Section 172-12-009 - PATIENT CARE RECORDSA licensee must ensure a patient care record for each incident, dry run, refused transportation, critical care run, community paramedic response, and stand-by service is completed by responding personnel. Patient care records must contain all data points as defined in the Nebraska Emergency Medical Services Data Dictionary.
009.01MAINTENANCE OF PATIENT CARE RECORDS. All patient care records for each incident, dry run, refused transportation, stand-by, critical care run, community paramedic response, and reporting of no incidents for a month must be: (A) Maintained and preserved, in electronic form, for a period of at least five years or in the case of minors, the records must be kept until three years after the age of majority has been attained;(B) Compliant with the highest standard as certified by the National Emergency Medical Services Information System, or successor organizations;(C) Sent to the Department as a complete record within 72 hours upon completion of an incident and when a unit is back in service to be used for inspection, data collection and research;(D) Submitted electronically to the Department. This requirement does not supersede any medical or legal requirements for maintenance of patient records; and(E) Compliant with the current version of the Nebraska Emergency Medical Services Data Dictionary.009.02THIRD PARTY PATIENT CARE REPORTING SYSTEMS. If a licensee chooses not to use the electronic Nebraska Ambulance Rescue Service Information System, the patient care and incident information must meet all requirements in this chapter:009.03PATIENT CARE RECORD CONFIDENTIALITY. Patient data must be kept confidential as required by Neb. Rev. Stat. § 38-1225. Records must be available for examination by authorized representatives of the Department.009.04DESTRUCTION OF PATIENT CARE RECORDS. In order to ensure the patient's right of confidentiality, medical records must be destroyed or disposed of by shredding, incineration, electronic deletion, or another equally effective protective measure or as otherwise provided by law.172 Neb. Admin. Code, ch. 12, § 009
Amended effective 7/20/2020Amended effective 12/9/2021Amended effective 3/5/2022Amended effective 7/15/2023