty supervisor. b. The AMR duty supervisor will contact local law enforcement as appropriate for stolen equipment. 6. CAD Outage: a. If the connection to CAD becomes non-functional, providers shall create the ePCR using a temporary case number created in coordination with Dispatch. b. The AMR duty supervisor should be notified that the CAD connection is down. SANTA BARBARA COUNTY EMERGENCY MEDICAL SERVICES

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POLICY NO: 701

TITLE: PATIENT CARE DOCUMENTATION (MEDS SYSTEM)

c. EPCRs with temporary case numbers should be “parked” and not transmitted. d. Once the CAD connection is restored, the ePCR is to be “unparked” and updated with the CAD data. The ePCR is then to be transmitted. Use of MEDS Computers and Printers in the Emergency Department: These devices are intended for conducting emergency medical services business; specifically, patient care record entry and retrieval, and other official EMS business as allowed by AMR policy. MEDS Committee: 1. The EMS Agency, in cooperation with AMR, will establish an EPCR committee. The committee will meet on the same recurring schedule as the Continuous Quality Improvement Committee. 2. The purpose of the EPCR committee will be advise AMR and the EMS Agency on the EPCR system as well as review requests for changes and other modifications to the system. 3. The EPCR committee will include representation from field providers as well as CES, AMR IT, provider CQI coordinators, and the hospitals. 4. The committee may meet more frequently as needed.

SANTA BARBARA COUNTY EMERGENCY MEDICAL SERVICES