Paramedics Records Keeping

[Arun]

Hi:

If paramedics find a crashed car on the road and the driver unconscious and took him/her to the hospital to save his/her life without calling 911 or cops. Would they keep any record of where/when they found the patient or anything at all? Any record at the hospital? anything regarding this particular kind of case.

Thanks,

Arun

[Linuss]

Yes, all the time.

Contact said EMS service or hospital, and they will have the information.

[Arun]

Thanks so much Linuss

[Richard B the EMT]

I need a clarification, here.

Situation: An EMS crew, in the ambulance, with no patient, stumbles into a car crash call (unit operating onscene, not otherwise involved), treats, packages, and transports an injury patient from the crash? Said crew never did any call response sheet? If I misinterpreted any of this, please correct me.

We call this a "Flag-Down". FDNY EMS policy is, notify EMD of where the call is, so they can "assign" the ambulance to the call, give it a Computer Assisted Dispatch assignment number, and possibly cancel off the assignment any unit previously assigned.

It is a call, and appropriate paperwork is supposed to be filled out.

[Arun]

Richard:

"An EMS crew, in the ambulance, with no patient, stumbles into a car crash call (unit operating onscene, not otherwise involved), treats, packages, and transports an injury patient from the crash?"

Just wanted to know if there is any procedure under such situations.

Thanks for the response.

[WolfmanHarris]

Any time we come across a Patient, we notify dispatch that we're stopping at a potential call. This immediately generates a run number. If it turns out there is nothing for us, it gets recorded as a "No Pt. found," but there's still a unique run number. Heck everything we redeploy to cover another station it gets a run number (and we can do that dozens of times in a shift).

[mobey]

I will assume you are digging for info to support a legal case.

This is not the place to gather such info, since each area is different. By area I mean country/province/state/county/ems service.

We are waay too diverse to apply a blanket statement to your question and hold water at all.

If you are wanting to get ahold of the paperwork (Patient care report) it must be requested through the proper channels. These are protected confidential reports, that are the property of the hospitals that recieve them.

This preticular statement applies only to Canada, as far as I know: The reports we fill out are NOT the patients property. That is too say; a patient may not have access to his/her own EMS patient care report. A paper copy is in his/her file at the recieving hospital, but the records dept nor EMS practitioner nor Dr are obligated to share the report with the patient.

[WolfmanHarris]

This preticular statement applies only to Canada, as far as I know: The reports we fill out are NOT the patients property. That is too say; a patient may not have access to his/her own EMS patient care report. A paper copy is in his/her file at the recieving hospital, but the records dept nor EMS practitioner nor Dr are obligated to share the report with the patient.

I will have to check chapter and verse to back this up, but Ontario's PHIPA (Personal Health Information Protection Act) does grant a Pt. unrestricted access to their medical records; with the caveat that Health Information Custodians (HIC's) may require payment for administrative costs and some other reasonable restrictions.

Until I have the chance to copy and paste the relevant sections, here is a link to the law:

Ontario e-laws

A document for public consumption created by the Ontario Information Privacy Commissioner.

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[Richard B the EMT]

Sounds like the HIPAA and PHIPA rules are, if differently worded, both serving the same function.

Mobey, see my mantra of "Local Protocols". You're reinforcing it. Good.

DocHarris, seems our protocols are the same, if only on this matter.

As for the patient not having access to the records, except through filing via the lawyers, remember this one?

Mr Jones confronted his doctor, and complained, "I borrowed my file from the nurses station to see what's going on with me, and I'm going to sue you for writing that about me, in my records!"

Dr. Smith looked at Mr Jones, and said, "First off, patients are really not supposed to be looking at their records while in the hospital, and second, the initials stand for Shortness Of Breath!"

Edited to correct an embarrassing mis-spelling

Edited January 13, 2011 by Richard B the EMT

[fiznat]

There would likely be a police report regarding the incident as well. Where I work, if we stumble upon something like this we would get the police, and possibly the fire department involved also. Usually in crashes like this, the car needs to be taken care of and a report made (Police), and fluids/debris on the road need to be cleaned up (Fire). So, there are two more written reports that would be generated from the incident in addition to the EMS paperwork.