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PA Bulletin, Doc. No. 09-16


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 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

   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.

   f.  EKG.

   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_04EMS Agency County
D01_07Level 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

Acting Secretary

[Pa.B. Doc. No. 09-16. Filed for public inspection January 2, 2009, 9:00 a.m.]

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