(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.