SECTION 310:641-15-22. Emergency medical response agency records and files

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

(b)   Each certified emergency medical response agency 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 care is transferred to an ambulance service, the following information will be, at a minimum, provided to the ambulance staff members at the time the patient(s) are accepted:

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

(ii)   patient assessment with 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 outcome if not immediately provided.

(B)   A signature from the staff member will be obtained to show the above information and the patient was received.

(2)   Certified emergency medical response agency patient care reports shall contain demographic, legal, medical, community health, and patient care information as detailed in the OKEMSIS data dictionary.

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

(c)   All certified emergency medical response agencies shall:

(1)   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. Event standby agencies will complete a checklist of equipment prior to scheduled events or duties.

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

(3)   Oklahoma license and certification,

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

(5)   Advanced Cardiac Life Support certification that meets or exceeds American Heart Association Standards if applicable for licensure,

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

(7)   verification of an emergency vehicle operations course or other agency approved defensive driving course,

(8)   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,

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

(d)   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.

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

(f)   Copies of the emergency medical response agency's:

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

(2)   medical protocols;

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

(g)   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)   the 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;

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

(i)   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.

(j)   The standardized data set and an electronic submission standard for EMS data as developed by the Department shall be mandatory for each emergency medical response agency. Reports 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.

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

(l)   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.

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

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

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