1. A. Patient care reports. All certified EMS agencies except special event EMS shall complete in a timely manner and keep on file a clearly written or computer-generated patient care report for each patient who is provided with emergency medical care or transported. Each patient care report shall be authored by the provider(s) actually responsible for the patient care, and shall be completed within forty-eight hours of the provision of care to the patient.
2. B. Submission of minimum pre-hospital data. An EMS agency shall compile and submit minimum data required pursuant to this rule on a quarterly basis, or as required by the bureau.

3. C. Minimum data elements; general EMS agency information. An EMS agency shall submit the following general data to the EMS bureau:

   (1) EMS agency number;

   (2) EMS agency state;

   (3) EMS agency county;

   (4) level of service;

   (5) organizational type;

   (6) organization status;

   (7) statistical year;

   (8) total service size area;

   (9) total service area population;

   (10) 911 call volume per year;

   (11) EMS dispatch volume per year;

   (12) EMS transport volume per year;

   (13) EMS patient contact volume per year;

   (14) EMS agency time zone;

   (15) national provider identifier;

   (16) EMS agency contact zip code.

4. D. Minimum pre-hospital data elements: An EMS agency shall compile and submit to the EMS bureau the following minimum pre-hospital data for every instance that patient care is provided by the EMS agency:

   (1) vehicle type;

   (2) patient care report number;

   (3) software creator;

   (4) software name;

   (5) software version;

   (6) EMS agency number;

   (7) incident number;

   (8) type of service requested;

   (9) primary role of the unit;

   (10) type of dispatch delay;

   (11) type of response delay;

   (12) type of scene delay;

   (13) type of transport delay;

   (14) type of turn-around delay;

   (15) EMS unit call sign (radio number);

   (16) response mode to scene;

   (17) complaint reported by dispatch;

   (18) EMD performed;

   (19) crew member role;

   (20) crew member level;

   (21) PSAP call date/time;

   (22) dispatch notified date/time;

   (23) unit notified by dispatch date/time;

   (24) unit en route date/time;

   (25) unit arrived on scene date/time;

   (26) arrived at patient date/time;

   (27) unit left scene date/time;

   (28) patient arrived at destination date/time;

   (29) unit back in service date/time;

   (30) unit back at home location date/time;

   (31) patient’s last name;

   (32) patient’s first name;

   (33) patient’s home zip code;

   (34) patient’s home country;

   (35) patient’s social security number;

   (36) patient’s gender;

   (37) patient’s race;

   (38) patient’s ethnicity;

   (39) patient’s age;

   (40) patient’s age units;

   (41) patient’s date of birth;

   (42) patient’s primary method of payment;

   (43) patient’s insurance company ID/name;

   (44) CMS service level;

   (45) condition code number;

   (46) number of patients at scene;

   (47) mass casualty incident;

   (48) incident location type;

   (49) scene GPS location;

   (50) incident address;

   (51) incident city;

   (52) incident county;

   (53) incident state;

   (54) prior aid;

   (55) person who performed prior aid;

   (56) outcome of the prior aid;

   (57) possible injury;

   (58) patient’s chief complaint;

   (59) chief complaint anatomic location;

   (60) chief complaint organ system;

   (61) primary symptom;

   (62) other associated symptoms;

   (63) provider’s primary impression;

   (64) provider’s secondary impression;

   (65) cause of injury;

   (66) whether injury was caused intentionally;

   (67) mechanism of injury;

   (68) use of occupant safety equipment;

   (69) airbag deployment;

   (70) height of fall;

   (71) cardiac arrest;

   (72) cardiac arrest etiology;

   (73) resuscitation attempted;

   (74) barriers to patient care;

   (75) alcohol/drug use indicators;

   (76) run report narrative;

   (77) total Glasgow coma score;

   (78) medication given;

   (79) medication complication;

   (80) procedure;

   (81) number of procedure attempts;

   (82) procedure successful;

   (83) procedure complication;

   (84) destination/transferred to, name;

   (85) destination/transferred to, code;

   (86) destination zip code;

   (87) incident/patient disposition;

   (88) transport mode from scene;

   (89) reason for choosing destination;

   (90) type of destination;

   (91) emergency department disposition;

   (92) hospital disposition.

5. E. Updates. An EMS agency shall maintain current operational information by providing regular updates to the bureau through the EMS reporting software and the application and renewal process. Review of completed patient care reports may be required during initial and subsequent inspections.
6. F. Location of records. An EMS agency shall maintain all required records at the agency’s principal place of business within the state of New Mexico. All required records are subject to inspection by the bureau and shall be maintained so that they are reasonably accessible. The EMS bureau may, upon a showing of good cause, allow an EMS agency to maintain required records at a location outside the state of New Mexico, provided that the EMS agency demonstrates to the satisfaction of the EMS bureau that the records will be reasonably accessible for the bureau’s inspection.
7. G. Completed patient care records. An EMS agency that transports a patient shall, upon delivery of the patient to the hospital, deliver a copy of the completed pre-hospital patient care record to the receiving facility’s emergency department for inclusion in the patient's permanent medical record. In the event that the transporting unit is dispatched on another call before the pre-hospital patient care record can be transmitted, the pre-hospital patient care record shall be delivered to the receiving hospital’s emergency department no later than forty-eight hours after the transportation and treatment of the patient.

8. H. Current records requirements.

   (1) Current records for all EMS agencies. An EMS agency shall at all times maintain current copies of the following records:

   (a) medical protocols signed by the EMS agency’s medical director;

   (b) operation plans and standard operating procedures and guidelines for the EMS agency;

   (c) rosters of EMS agency personnel;

   (d) applications of EMS agency employees and other personnel;

   (e) copies of certification and licensure documentation for all EMS agency personnel;

   (f) HIPAA documentation for all EMS agency personnel;

   (g) service area maps with global positioning system (GPS) coordinates of EMS agency stations;

   (h) board of pharmacy clinic license and pharmacy license, if applicable;

   (i) federal drug enforcement administration (DEA) license, if applicable;

   (j) driver’s license and driver certification copies for each employee / volunteer; and

   (k) infection control policy.

   (2) Additional current records for all medical rescue agencies. Additionally, a medical rescue agency shall at all times maintain a current, valid copy of the title for each vehicle owned by the medical rescue agency.

   (3) Additional current records for all emergency medical dispatch agencies. Additionally, an emergency medical dispatch agency shall at all times maintain current copies of the following documents:

   (a) training records (rosters, course outlines, etc.);

   (b) E-911 updates street mapping / maps; and

   (c) a public safety answering points (PSAP) directory.

9. I. Other records required (extended retention).

   (1) Medical records. An EMS agency other than special event EMS shall retain all adult medical records (including patient care reports) for at least ten years. An EMS agency other than special event EMS shall retain all medical records of minors (including patient care reports) for at least ten years, or at least one year after the person reaches the age of majority, whichever period of time is greater.

   (2) Other records. An EMS agency shall retain the following records for a period of not less than seven years:

   (a) a copy of the EMS agency’s application for certification from the EMS bureau;

   (b) certificate of insurance for the EMS agency;

   (c) business license and incorporation documents for the EMS agency, as applicable, or documentation verifying the EMS agency’s status as a governmental entity;

   (d) all current and expired mutual aid agreements and memoranda of agreement entered into by the EMS agency;

   (e) medical director contract or professional agreement;

   (f) criminal background check documentation for EMS agency personnel, as applicable;

   (g) copies of EMS agency certification updates; and

   (h) quality assurance documentation.

   (3) Additional medical rescue agency records. Additionally, a medical rescue agency shall retain the following records for a period of not less than seven years:

   (a) vehicle maintenance records;

   (b) annual safety inspection certificates for each vehicle operated by the EMS agency; and

   (c) consultant pharmacist contract or professional agreement.

   (4) Additional emergency medical dispatch agency records. Additionally, an emergency medical dispatch agency shall retain the following records for a period of not less than seven years:

   (a) telephone and radio audio recordings, including magnetic tapes and digital file format recordings (DAT, CD, DVD, etc.);

   (b) 911 system and call records (printed output, electronic files, etc.);

   (c) CAD files; and

   (d) hand-written (manual) reports.

10. J. Extension of retention period; contingencies. If at the end of a stated retention period an EMS agency is involved in or is aware of pending legal obligations (contractual or otherwise), litigation, administrative action, governmental investigation, insurance claims, or court orders that relate in whole or in part to a required record, the EMS agency shall continue to retain the required record for at least six months after said contingency has been resolved or concluded.
11. K. Protection of records. An EMS agency shall take reasonable precautions to protect required records from destruction and damage. If an EMS agency’s required records are destroyed or damaged prior to the end of the retention period established in this rule, the EMS agency shall immediately notify the bureau.

[7.27.10.12 NMAC - N, 3/15/2010]