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".

D. If additional sheets are necessary for the narrative, EMS System Continuation Forms are to be used and distributed in the following manner:

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.