N.J. Admin. Code § 8:41-3.8

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

Section 8:41-3.8 - 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.

2. The patient care report shall be signed by all of the ALS crewmembers who made direct contact with the patient.

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

1. The patient's name and home address;

2. The location of the call;

3. The patient's date of birth or approximate age;

4. For MICUs, the location of the MICU intercept (if different from the location of the call);

5. Statistical information to include the patient's sex and weight;

6. Information as to the patient's chief complaint, prior medical history, medications and allergies, findings obtained during the physical exam, treatment rendered, time the treatment was rendered and any response to treatment, medications administered (including dosage), route and time of administration (that is, flow sheet);

7. A description of care given to the patient at the scene and in transit;

8. Electrocardiogram documentation in those instances where a patient's cardiac rhythm was monitored;

9. Any other information the provider deems necessary, including insurance information;

10. Voice recording number, if applicable;

11. Date and times as follows:

i. The time of dispatch;

ii. The time the vehicle is en route;

iii. The time at which contact was made with the medical command physician, if applicable;

iv. The time the vehicle arrived at the scene or sending health care facility, as applicable;

v. The time the patient is en route to the receiving health care facility; and

vi. The time the patient arrived at the receiving health care facility;

12. The names and certification numbers of each attending crewmember;

13. Any treatment rendered to the patient prior to the arrival of the MICU, SCTU or AMU crewmembers;

14. The vehicle recognition number;

15. The BLS squad name and vehicle recognition number (if applicable);

16. The provider-assigned call number;

17. The type of communications utilized for medical command;

18. The printed name of the medical command physician;

19. For MICUs and AMUs, the signature of the medical command physician within 60 days from the date of service;

20. For SCTUs, a copy of the patient's transfer orders signed by the patient's physician or a verbal order to transfer signed by a registered nurse at the sending facility including the level of care to be provided during transfer and the name of the receiving health care facility;

21. The name of the receiving health care facility and the time that care was transferred to the receiving health care facility; and

22. The receiving health care facility's disposition of the patient to include admission or discharge diagnosis and type of admission (for example, critical care unit).

(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 delivered to an authorized representative of 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 a record of all calls answered or transports provided, as applicable, and shall track the destination, diagnosis and disposition of each patient evaluated by the crewmembers. The receiving health care facility shall supply the provider with the information needed to comply with this section.

(f) Every provider of mobile intensive care and air medical services shall develop and maintain a means for recording cancelled or recalled calls, missed calls, and other activity that does not result in patient contact, but did result in a dispatch.

(g) The provider shall keep all patient care reports in accordance with the provisions for the retention of medical records set forth at 8:41-3.11.

N.J. Admin. Code § 8:41-3.8