CHAPTER 300



Purpose - The Missouri Ambulance Reporting Form (MARF) is the most important document that the EMT or Paramedic completes. It is the official record of treatment rendered to a patient in the field. The purpose of this policy/procedure is to outline District policies regarding completion of the MARF.

Policy

1. To comply with State laws and regulations, District personnel will accurately complete a Missouri Ambulance Reporting Form (MARF) for each ambulance run, whether a patient was transported or not.

2. If more than one patient is transported, a separate form must be completed for each patient. A separate refusal form must also be completed for each ill or injured patient who is refusing treatment or transportation to the hospital.

3. The primary attendant is responsible for the completion of all patient related paperwork, including the MARF, however all crew members are accountable for the accuracy of each report.

4. All patient information obtained will be kept strictly confidential in accordance with District HIPAA Policies outlined in Chapter 500.

5. MARF’s are to be completed as soon as the call is finished unless responding to another call. All patient records must exhibit correct spelling and good grammar. Employees may not pursue their own interests until all paperwork is completed. Lack of a reasonable explanation is grounds for disciplinary action.

6. All Completed MARF’s must be faxed to the receiving hospitals as soon as possible, this includes MARF’s of patients that were flown.

7. Any supplemental paperwork should have the run number written on it and be placed in one of the following:

a. The HIPAA box at Troy or

b. Outlining Base Ambulance folder until it can be placed in the HIPAA box at Troy or

c. given to the Battalion chief.

8. Once a report has been started it will automatically Lock the file after 24 hours. To make any changes after this then the program administrators must be contacted to reset the report back to data entry.

MARF Completion Procedure

The following item-by-item instructions are intended to serve as a guideline when you are completing the Missouri Ambulance Reporting Form:

Any field that has a green circle with a check mark in it beside the field title, when clicked on will placed the top value in the field.

Any field that has a blue box, with a circle with diagonal line in it, after a field has pertinent negatives values.

There are 2 types of incident create modes;

Quick – just requires a date to start.

Typical –has the following screens which are described further down in the policy;

CAD – Dispatch information for an incident. This will auto populate the report number, Medic unit, Dispatch reason, address, and times. Can be refreshed any time, remember that it will over write what is in the fields, so any changes you have made will be reset to the dispatch information.

Disposition – see section 2

Pre-Arrival -

Dispatch to – Scene

Patient - Search or Add new patient

1. Date of Run - The program gives an option of today, yesterday or tomorrow. Ensure that the appropriate date is chosen as it will affect the times on the report if it needs to be changed.

1. Disposition – Determines the mandatory fields and signatures required. This should be chosen early in the report writing. If the disposition is changed then the Logic must be refreshed to show the mandatory fields for the new disposition. Disposition Choices;

i. Standby- this is for Fire or Law enforcement standby.

1. No Services provided

2. Services provided

ii. Assist- This is for assisting an individual that has no injury or need for transport. If you believe the patient needs to be seen, then do a refusal.

iii. Cancelled En route- When disregarded before arriving on scene

iv. No Patient- either cancelled on scene, or no patient found. Do not use if completing patient information

v. DOA –

1. No resuscitation attempted. Pt has obvious signs of death

2. Resuscitation attempted. Code is worked and terminated before transport initiated.

vi. Refusal- Patient is not transported.

vii. Treat & Transfer – When care is transferred to another unit or agency for transport

viii. Treat & Transport by EMS

Dispatch & Response screen

2. Dispatch Complaint – The complaint that you were called for. For transfers this is Transfer.

3. Call Reason- This is often the same as dispatch complaint and will auto populate from CAD system. This is where you will enter the reason for the transfer.

4. EMD performed – Emergency Medical Dispatch. Were pre-arrival instructions given?

5. Response Type –

a. 911 Response (scene) 911 calls

b. Interfacility Transfer – hospital to hospital Transfers

c. Mutual Aid – Used when we respond in place of another Ambulance District

d. Public assist/ Other – Lift assist or PR event

e. Scheduled Transport – Transfer to Nursing home, or residence, or Logistic care transports to pre-authorized Doctor appointments

f. Standby – When we respond with Law enforcement or Fire.

6. Response Category – Select appropriate choice from selection.

7. Run Report # - The number is assigned by dispatch. This will have two-digit year – number. This will auto populate from CAD.

8. Vehicle - The medic number you are assigned to. This should auto populate, but confirm it is correct

9. Response Mode – Select from options given. Emergent has nothing to do with lights or sirens.

a. Emergent (immediate Response).

i. The call is a 911 dispatch and you responded immediately, or as soon as possible from clearing another call. ( Charlie, Delta Echo responses)

ii. May be a transfer if it is a Time Critical Diagnosis such as Cath lab

b. Emergent downgraded to Non-Emergent

c. Non-Emergent.

i. This would be Transfers, or

ii. low acuity 911 calls such as public assists or Alpha Bravo calls.

d. Non-Emergent upgraded to Emergent.

10. Response Delays - Make selection from choices, if there is any delay in response please indicate here.

Scene Screen

11. Location of pickup - Address (or best approximation) where patient was found, or, if not patient, address to which unit responded. Abbreviations are not acceptable. Clinic names and street addresses should be as accurate as possible. City, county, state and zip must always be completed. For dry runs, indicate the location to which you were dispatched.

a. If picking up from a facility use the quick fill drop down to complete address. Bases are listed as Locations for walk ins.

b. If the location is the same as Patients address on file, then use “same as patient”

12. Scene Information –

a. # of patients – On scene

b. MCI

c. Delays- This is for scene delays

d. Location Type- select from drop down

Situation Screen

13. Priority Level & category

a. Priority 3- Non-critical patient.

b. Priority 1 – patient with immediate life-threatening injury or illness

c. Priority 2 – patient with Serious but not immediate life threats

d. Priority 4 – deceased

e. Priority 6 – Potential hazardous infectious disease scene requiring Higher levels of personal protection.

14. Clinical Impression

a. Primary Impression – This is what you are primary treating. It may change, such as from Chest Pain Cardiac, to Chest Pain MI,

b. Secondary Impression – Can have multiple secondary, If your primary Clinical impression changes list the prior ones here.

15. Compliant-

a. Primary

b. Secondary- Additional complaints can be added in Complaint tab

16. Symptom –

a. Primary

b. Secondary - Additional complaints can be added in Symptom tab

17. Prior Aid – Care given by Lay person or other first responder before our arrival. Such as CPR, or Narcan. Remember to also document additional information in Narrative such as amount given of the medication.

Time & Mileage Screen

At top of screen, the selection is “show Mandatory Times” or “show all Times”

18. Times - All times include date and military time, to include seconds. Many of these times can be auto populated by CAD system.

19. Time Call Received - Date & time EMS dispatch is called to respond to an ambulance medical emergency.

20. Time Unit Dispatched – Date and time ambulance unit is notified by EMS dispatch.

21. Time Unit En Route – Date and time that the ambulance unit begins physical motion.

22. Time of Arrival at Location - Time ambulance unit stops physical motion at scene (last place that the unit or vehicle stops prior to assessing the patient).

23. Time of Arrival at Patient - Time ambulance personnel establish direct contact with patient.

24. Time Unit Departs Location - Time when the ambulance unit began physical motion from scene.

25. Time of Arrival at Destination - Time when the ambulance unit with the patient arrives at destination or transfer point.

26. Time of transfer of care -

27. Time of departing Destination - Time when the ambulance unit leaves the facility or landing zone.

28. Time Unit Available - Time when the ambulance unit is back in service and available for another response.

29. Odometer reading - Must document the loaded miles to 1/10th of a mile

30. Odometer Reading at Scene - Odometer reading at the location where the patient is found, or set trip reader to 0 (zero)

31. Odometer Reading at Destination - Odometer reading at the destination that the patient is transported, or Trip mileage.

Personnel Screen-

Crew Members- Select all Personnel on scene

Under personnel there are the following choices: Law Enforcement, Fire Personnel, and Student. Please select these if any of these did procedures during the incident or prior to our arrival.

Fire departments in Lincoln County work at BLS level. If a firefighter is also an employee of the district they may preform ACLS skills, you will need to list them by their name in personnel.

Facility Nurse is a choice if you have them witness waste of controlled substances with you, so they can be added to the Controlled Substance waste Intelli form.

Other agencies:

Please document the agencies on scene with you.

Patient Screen

32. Select Patient – Enter patient name. If the patient is in the system then select after confirming birth date, Social Security number or other identifying information. If there is a discrepancy in this information start a new patient contact. If using an existing patient account, ensure the information is correct.

33. Demographic page – Complete fields

34. Address – Complete residence & mailing address if different.

35. History- Please enter allergies, medications & medical conditions for a patient.

Cardiac Screen

36. Arrest occurred- is mandatory.

If yes, then other fields become mandatory on this screen.

Trauma

37. Possible Injury – is mandatory

If yes, then other fields become mandatory on this screen

• Causes

• Mechanism

• Risk fact

MVC if marked as yes then the following tabs have mandatory fields

• Vehicle - Safety equipment

• Collison – Impact location

• Occupants – not mandatory but can include location in vehicle.

Chrono Chart Screen-

Able to view events by time, from multiple screens, and can quick add events.

Vital Signs Screen – Interface Bridge can be used to bring vitals obtained on the Monitor.

At least one set of vital signs preferably a minimum of two, should be obtained on each patient contact.

Review the vitals to ensure they are accurate, and make sense.

38. Vital signs are grouped into the following;

a. Over view – shows most common vital signs.

b. General

i. Time

ii. Level of consciousness

iii. Temp

iv. Crew

v. Blood glucose

c. Cardiology

i. Pulse Rhythm

ii. Pulse Rate

iii. Blood pressure

iv. ECG Rhythm

d. Respiratory

i. Respiratory effort

ii. Respiratory rate

iii. Spo2 % - Pulse Ox

iv. CO %

v. CO2 mmHg- Capnography

e. Scales & Scores

i. Pain

ii. Stroke

iii. Glasgow Coma Score (GCS) / Revised Trauma Score (RTS)

iv. Pediatric – APGAR and Trauma score

Vent Settings

Documenting the settings of the vent for the mode you are using. Remember to document frequently, not just if there is a change in values.

Includes: Time

Mode

Assist Control

SIMV

CPAP

BiLevel

I:E Ratio

Tidal Volume

FI O2

PEEP

PIP

Pressure Support

PPLAT

IPAP

EPAP

Exams and Assessment Screen

Body view or list view

Device Cases Screen

This screen shows the EKGs, and 12 leads attached to the report.

Medications.

Document all medications given by individual dose.

Remember negative pertinent. Example; when you would normally give a medication but either the patient is Allergic or had already taken prior should be documented here.

39. Interface Bridge will bring any medications stamped in the Monitor event section. Any marked as generic medication must be changed to what was given.

40. For each administration, Time, Medication name, dose, route, crew member administering, Response, complications, authority type. Waste amount can be entered, if there is multiple administration from the same Vial, then only the last administration should show what was wasted.

41. To use “the controlled substance waste” intelli form the Medication information must be entered into the report prior.

Procedure Screen

42. Interface Bridge will bring procedure events into this screen from the monitor file. Generic Procedure must be changed to the actual procedure performed. As the monitor cannot determine when a 15 lead is done it will show it as a 12 lead, please remember to change to 15 lead.

43. Please document all procedures performed, including Patient assessment. Remember pertinent negatives. Example; unable to perform a procedure such as missed IV.

Airway Screen

44. This screen is for documentation of advanced airways.

Communication Screen

45. This screen is for documenting communications.

Disposition Screen

46. Disposition is generally chosen early in report writing. Refer to 2

47. Transport from Scene Mode –

i. Emergent (Immediate Response)- Priority 1 or 2 patient, or TCD

ii. Emergent downgraded to non-emergent

iii. Non-Emergent- priority 3 patient

iv. Non-Emergent upgraded to Emergent

48. Transit delays – delays in transporting patient to facility.

49. Activations. When you notify the receiving facility for the following.

• Code STEMI

• Code Stroke

• Sepsis Alert

• Trauma

50. Transfer patient to agency-

a. Used with Treat and Transfer List the agency or unit care given to.

51. Destination Facility

a. Location patient transported to

i. List includes Patient’s residence

ii. If select “Not listed” please include the facility Name and Address in narrative section

52. Choice Reasons

Why location was chosen and can have multiple Reasons.

Narrative screen

53. This should be a complete, accurate and objective account of the incident.

54. Only commonly accepted abbreviations shall be used.

55. Use the CHART format. Each component will be a separate paragraph.

a. Dispatch information and Chief Complaint.

i. What you were dispatched to.

ii. How you responded to the scene. Do not use Emergency or non-emergency as they mean different things to billing.

iii. Medic’s scene size-up.

iv. Chief Complaint as indicated by the patient or observed by EMS

b. History of the present illness or injury.

i. This is where you document your answers to the questions you asked about the Chief Complaint.

c. Patient Assessment

i. A complete appropriate assessment for patient condition. Document all your findings including pertinent negatives.

ii. Document here why the patient is incapacitated and unable to sign the report if appropriate.

d. Rx- Treatment

i. What treatments were provided on scene,

ii. Reason for providing treatments, do not use Per Protocol.

iii. how the patient responded.

iv. How the patient got to the ambulance stretcher, if assisted how much assistance.

e. Transport

i. Should include reassessments.

ii. Treatments done en route

iii. Responses to treatment

iv. Where patient was left and how they got there

v. Transfer of patient care and any belongings.

vi. Explanation for destination choice.

Signatures

56. The choice of disposition will Auto populate the Signatures required. Additional signatures can be added by selecting “add new”

a. All crew members must sign the MARF.

b. Please attempt to get a patient treatment Authorization Signature. This gives the District permission to give out information necessary to file the patient's insurance for them. A reasonable effort to obtain the Patient signature at time of service is required. Alternative signatures outlined in subsections below can not be used for the convenience of the patient or crew.

c. If the patient is deceased then a signature is not required, document time of death and who pronounced.

d. When the patient is physically or mentally incapable of signing then one of the following Authorized Representatives may sign. Remember to document the reason why the patient is incapable to sign and the Authorized Representative information.

Authorized Representative are:

1. Patient’s Legal guardian or Health Care power of Attorney

2. Relative or other person who receives government benefits on behalf of the patient.

3. Relative or other person who arranges for the patient’s treatment or exercises other responsibilities for the patient’s affairs

4. Representative of an agency or institution that furnished care, or assistance to the patient. (Cannot be Ambulance district)

e. If the patient is unable to sign, and no Authorized representative is available or willing to sign. The “Crew Member Statement” must be signed by LCAD personnel and obtain the signature of a Facility representative receiving the patient.

i. The Crew Member statement, includes;

a. The reason the patient was incapable of signing,

b. That an Authorized Representative was not available or willing to sign at the time of service,

c. Receiving facility Representative information is documented

d. A copy of the face sheet needs to be attached to the report

Attachments

57. Shows the attached files to the report includes

a. Face Sheet

b. Certification of Medical Necessity

c. Monitor file

d. Intelli forms

e. 4 & 12 leads

f. Other paperwork scanned in.

Intelli Forms

58. Intelli forms are a pdf created from pulling data from fields within AmbuPro. The data must be entered in to AmbuPro prior to opening the Intelli form. The forms in use are;

a. Advance Beneficiary Notice (ABN)

b. Controlled Substance waste form

c. Billing Privacy

d. QA-QI

59. An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a notice given to the Medicare patient before they receive services if, based on Medicare coverage rules, there is a reason to believe Medicare will not pay for the service.

ABN’s are not required for care that is never covered, such as mileage to a facility further away. We may choose to do a voluntary ABN, which does not have to be signed, it may just be verbal.

The only times we need an ABN are:

Residence or SNF to Hospital transport when service could have been done more economically at the home or SNF.

This is not a blanket form and cannot be used on every call. This form must be only used when the Provider believes the services will not be covered.

i. The following fields in AmbuPro need to be completed before opening the ABN

1. Patient name,

2. date of Birth, and

3. Social Security Number

a. Select the reasons that you believe the service will not be paid for by Medicare

b. Have the patient select one of the three options.

i. I want the Service listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

ii. I want the Service listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

iii. I don’t want the Service listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

c. Have the patient sign the completed ABN in the signature box. Once it is signed then save. It will be attached to the report under attachments.

60. Controlled Substance Waste Form is used when Not all the Controlled substance is Administered to the patient, or when the Controlled substance is drawn up but not given to a patient.

a. The following fields need to be completed prior to opening the form;

i. Patient Name

ii. Controlled substance Administered or drawn up

iii. Amount administered

iv. Administration time

v. Personnel screen. List anyone who is involved with the administration and waste.

b. Add the amount of waste in the appropriate box,

c. Check the appropriate box for witness

d. Select the personnel for each activity and have them sign the form

e. Save report, it will attach in Attachments.

61. Billing Privacy this form is optional for Patient signature. The form has three separate sections of which only one needs to be completed. There is also a paper copy on the ambulances that can be used and scanned into the attachment section of the report.

a. The following Fields should be completed in AmbuPro prior to opening the Intelli form.

i. Patient Information

ii. Crew Member information

iii. Select reason Patient cannot sign in signature field.

b. The Sections are;

i. Patient signature: Used when patient is capable of signing.

ii. Authorized Representative Signature: Used when the patient is unable to sign, and there is a representative available & willing to sign.

iii. Crew Member Statement & Signatures; Used when the other choices are not available.

62. QA-QI This form maybe be used by the Battalion Chief, Captain, Chief Medical Officer or Medical Director when reviewing a report.

Zoll File Transfers.

63. Any time the monitor is attached to the patient the file should be attached to the MARF by interface bridge.

64. The file can be uploaded by Wi-Fi, Bluetooth or jump drive.

65. The program will highlight by check mark all monitor strips and 12 leads, it allows the user to select the vital signs to be imported.

66. Once the file is imported by Interface bridge, check the information and complete the necessary fields.

67. For Any Cardiac arrest, the EMS crew should review the Zoll file with the CMO after the call.

Procedure for Refusal Form

1. A patient has the right to refuse a treatment, Transportation or a destination facility.

2. If an ill or injured patient is refusing treatment or transportation to the hospital, it is important that the examining EMT or Paramedic fully explain the possible medical consequences of their refusal of care or transport.

2. It is very important that a patient's condition be accurately reported on the MARF, especially when the patient refuses treatment or transportation to the hospital. This includes the findings of a physical assessment and recording the patient's vital signs.

3. If the patient still wishes to refuse care, the patient should be instructed to read and sign the Refusal of Care Form either on the computer or paper. The completed paper Refusal of Care Form should have the run number written on top and be placed in the HIPAA box to be attached to the electronic report.

4. The refusing patient's signature must be witnessed, preferably by a family member. If a family member is not present, police officer or fire personnel should witness the refusal signature. Crew partner should be the last resort for witness.

5. If the patient is uncooperative and refuses to be physically examined or to sign the Refusal of Care Form, then thoroughly document this on the MARF and have it signed by a witness as above.

Procedure for Flying a patient.

1. If any Ill or Injured Patient is to be flown. It is important in the Rx – Treatment Paragraph of the narrative to include the criteria used to determine the need for a helicopter. It should take in to consideration the patient condition, and not just distance to a level 1 center.

2. The Disposition should be “Treated, transferred care for Transport”.

3. If the patient is flown from the scene, then use the Transfer Patient care Time for on Scene. Clearly document in Narrative that patient was flown from the scene.

4. If the Patient was taken to a landing zone. Please document mileage from scene to Landing zone. Clearly document in narrative patient was driven to the landing zone. The extra Times will be the following.

a. Time departed scene

b. Time Arrival Landing Zone

c. Transfer of patient care

d. Time left landing zone

Adopted by Medical Director January 19th, 2019

NEMSIS 3 update. Approved 2/25/ 2020

This policy supersedes any previous policy or memorandum on this topic.

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