ARM 37.104.212. RECORDS AND REPORTS

(1) Each emergency medical service must maintain a patient care record for every EMS incident. (a) In incidents where more than one patient is encountered, one patient care record shall be completed for each patient. (b) In the event more than one emergency medical service arrives at the scene of an EMS incident, each service having actual contact with a patient is responsible for completing a patient care record on the patient. (2) Ambulance services and nontransporting units must provide data as identified by the department in this rule. (3) Electronic data submitted to the department must be in the format prescribed by the National Emergency Medical Services Information System (NEMSIS). (a) For emergency medical services directly using the reporting system provided by the department, the data is considered submitted to the department as soon as it has been entered or updated in the department-provided system. (b) For emergency medical services using third-party software, the data is considered submitted to the department as soon as it has been uploaded or updated into the department-provided system. (4) The following NEMSIS demographic data elements for ambulance service or nontransporting unit licensing must be reported and updated no less than annually: D01_01 EMS Agency Number D01_02 EMS Agency Name D01_03 EMS Agency State D01_04 EMS Agency County D01_07 Level of Service D01_08 Organizational Type D01_09 Organization Status D01_10 Statistical Year D01_12 Total Service Size Area D01_13 Total Service Area Population D01_14 911 Call Volume per Year D01_15 EMS Dispatch Volume per Year D01_16 EMS Transport Volume per Year D01_17 EMS Patient Contact Volume per Year D01_19 EMS Agency Time Zone D01_21 National Provider Identifier D02_01 Agency Contact Last Name D02_02 Agency Contact Middle Name/Initial D02_03 Agency Contact First Name D02_04 Agency Contact Address D02_05 Agency Contact City D02_06 Agency Contact State D02_07 Agency Contact Zip Code D02_08 Agency Contact Telephone Number D02_09 Agency Contact Fax Number D02_10 Agency Contact Email Address D03_01 Agency Medical Director Last Name D03_02 Agency Medical Director Middle Name/Initial D03_03 Agency Medical Director First Name D03_04 Agency Medical Director Address D03_05 Agency Medical Director City D03_06 Agency Medical Director State D03_07 Agency Medical Director Zip Code D03_08 Agency Medical Director Telephone Number D03_09 Agency Medical Director Fax Number D03_11 Agency Medical Director Email Address D04_02 EMS Unit Call Sign D05_01 Station Name D05_02 Station Number D05_04 Station GPS D05_05 Station Address D05_06 Station City D05_07 Station State D05_08 Station Zip D05_09 Station Telephone Number D06_01 Unit/Vehicle Number D06_03 Vehicle Type D06_04 State Certification/Licensure Levels D06_07 Vehicle Model Year D06_08 Year Miles/Hours Accrued D06_09 Annual Vehicle Hours D06_10 Annual Vehicle Miles D07_01 Personnel's Agency ID Number D07_02 State/Licensure ID Number D07_05 Personnel's Level of Certification/Licensure for Agency D08_01 EMS Personnel's Last Name D08_02 EMS Personnel's Middle Name/Initial D08_03 EMS Personnel's First Name D08_04 EMS Personnel's Mailing Address D08_05 EMS Personnel's City of Residence D08_06 EMS Personnel's State D08_07 EMS Personnel's Zip Code D08_09 EMS Personnel's Home Telephone D08_10 EMS Personnel's Email Address D08_15 State EMS Certification Licensure Level D08_17 State EMS Current Certification Date (5) The following NEMSIS EMS data elements must be reported by ambulance services for each incident: E01_01 Patient Care Report Number E02_01 EMS Agency Number E02_04 Type of Service Requested E02_05 Primary Role of the Unit E02_06 Type of Dispatch Delay E02_07 Type of Response Delay E02_08 Type of Scene Delay E02_09 Type of Transport Delay E02_10 Type of Turn-Around Delay E02_12 EMS Unit Call Sign (Radio Number) E02_20 Response Mode to Scene E03_01 Complaint Reported by Dispatch E03_02 EMD Performed E05_02 PSAP Call Date/Time E05_04 Unit Notified by Dispatch Date/Time E05_05 Unit En Route Date/Time E05_06 Unit Arrived on Scene Date/Time E05_07 Arrived at Patient Date/Time E05_09 Unit Left Scene Date/Time E05_10 Patient Arrived at Destination Date/Time E05_11 Unit Back in Service Date/Time E05_13 Unit Back at Home Location Date/Time E06_08 Patient's Home Zip Code E06_11 Gender E06_12 Race E06_13 Ethnicity E06_14 Age E06_15 Age Units E07_01 Primary Method of Payment E07_34 CMS Service Level E07_35 Condition Code Number E08_05 Number of Patients at Scene E08_06 Mass Casualty Incident E08_07 Incident Location Type E08_15 Incident ZIP Code E09_01 Prior Aid E09_02 Prior Aid Performed by E09_03 Outcome of the Prior Aid E09_04 Possible Injury E09_11 Chief Complaint Anatomic Location E09_12 Chief Complaint Organ System E09_13 Primary Symptom E09_14 Other Associated Symptoms E09_15 Provider's Primary Impression E09_16 Provider's Secondary Impression E10_01 Cause of Injury E11_01 Cardiac Arrest E11_02 Cardiac Arrest Etiology E11_03 Resuscitation Attempted E12_01 Barriers to Patient Care E12_19 Alcohol/Drug Use Indicators E18_03 Medication Given E18_08 Medication Complication E19_03 Procedure E19_05 Number of Procedure Attempts E19_06 Procedure Successful E19_07 Procedure Complication E20_07 Destination Zip Code E20_10 Incident/Patient Disposition E20_14 Transport Mode from Scene E20_16 Reason for Choosing Destination E20_17 Type of Destination E22_01 Emergency Department Disposition E22_02 Hospital Disposition (6) Emergency medical services must provide patient care report data to the department at least quarterly based on a calendar year or on a schedule submitted to and approved by the department. (a) These quarterly data must be submitted to the department within 60 days of the end of the quarter as follows: (i) data for EMS responses occurring in January through March must be submitted by June 1; (ii) for responses in April through June by September 1; (iii) for responses in July through September by December 1; and (iv) for responses in October through December by March 1. (b) The data may be submitted more frequently than quarterly. (c) An emergency medical service with no EMS incidents during the quarter must report such to the department. (7) Ambulance services are not required to submit other NEMSIS data elements, but may do so. Nontransporting units are not required to submit NEMSIS data, but may do so. (8) Other software may be used to submit required data, but agencies must consult with the department before purchasing such software. (9) The department adopts and incorporates by reference the National Emergency Medical Services Information System (NEMSIS) Uniform Pre-Hospital Emergency Medical Services Dataset, Version 2.2.1, (5/04/2010) published by the National Highway Traffic Safety Administration (NHTSA). A copy may be obtained at http://www.nemsis.org/v2/downloads/datasetDictionaries.html or from the Department of Public Health and Human Services, Public Health and Safety Division, Emergency Medical Services and Trauma Systems Section, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951. (10) Patient care reports may be reviewed by the department. (11) Copies of patient care reports must be maintained by the service for a minimum of seven years. (12) Immediately or as soon as possible upon arrival at a receiving facility, but no later than 24 hours after the end of the patient transport, an ambulance service must provide a copy of the patient care report to the hospital that receives the patient. (a) If a completed patient care report cannot be left at the facility at the end of the patient transfer to the licensed hospital, an abbreviated patient encounter form containing information essential to continued patient care shall be provided until a patient care record can be left. (b) If an immediate response to another patient is required of an ambulance delivering a patient to a licensed hospital, a complete oral report on the patient being delivered will be given to the receiving facility until a patient encounter form or patient care record can be provided.