112 A Southgate Drive
Bloomington, IL 61704
Phone (309) 827-4348Fax (309) 827-2017
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| BroMenn/St. Joseph EMS Systems | Policy and Procedure Manual |
TITLE: AMBULANCE REPORT FORM REQUIREMENTS
POLICY STATEMENT:
Documentation of all patient care is essential for record keeping and communicating patient information to patient care personnel.
GOAL/PURPOSE:
To insure appropriate documentation of all patient care by pre-hospital personnel who are affiliates of either BorMenn or St. Joseph EMS Systems.
POLICY/PROCEDURE:
Currently both local Resource Hospitals and EMS Systems are in the process of implementing computer software technology to correctly obtain the data collection elements as required in the Rules and Regulations, Section 515.350. When the total system-wide implementation process has been completed, a System Plan amendment shall be submitted to the Illinois Department of Public Health for approval. Once the computerized system has received approval, a timeline shall be established as to when manual reporting shall no longer be accepted. This policy for manual reporting shall remain in effect until the total EMS System-wide computerized documentation system goes on-line.
A. All transporting agencies must complete an ILLINOIS Emergency Medical Services Pre-hospital Care Report form for EMS transports and/or patient contact.
B. This form consists of a three-part carbonless copy computer scanned DATA (bubble) sheet and a three-part carbonless copy NARRATIVE form.
C. These forms are broken down and distributed in the following manner:
Scannable Data (Bubble) Sheet (This form will need to be photocopied)
Refer to page 4 of this policy for example of "Bubble Sheet".
1. White Scannable copy, labeled IDPH Copy, shall be forwarded to IDPH by the EMS System. This copy is to be left at BroMenn/St. Joseph EMS Systems hospitals in the designated collection areas for collection by the EMS System or forwarded to the EMS System according to agency specific procedures.
DO NOT STAPLE THIS FORM! IT IS NOT INTENDED TO BE ATTACHED TO ANY OTHER COPY.
2. Blue Scannable copy, labeled Service/Provider Copy, shall be attached to the top White Narrative (Service/Provider) copy and maintained by the transporting agency. Refer to page 5 of this policy for example of "Narrative Copy".
3. Pink Scannable copy, labeled Receiving Facility Copy, shall be attached to the Pink Narrative (Receiving Facility) copy and shall be provided to the receiving facility as soon as possible upon arrival at the facility unless circumstances require responding to another emergency.
4. The Photocopy (of the bubble sheet) shall be attached to the White Narrative (EMS Resource Hospital) copy and shall be forwarded to the EMS System with the Original bubble sheet paper-clipped to the copies.5. If the patient is transported to a hospital other than a Bloomington/Normal Area EMS System hospital, the IDPH and Resource Hospital copies should be mailed or delivered to the EMS Office.
D. If additional sheets are necessary for the narrative, EMS System Continuation Forms are to be used and distributed in the following manner:
1. First white copy maintained by the transporting agency.
2. Second copy (pink) stays with the patient record (immediately after completion of the call)
3. Tired copy (white) included with EMS Resource Hospital copies.
E. Ideally, forms shall be left in the receiving hospital's Emergency Department area immediately after completion of the run.
F. The BroMenn or St. Joseph EMS System Ambulance Report Form respectively may be used to document routine, scheduled, inter-facility transfers.
G. Incomplete forms or forms needing corrections shall be returned to the provider for correction.
H. Run forms are to be completed and distributed immediately after completion of the call. If a sufficient reason exists to delay completion of the forms immediately following the call, THE FORM MUST BE COMPLETED AND DISTRIBUTED TO THE APPROPRIATE FACILITY WITHIN 8 HOURS OF THE PATIENT TRANSPORT. The EMS System Coordinator shall determine if a sufficient reason existed.
If such reason did not exist, agencies and/or personnel in a delinquent
status will be reported to their EMS Medical Director who will take action
as is deemed appropriate to insure the forms are immediately completed.