SECTION 310:641-11-22. Specialty care ambulance service records and files

(a)   All required records for licensure will be maintained for a minimum of three (3) years.

(b)   Each licensed specialty care ambulance service shall maintain electronic or paper records about the operation, maintenance, and such other required documents at the business office. These files shall be available for review by the Department during normal work hours. Files which shall be maintained include the following:

(1)   Patient care records:

(A)   at the time a patient is transported to a receiving facility, the following information will be, at a minimum provided to the facility staff members at the time the patient is accepted:

(i)   personal information such as name, date of birth, and address;

(ii)   patient assessment with medical history;

(iii)   medical interventions and patient responses to interventions;

(iv)   any known allergies; and

(v)   other information from the medical history that would impact the patient outcomes if not immediately provided.

(B)   A signature of the receiving facility health care staff member will be obtained to show the above information and the patient were received.

(2)   A complete copy of the patient care report shall be sent to the receiving facility within twenty-four (24) hours of the hospital receiving the patient.

(3)   Completed patient care reports shall contain demographic, administrative, legal, medical, community health, and patient care information required by the Department through the OKEMSIS Data Dictionary.

(4)   All run reports and patient care information shall be considered confidential.

(c)   All licensed agencies shall maintain electronic or paper records on the maintenance, and regular inspections of each vehicle. Each vehicle must be inspected and a checklist completed after each call, or on a daily basis, whichever is less frequent.

(d)   All licensed agencies shall maintain a licensure or credential file for licensed and certified emergency medical personnel employed by or associated with the service to include:

(1)   Oklahoma license and certification,

(2)   Basic Life Support certification that meets or exceeds American Heart Association standards,

(3)   Advanced Cardiac Life Support certification that meets or exceeds American Heart Association Standards if applicable for the license level,

(4)   Incident Command System or National Incident Management Systems training at the 100, 200, and 700 levels or their equivalent,

(5)   verification of an Emergency Vehicle Operations Course or other agency approved defensive driving course,

(6)   contain a list or other credentialing document that defines or describes the medical director authorized procedures, equipment, and medications for each certified or licensed member employed or associated with the agency, and

(7)   a copy of the medical director credentials will be maintained at the agency.

(e)   The electronic or paper copies of the licenses and credentials described in this section shall be kept separate from other personnel records to ensure confidentiality of records that do not pertain to the documents relating to patient care.

(f)   Copies of staffing patterns, schedules, or staffing reports which indicate the ambulance service is maintaining twenty four (24) hour coverage at the highest level of license;

(g)   Copies of in-service training and continuing education records.

(h)   Copies of the ambulance service:

(1)   operational policies, guidelines, or employee handbook;

(2)   a list of the patient care equipment that is carried on any "Class E" unit(s) will be part of the standard operating procedure or guideline manual,

(3)   medical protocols; and

(4)   OSHA and/or Department of Labor exposure plan, policies, or guidelines.

(i)   A log of each request for service received and/or initiated, to include the:

(1)   disposition of the request and the reason for declining the request if applicable,

(2)   patient care report number,

(3)   date of request,

(4)   patient care report times,

(5)   location of the incident,

(6)   where the ambulance originated, and

(7)   nature of the call.

(j)   Documentation that verifies an ongoing, physician involved quality assurance program.

(k)   Such other documents which may be determined necessary by the Department. Such documents can only be required after a thorough, reasonable, and appropriate notification by the Department to the services and agencies.

(l)   The standardized data set and an electronic submission standard for EMS data as developed by the Department shall be mandatory for each licensed ambulance service. Reports of the EMS data standard shall be forwarded to the Department by the last business day of the following month. Exceptions to the monthly reporting requirements shall be granted only by the Department, in writing.

(m)   Review and the disclosure of information contained in the ambulance service files shall be confidential, except for information which pertains to the requirements for license, certification, or investigation issued by the Department.

(n)   Department representatives shall have prompt access to files, records, and property as necessary to appropriately survey the provider. Refusal to allow access by representatives of Department to records, equipment, or property may result in summary suspension of licensure by the Commissioner of Health.

(o)   All information submitted and/or maintained in files for review shall be accurate and consistent with Department requirements.

(p)   A representative of the agency will be present during the record review.

[Source: Added at 33 Ok Reg 1529, eff 9-11-16]