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HomeMy WebLinkAboutacems-electronic-healthcare-record-final Alameda County Emergency Medical Services Agency Click here for all Administrative Policies 1 | P a g e Electronic Health Records Effective: December 1, 2023 Review: December 2026 Approved: Link to Record of Review and Approval I. Purpose To define Electronic Health Record (EHR) documentation requirements for 9-1-1 ALS and BLS EMS Clinicians. II. Procedure a. All Alameda County EMS provider agencies shall utilize an electronic health record system compliant with the current versions of the California Emergency Medical Services Information System (CEMSIS) and the National Emergency Medical Services Information System (NEMSIS) standards and includes those data elements that are required by the local EMS agency. The EHR data shall be exported to the Alameda County Data Collection System and CEMSIS. b. An EHR shall be completed when: i. The responding unit/apparatus arrives on scene of an incident and/or ii. The responding unit/apparatus makes patient contact c. An EHR is not required to be completed if: i. The responding unit/apparatus is cancelled prior to arrival on scene III. Documentation Requirements a. EMS Clinicians on Non-Transporting Resources i. Non-transporting clinicians, to include but not limited to those on Fire apparatus, QRVs, or single-role EMS Supervisors, arriving first on scene shall provide responding transport clinicians a report, at a minimum field notes, on all care provided and assessment prior to their arrival. ii. A “Transfer of EMS care" time shall be documented when a non- transporting resource transfers patient care to another EMS unit. iii. Whenever possible, non-transporting clinicians, should merge their EHR with the transporting unit on scene. if their EHR hardware is capable. This process reduces redundant data entry and ensures that non-transport first responder clinicians can receive outcome data on transported patients from health data exchange (HDE) enabled facilities. Alameda County Emergency Medical Services Agency Click here for all Administrative Policies 2 | P a g e iv. The EHR shall be completed and entered into the County system prior to the end of shift but no later than twenty-four (24) hours following the incident. 1. Once the EHR is completed and posted, the EHR may not be modified for any reason. Corrections or additions should be in the form of an addendum to the EHR. 2. When unusual and/or extenuating circumstances exist, the EHR may be completed within seventy-two (72) hours following the incident. b. EMS Clinicians on Transporting Resources: i. The completed and locked EHR shall be electronically provided to receiving facilities prior to departure of transport clinicians. 1. In the event the transporting clinician is unable to leave a completed and locked EHR with the receiving facility, a shorter version of the EHR can be left instead. ii. The EHR shall be completed, locked, and entered into the County system prior to the end of shift but no later than twenty-four (24) hours following the incident. 1. Once the EHR is completed and posted, the EHR may not be modified for any reason. Corrections or additions should be in the form of an addendum to the EHR. 2. When unusual and/or extenuating circumstances exist, the EHR may be completed within seventy-two (72) hours following the incident. IV. Documentation Essentials a. When the responding unit/apparatus makes patient contact, an EHR shall contain the following at a minimum: i. Patient Information and History 1. Complete demographic information 2. Resident status: Homeless or Not Homeless 3. Clear history of the present illness 4. Current medications 5. Medication allergies ii. Vital Signs 1. At least one complete sets of vital signs for every patient including: pulse, respirations, blood pressure and pulse oximetry a. An additional set of vital signs are required after any intervention or medication administration 2. A pain scale shall be documented before and after every pain medication administration iii. Physical Examination 1. Conduct a physical assessment that includes relevant portions of a head-to-toe physical exam Alameda County Emergency Medical Services Agency Click here for all Administrative Policies 3 | P a g e a. For patients with extremity injury, neurovascular status must be noted before and after immobilization. b. For patients with spinal motion restriction, document motor function before and after motion restriction. iv. Medication administration when indicated 1. For all medication administrations the dosage, route, administration time and response shall be documented. 2. IV administrations, or saline lock placements, shall include the catheter size, site, number of attempts, fluid type, and total volume administered. v. Cardiac monitoring when indicated 1. 12-leads ECGs shall be attached to the EHR a. Initial STEMI positive 12-lead ECG shall be transmitted to the STEMI Receiving Center 2. For Cardiac Arrests the initial strip, ending strip, pre and post defibrillation, and pacing attempts, should be attached. vi. Base hospital contact when applicable 1. Any requested Base Hospital orders, whether approved or denied, shall be documented clearly along with the name of the Base Hospital Physician consulted. VI. Electronic Health Record System Failure a. Electronic documentation system failure is not an exemption for completing and providing the required EHR documentation. b. If there is an EHR system failure, a paper health record shall be utilized. If a paper health record is utilized, a copy shall be left at the receiving facility if the patient is transported, and the documentation shall be attached to an EHR for the incident as soon as possible after the electronic system recovers and is back online. c. Provider agencies shall notify the LEMSA Duty Officer of EHR downtime or transmission difficulties lasting more than twenty-four (24) hours.