Failure to Leave EMS Medical Record at Hospital
Posted by , Last modified by on 23 September 2013 03:56 PM
The Office of EMS continually is asked by hospital stakeholders about the failure of EMS crews leave an EMS medical records for patients transported to hospitals. The Division of Trauma/Critical Care wishes to close the loop on the long standing topic and this document will be utilized as a resource and made available to those who make this inquiry in the future.
Medical Records from a Transferring Hospital - The VDH/OEMS does not have purview over the lack of medical records sent from a transferring medical facility. We would recommend contacting the agency that manages compliance with EMTALA.
EMS Medical Records for Transport to a Transferring Hospital – An EMS agency is required by regulation to leave an EMS medical record at the hospital they transfer to. You may work with transferring hospitals to request this be included with the medical records that they send with the patient. The only provisions for who an EMS agency is required to provide an EMS medical record to includes:
EMS Medical Records for Patients Where EMS Directly Transferred Care to Your Hospital - The following is the current EMS regulation regarding EMS crews leaving patient care documentation:
12VAC5-31-1140. Provision of patient care documentation.
OEMS’ internal policy is that either a paper EMS medical record is left at the hospital with the patient or the EMS medical record is available within the VPHIB system at the time of patient transfer. A combination of an abbreviated form (we call short form) and a later provided full report is also acceptable.
If the above is not followed, your only recourse is to submit a complaint to the VDH/OEMS. The complaint form has been placed on the OEMS Trauma Web page for your convenience at http://www.vdh.virginia.gov/OEMS/Trauma/LinksDocuments.htm please follow the instructions on the form of where to submit your complaint; the Division of Trauma/Critical is not responsible to EMS agency enforcement.
Prior to filing a complaint, please ensure internally that an EMS medical record truly was not left by the EMS crew and that it is not a matter of the EMS medical record not being incorporated into your hospital’s medical record.
While it is the sole responsibility of the EMS agency to provide your hospital with an EMS medical record for all patients that they directly transfer care to your hospital; VDH/OEMS has provided some additional resources for your convenience. The VPHIB system has a hospital level access that allows hospitals to access the EMS medical record for patient’s transferred directly between an EMS crew and your hospital. Hospital ED staff are provided with access to these records for five days and staff such as a trauma registrar that are part of a structured PI process are granted six months access.
There are limitations to this convenience. EMS agencies are required to submit to VPHIB within 30 days from the time the incident ended. EMS agencies are not required to use VPHIB as there method of fully documenting their EMS response. EMS agencies are only required to submit an extract of their medical record; though most just submit the whole record. Real-time submission to VPHIB is not mandatory, but VPHIB offers the ability to submit real-time and most other software programs have the ability to submit in real-time. Real-time submission is optional and VDH/OEMS actively encourages this. We have begun requiring real-time submission when providing state grant funding for EMS patient documentation products.
There is no further redress than the above information. Changes to this process will need to be addressed by local/regional champions encouraging EMS system to use available technology that is optional, by providing public comment when future EMS regulations are open for public comment (currently no activity in this area), or through changes in legislation.