Rob McCartin

Greetings,

See this weeks NEMSIS Educational Snip:

The Data and Informatics (DI) Unit at the Bureau of EMS & Trauma Systems is sending weekly Educational Snips highlighting various NEMSIS fields. Our goal is to help providers reduce documentation errors and warnings requiring adjustment throughout documentation. Each Educational Snip will start with a question, an outline of various fields, and elements (answers) within those fields. We are providing the NEMSIS named elements; the ePCR software used by your EMS agency might look different, and you should have custom values selected by the Department of Health available to you. If you have questions about specific documentation scenarios or if you would like clarification on particular data elements, please reach out to your organization’s leadership, Regional Program Agencies, or the DI Unit.   

  

EMS agencies credentialed by New York State are now submitting ePCRs that adhere to the National Emergency Medical Services Information System (NEMSIS) 3.5 documentation standard. NEMSIS establishes a minimum documentation standard that requires fields that must be completed on an ePCR and NYS further defines these requirements to meet minimal additional requirements. Standardized documentation improves quality documentation. Measuring provider effectiveness, system efficiency, and patient outcomes is paramount to the success of EMS organizations across New York State.  

  

The DI Unit is holding monthly NEMSIS 3.5 ePCR briefings via Webex. In these briefings, issues that EMS agencies commonly face regarding patient care documentation will be addressed. EMS providers will have the opportunity to ask any questions or raise any concerns about 3.5 submission criteria they wish. Feedback from these briefings is vital for their ongoing success. If you are an EMS provider, an EMS leader, an EMS medical director, or a software vendor who attends these meetings, please fill out a survey through this link, under the ‘Data’ section of the page.  

 

Q: How has documentation of procedures (eProcedures) changed under NEMSIS 3.5? 

Many response elements were changed across procedure fields. 

Note: all fields are named by NEMSIS with the Field Name (Field Identifier) (e.g. EMS Agency Number (eResponse.01))  

 

Date/Time Procedure Performed (eProcedures.01, validation rule BLSFR 2582/ALSFR & Ambulance 2583) 

When a procedure is performed, this field is required by NYS. It triggers additional required fields listed below.  

 

Procedure Performed Prior to this Unit’s EMS Care (eProcedures.02, ALSFR & Ambulance 2585) 

This field is recommended by NYS. Response elements include “yes” and “no”. The date and time of the procedure cannot be prior to arrival at the patient unless this is answered “yes”.  

 

Procedure (eProcedures.03, BLSFR 2586/ALSFR & Ambulance 2587) 

This field is required by NYS when Date/Time Procedure Performed is documented. To view the entire list of procedures, visit New York – NEMSIS and download the data dictionary excel file.  

 

Number of Procedure Attempts (eProcedures.05, BLSFR 2588/ALSFR & Ambulance 2589) 

This field is required by NYS when procedures are performed by crew members of unit caring for patient. This field numbers between 1 through 10.  

 

Procedure Successful (eProcedures.06, BLSFR 1238/ALSFR & Ambulance 1239) 

This field is required by NYS when a procedure is attempted on the patient. The response options for this field are “Yes” and “No”. 

 

Procedure Complication (eProcedures.07, BLSFR 2592/ALSFR & Ambulance 2593) 

This field is recommended (especially for ALS/Transporting units) by NYS when procedures are performed by crew members of unit caring for patient. Response values are listed below. Note, if there is no complication one should respond “none” instead of using a not value like “not applicable”.  

·       Altered Mental Status 

·       Apnea 

·       Bleeding 

·       Bradypnea 

·       Diarrhea 

·       Esophageal Intubation-immediately 

·       Esophageal Intubation-other 

·       Extravasation 

·       Hypertension  

·       Hyperthermia 

·       Hypotension 

·       Hypothermia 

·       Hypoxia 

·       Injury 

·       Nausea 

·       None 

·       Other 

·       Respiratory Distress 

·       Tachycardia 

·       Vomiting 

·       Bradycardia 

·       Itching 

·       Urticaria 

 

Response to Procedure (eProcedures.08, BLSFR 2594/ALSFR & Ambulance 2595) 

This field is recommended (especially for ALS/Transporting units) by NYS when procedures are performed by crew members of unit caring for patient. Response elements include “Improved”, “Unchanged”, and “Worse”.  

 

Procedure Authorization (eProcedures.11, BLSFR 2596/ALSFR & Ambulance 2597) 

This field is required by NYS. Response elements listed below.  

·       On-Line (Remote Verbal Order) 

·       On-Scene 

·       Protocol (Standing Order) 

·       Written Orders (Patient Specific) 

 

Procedure Authorizing Physician (eProcedures.12, BLSFR 2598/ALSFR & Ambulance 2599) 
This field is required by NYS when a procedure was authorized outside of standing orders. It is a free text field.  

 

Vascular Access Location (eProcedures.13, ALSFR & Ambulance 2620) 

This field is recommended by NYS when vascular access is obtained. It is now associated with the date and time of the procedure and allows documentation for each attempt at vascular access. EMS professionals can also document when a patient received vascular access prior to arrival of EMS. Options have been added to this field. All elements are listed below.  

·       Antecubital Left 

·       Antecubital-Right 

·       External Jugular-Left 

·       External Jugular-Right 

·       Femoral Left IV 

·       Femoral-Right IV 

·       Foot-Right 

·       Foot-Left 

·       Forearm-Left 

·       Forearm-Right 

·       Hand-Left 

·       Hand-Right 

·       Internal Jugular-Left 

·       Internal Jugular-Right 

·       IO-Iliac Crest-Left 

·       IO-Iliac Crest-Right 

·       IO-Femoral-Left Distal 

·       IO-Femoral-Right Distal 

·       IO-Humeral-Left 

·       IO-Humeral-Right 

·       IO-Tibia-Left Distal 

·       IO-Sternum 

·       IO-Tibia-Right Distal 

·       IO-Tibia-Left Proximal 

·       IO-Tibia-Right Proximal 

·       Lower Extremity-Left 

·       Lower Extremity-Right 

·       Other Peripheral 

·       Other Central (PICC, Portacath, etc.) 

·       Scalp 

·       Subclavian Left 

·       Subclavian-Right 

·       Umbilical 

·       Venous Cutdown-Left Lower Extremity 

·       Venous Cutdown-Right Lower Extremity 

·       Upper Arm-Left 

·       Upper Arm-Right 

·       Radial-Left 

·       Radial-Right 

·       Wrist-Left