Emergency Medical Services Patient Care Report Data Elements, Confidential and Nonconfidential Data Elements and Essential Patient Information for Transmission at Patient Transfer
[39 Pa.B. 68]
[Saturday, January 3, 2009]
Under 28 Pa. Code § 1001.41 (relating to data and information requirements for ambulance services) the Department of Health (Department) is publishing the following: (a) a list of data elements and form specifications for the emergency medical services (EMS) patient care report (PCR); (b) requirements that a prospective vendor must satisfy to secure endorsement of the vendor's software by the Bureau of Emergency Medical Services (Bureau); (c) a designation of data items for the PCR that are confidential; and (d) patient information in the PCR designated as essential for immediate transmission to the receiving facility for patient care.
(A) Data Elements and Form Specifications. The following standards must be met for an EMS data collection software program to satisfy the requirements for electronic PCR reporting:
1. A prospective vendor's software must be capable of collecting and reporting data in the format detailed in the National Emergency Medical Services Information System (NEMSIS) Data Dictionary version 2.2.1, published by the National Highway Traffic Safety Administration. Information on NEMSIS is published at www.nemsis.org. Prospective vendors are encouraged to contact the NEMSIS Technical Assistance Center (TAC) to clarify issues regarding the NEMSIS 2.2.1 requirements. Software marketed to Commonwealth ambulance services must be the version that has demonstrated that it is capable of collecting and reporting all NEMSIS 2.2.1 elements. Prospective vendors must use the Commonwealth list of Federal Information Processing Standard (FIPS) Codes for Commonwealth Municipalities, Hospital Identification Codes and Medication Codes (Codes). These are provided by the Bureau. The Bureau will maintain a list of required fields, Codes and resources on the Bureau's webpage at www.health.state.pa.us/ems.
2. A PCR data collection software program must satisfy the following:
i. It must be capable of recording all of the data elements identified in the column titled ''Required Data Elements'' on the EMS Patient Care Report Data and Information Chart included in this notice. It must have the ability to error check PCRs using the NEMSIS Data Dictionary published on the Bureau's webpage.
ii. It must produce an XML output file meeting the NEMSIS 2.2.1 standard.
iii. It must be able to collect and print narrative.
iv. It must allow for the ambulance service to make corrections when data elements are omitted or an error occurred when the form was initially completed.
v. It must annotate additions and corrections made to the PCR by identifying what data element was added or changed, the date of change and who made the change.
vi. It must assign a specific Patient Care Report Number (NEMSIS Field E01_01) to each PCR and prevent duplication of this identifier.
3. A prospective vendor must assist ambulance services in setting up software and is to validate that PCR data created by the software being proposed will be compliant with the ''Required Data Elements'' on the EMS Patient Care Report Data and Information Chart included in this notice.
4. A prospective vendor must coordinate with a regional EMS council that is willing to conduct a test of the software program using (10 of the PCRs previously submitted to the NEMSIS TAC) configured for use in the region where the test is conducted.
The test will include:
i. Printing of the 10 PCRs.
ii. Printing a list of the data elements collected.
iii. Printing reports that identify unit utilization for:
a. Response outcome, hour/day of week.
b. Fractal time.
c. Municipal response for the test site.
iv. Printing the following reports:
a. Incident location/type report with number of calls and percentage of calls.
b. Trauma summary.
c. Revised trauma scores.
d. Glasgow coma scale.
e. Medical summary.
g. Treatment summary.
h. Admission summary.
i. BLS and ALS skills report for each practitioner.
j. BLS and ALS skills report for each beta test site.
k. Demographics summary (age, gender, total).
l. Vital signs summary (ranges, systolic, diastolic, pulse, respiration).
m. Attendant activity.
v. Printing output files of data elements to include:
a. Field number.
b. Field name.
c. Number of fields for each field name.
d. Type of field (that is, numeric, blanks stored as ''0,'' mm/dd/yyyy, character, and acceptable field values).
5. A prospective vendor must secure a determination of software compliance from the Bureau by requesting a determination of compliance from the Bureau, upon which the Bureau will notify the prospective vendor of reports and information that the prospective vendor must submit to the Bureau to seek a determination of compliance.
(B) Bureau Endorsement of Software. To secure endorsement of the software by the Bureau, in addition to securing a determination of compliance from the Bureau, a prospective vendor must do the following:
1. Agree, in writing, to make changes to the software program at no cost to the ambulance service if the change is the addition of additional data elements included in the NEMSIS Data Dictionary version 2.2.1.
2. Agree, in writing, to provide to the Bureau and to Commonwealth ambulance services and quick response services (QRS) using the vendor's software, 30-days advance notice before selling the program source code or company, or going out of business. The prospective vendor must further agree, in writing, that if circumstances prevent the prospective vendor from meeting the 30-day notice requirement, the vendor will provide input specifications and the source code for the software program to the Bureau at no cost.
(C) Confidential PCR Data Elements. Under 28 Pa. Code § 1001.42 (relating to dissemination of information) the release of the PCR, disclosure of confidential information in the PCR or a report or record thereof, is prohibited except as authorized under 28 Pa. Code § 1001.42(a)(1)--(7). The Department has the authority under 28 Pa. Code § 1001.41(b) to designate some of the information in the PCR as nonconfidential but has chosen not to do so at this time. Consequently, the PCR is confidential in its entirety, and all information in the PCR is subject to the disclosure restrictions in 28 Pa. Code § 1001.41(b). The Bureau and the regional EMS councils will, however, release aggregate data extracted from PCRs.
(D) Patient Information Required to be Transmitted to Hospital at Time of Patient Delivery. Under 28 Pa. Code § 1001.41(d) an ambulance service is to provide to the individual at the hospital assuming responsibility for the patient the patient information designated in the PCR as essential for immediate transmission to personnel for patient care. The Bureau encourages ambulance services to transmit immediately to the facility all information solicited by the PCR, including the narrative section. If the ambulance service does not provide all of the information solicited by the PCR at the time the hospital or facility assumes care, essential information that must be transmitted are the items listed on the following EMS Patient Care Report Data and Information Chart. The information may be transmitted verbally, in writing or electronically in a format [developed by the hospital or other entity] that the hospital finds acceptable to ensure the confidentiality of information designated as confidential in the PCR form.
Persons with a disability who require an alternate format of this notice (for example, large print, audiotape or Braille) should contact Robert Cooney, Department of Health, Bureau of Emergency Medical Services, Room 606, 625 Forster Street, Health and Welfare Building, Harrisburg, PA 17120, (717) 787-8740. Speech or hearing impaired persons may use V/TT (717) 783-6154 or the Pennsylvania AT&T Relay Service at (800) 654-5984 (TT).
EMS Patient Care Report Data and Information Chart Required PA NEMSIS Elements Name Essential Information for Immediate Transmission to Receiving Facility at Time of Patient Delivery D01_01 EMS Number 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_07 Agency Contact Zip Code D04_04 Procedures Required D04_06 Medications Given Required D04_08 List of Protocols D04_11 Hospitals Served D04_12 Hospital Facility Number E01_01 Patient Care Report Number E01_02 Software Creator E01_03 Software Name E01_04 Software Version E02_01 EMS Agency Number E02_02 Incident 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 (Decal Number) E02_20 Response Mode to Scene E03_01 Complaint Reported by Dispatch E03_02 EMD Performed E04_01 Crew Member ID E04_02 Crew Member Role E04_03 Crew Member Level E05_02 PSAP Call Date/Time E05_03 Dispatch Notified Date/Time E05_04 Unit Notified by Dispatch Date Required 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 Required E06_12 Race E06_13 Ethnicity E06_14 Age Required E06_15 Age Units E06_16 Date of Birth E07_01 Primary Method of Payment E07_15 Work-Related E07_34 CMS Service Level E07_35 Condition Code Number Required E08_05 Number of Patients at Scene E08_06 Mass Casualty Incident E08_07 Incident Location Type E08_12 Incident City E08_13 Incident County E08_14 Incident State 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_05 Chief Complaint Required E09_11 Chief Complaint Anatomic Location E09_12 Chief Complaint Organ System Required E09_13 Primary Symptom Required E09_14 Other Associated Symptoms E09_15 Providers Primary Impression Required E09_16 Provider's Secondary Impression E10_01 Cause of Injury Required E10_02 Intent of Injury E10_04 Vehicular Injury Indicators Required E10_08 Use of Occupant Safety Equipment Required E10_09 Airbag Deployment E10_10 Height of Fall Required E11_01 Cardiac Arrest E11_02 Cardiac Arrest Etiology E11_03 Resuscitation Attempted E11_04 Arrest Witnessed By E11_05 First Monitored Rhythm of the Patient Required E11_11 Cardiac Rhythm on Arrival at Destination E12_01 Barriers to Patient Care E12_08 Medication Allergies Required E12_10 Medical/Surgical History E12_14 Current Medications Required E12_19 Alcohol/Drug Use Indicators E13_01 Run Report Narrative E14_03 Cardiac Rhythm Required E14_04 SBP (Systolic Blood Pressure) Required E14_05 DBP (Diastolic Blood Pressure) Required E14_06 Method of Blood Pressure Measurement Required E14_07 Pulse Rate Required E14_08 Electronic Monitor Rate E14_11 Respiratory Rate Required E14_15 Glasgow Coma Score-Eye E14_16 Glasgow Coma Score-Verbal E14_17 Glasgow Coma Score-Motor E14_27 Revised Trauma Score E14_28 Pediatric Trauma Score E15_01 NHTSA Injury Matrix External/Skin E15_02 NHTSA Injury Matrix Head Required E15_03 NHTSA Injury Matrix Face Required E15_04 NHTSA Injury Matrix Neck Required E15_05 NHTSA Injury Matrix Thorax Required E15_06 NHTSA Injury Matrix Abdomen Required E15_07 NHTSA Injury Matrix Spine Required E15_08 NHTSA Injury Matrix Upper Extremities Required E15_09 NHTSA Injury Matrix Pelvis Required E15_10 NHTSA Injury Matrix Lower Extremities Required E15_11 NHTSA Injury Matrix Unspecified E18_03 Medication Given Required E18_05 Medication Dosage Required E18_06 Medication Dosage Units E18_08 Medication Complication E18_09 Medication Crew Member ID E19_02 Procedure Performed Prior to this Units EMS Care E19_03 Procedure E19_05 Number of Procedure Attempts E19_06 Procedure Successful E19_07 Procedure Complication E19_09 Procedure Crew Member ID E19_10 Procedure Authorization E19_12 Successful IV Site E20_02 Destination/Transferred To, Code E20_07 Destination Zip Code E20_10 Incident/Patient Disposition E20_14 Transport Mode from Scene E20_15 Condition of Patient at Destination E20_16 Reason for Choosing Destination E20_17 Type of Destination E22_01 Emergency Department Disposition E22_02 Hospital Disposition E23_03 Personal Protective Equipment Used E23_09 Research Survey Field E23_10 Who Generated This Report E23_11 Research Survey Field Title
Essential Information for Immediate Transmission to Receiving Facility at Time of Patient Delivery, Not Required to be Transmitted to the Regional EMS Council. NEMSIS Elements Name D01_02 EMS Agency Name D08_01 EMS Personnel's Last Name D08_03 EMS Personnel's First Name E06_01 Patient's Last Name E06_02 Patient's First Name
A. EVERETTE JAMES,
[Pa.B. Doc. No. 09-16. Filed for public inspection January 2, 2009, 9:00 a.m.]
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