Okla. Admin. Code § 310:641-3-63

Current through Vol. 41, No. 19, June 17, 2024

Section 310:641-3-63 - Ambulance service files

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

(b) Each licensed 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(s) are 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;

(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 was 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 public information required by the Department through the OKEMSIS Data Dictionary;

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

(5) all licensed agencies shall maintain records on the maintenance, and regular inspections of each vehicle.

(A) Each vehicle must be inspected and adetailed equipment checklist completed after each call, or on a daily basis, whichever is less frequent; and

(B) documentation that shows routine vehicle maintenance for each vehicle as required by vehicle manufacture recommendations,

(6) all licensed agencies shall maintain a credential or licensure file for licensed and certified emergency medical personnel employed by or associated with the service that includes:

(A) Oklahoma license and certification;

(B) Basic Life Support certification or documentation of BLS cognitive objectives and psychomotor skills that meets or exceeds American Heart Association standards, and approved by the medical director;

(C) Advanced Cardiac Life Support certification or documentation of BLS cognitive objectives and psychomotor skills that meets or exceeds American Heart Association Standards as applicable for advanced licensure level(s)and approved by the medical director;

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

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

(F) 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

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

(7) 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.

(8) 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;

(9) Copies of in-service training and continuing education records;

(10) Copies of the ambulance service:

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

(B) medical protocols;

(C) 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 and;

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

(c) 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 as required by the OKEMSIS data dictionary;

(5) location of the incident;

(6) nature of the call;

(7) Such other documents which may be determined necessary by the Department.

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

(e) 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.

(f) 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.

(g) 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.

(h) 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.

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

Okla. Admin. Code § 310:641-3-63

Added by Oklahoma Register, Volume 33, Issue 24, September 1, 2016, eff. 9/11/2016

Amended by Oklahoma Register, Volume 39, Issue 24, September 1, 2022, eff. 9/11/2022