OAR 333-250-0310: Patient Care Report

(1) A licensed ambulance service must complete an electronic patient care report (ePCR) in each instance where patient contact is initiated. The ePCR shall include the data elements identified in section (4) of this rule. (a) A complete ePCR shall be submitted to: (A) Oregon Emergency Medical Services Information System (OREMSIS) within 24 hours of patient contact; and (B) A hospital or facility receiving the patient within 24 hours of the patient being transported. (b) Only one ePCR is required per patient contact. The licensed ambulance service agency or the non-transporting emergency medical services (EMS) agency providing patient care shall complete the ePCR. (2) A non-transporting EMS agency that submits ePCR data to OREMSIS must comply with OAR 333-250-0315 and section (1), subsection (4)(a), sections (6) through (8) and section (10) of this rule. (3) At the time a patient is transferred to a hospital or a receiving facility, the licensed ambulance service shall ensure that personnel relay pertinent patient care information to the hospital or receiving facility staff prior to leaving the hospital or receiving facility. Pertinent patient care information may be shared orally or in paper form. The hospital or receiving facility may request additional information. (4) A licensed ambulance service must ensure that an ePCR contains: (a) Data points as defined in the National Highway Transportation Safety Administration National EMS Information System (NEMSIS) data dictionary, using a version determined by the Oregon Health Authority (Authority); and (b) For any patient meeting the criteria for trauma patient as defined in OAR 333-200-0010: (A) The trauma band number; and (B) Triage criteria as defined in OAR chapter 333, division 200, Exhibit 2. (5) Notwithstanding the requirements in this rule, a completed ePCR is not required when: (a) There is a disaster or a multiple patient incident consisting of more than five patients or the number of patients prescribed in the county's ambulance service plan, and which results in a single ambulance transporting two stretcher patients at the same time or when an ambulance is required to make more than one trip to and from the incident site. (b) In the situation described in subsection (5)(a) of this rule, the following information is acceptable patient care documentation as allowed by the triage tag used by the licensed ambulance service: (A) The trauma system identification bracelet number or other identifier if not a trauma; (B) A record of the times and results of vital signs and list of injuries; and (C) A record of the times and types of treatment given; (c) Every reasonable attempt must be made by the ambulance personnel or ambulance-based clinicians to complete an approved ePCR for each patient at the conclusion of the incident. The following minimum information is required: (A) The time the crew assumed care; (B) The time the patient was dropped off at the hospital; and (C) The triage tag number or other identifier. (6) The licensed ambulance service must: (a) Store non-electronic patient care reports and ePCRs in a secure manner, in accordance with state and federal privacy regulations; (b) Organize the patient care reports in a manner that will allow an authorized ambulance service representative to locate a patient care report within a reasonable amount of time, using the patient's name and the date and time of the ambulance call; (c) Establish a procedure for releasing a patient care report that complies with applicable confidentiality and security requirements; (d) Protect the confidentiality of patient information including during quality improvement sessions by limiting access to the patient care report. All persons having access to patient care reports must sign a confidentiality statement; and (e) Establish a procedure for the method and verification of the destruction of a patient care report which includes at a minimum: (A) A patient’s medical record or report not be destroyed for 10 years after the record or report is made, or longer if so required by law or regulation unless the patient is notified and destruction is otherwise permitted by law or regulation; and (B) In the case of a minor patient, a medical record or report may not be destroyed until the patient attains the age of majority plus three years or for 10 years after the record or report is made, whichever is later, unless the parent or guardian of the minor patient is notified and destruction is otherwise permitted by law or regulation. (7) In accordance with paragraph (6)(e)(B) of this rule, the notification of a minor patient or the parent or guardian of the minor patient of the potential destruction of a patient care report must: (a) Be made by first class mail to the last known address of the patient; (b) Include the date on which the record of the patient shall be destroyed; and (c) Include a statement that the record or synopsis of the record, if wanted, must be retrieved at a designated location within 30 days of the proposed date of destruction. (8) A patient care report is considered protected health information and may only be used or disclosed in accordance with state and federal privacy regulations. (9) A patient care report must be made available for review and duplication when requested by the Authority as authorized by ORS 41.675 and 41.685. (10) In accordance with policies adopted by the Authority, ePCR data may be made available upon approval by the Authority for the purposes of: (a) Quality assurance; (b) Quality improvement; (c) Public health activities; or (d) Research, if an institutional review board has approved the research in accordance with 45 CFR 46. (11) The Authority will provide information and technical assistance to licensed ambulance service agencies in reporting patient encounter data and interoperability.