ADVISORY 

TO:		All Massachusetts Ambulances Services
CC:		EMCAB Members
FROM:	Abdullah Rehayem, Acting Director
RE:		Delivery of Ambulance Trip Records to Receiving Hospitals
DATE: 	April 13, 2006                                
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The Massachusetts Department of Public Health (DPH), Office of Emergency Medical Services (OEMS) is aware there is some confusion about the requirement for preparing trip records promptly and leaving them with the patient at the receiving facility. 

Trip records must be delivered to the receiving health care facility in accordance with 105 CMR 170.345 of the Commonwealth’s EMS System regulations. Applicable parts of this regulation state the following: 

	170.345: Records
	(B)     "Each trip record shall be prepared contemporaneously with, or as soon as 
                         practicable after, the EMS call that it documents....”
 
	(C)(2) "The EMTs on each transporting ambulance shall leave a copy of the trip record at
                         the receiving health care facility with the patient at the time of transport" 

This means trip records must be prepared at the time of the call and physically left at the receiving facility with the patient. The portion of 170.345 (B) which states "or as soon as practicable after, the EMS call," allows for the temporary delay in preparing a trip record, recognizing that there will be occasions when the ambulance may be needed to respond immediately to a pending medical emergency, for which backup resources are demonstrably unavailable.  When this occurs, the ambulance service must document justification for each time its EMTs were unable to meet the requirement to prepare a trip record contemporaneously with the EMS call and physically leave it at the receiving facility at the time of transport.

Under 105 CMR 170.345, and under the definition of “trip record,” at 105 CMR 020, all EMS calls must result in the generation of a trip record, which for calls that do not result in transport can mean a dispatch record. The regulatory requirements pertaining to trip records are applicable to all such records, whether written or electronic-generated. These requirements also apply to both emergent calls and routine scheduled patient transports, and for transport to hospitals and all other health facilities. 

Patient care is only enhanced when the receiving health care facility knows about the care EMTs provided the patient. In addition to providing them a timely and well-documented trip record, EMTs are expected to report verbally to the facility’s staff members who are taking over care of the patient, to make sure they are fully informed about the care the EMTs have already provided the patient.

If you have any questions, please contact OEMS at (617) 753-7300.