The Schematron establishes the documentation standard implemented by all EMS agencies and ePCR software vendors for care provided by New York State EMS agencies. The Schematron is updated to adapt to a changing EMS system or current situations. The COVID-19 Schematron Update is designed to improve documentation standards during the COVID-19 pandemic response. The 2020 COVID-19 Schematron Update is being implemented by ePCR software vendors and the Regional Elite Sites on Tuesday, April 06, 2020.
Pulse Rhythm: the requirement for providers to document a pulse rhythm when a pulse rate is documented has been eliminated. This rule caused multiple validation issues and providers felt compelled to submit inaccurate data. While the rule is no longer effective, the field may still be completed, if appropriate, as it provides a more comprehensive picture of the patient’s condition.
Incident County: one of the Incident County (eScene.21) rules has been eliminated. There were two rules which were a duplicate of each other and is being addressed completely in rule 935.
Incident County: Rule 935 (eScene.21 County) and 693 (eScene.19 Zip Code) have been redesigned to reflect that any incident location within the United States, that both the County and Zip Code be properly documented. This rule will only take effect when the Country documented is listed as “United States.” When the Incident Country is anything else such as Canada, this rule will not apply.
Times : At Patient Side: four dispositions have been eliminated from requiring an “At Patient Side” time (eTimes.07). When Providers utilize the dispositions of “Assist Unit, Assist Agency, Assist Public, and Treated/ transported by law enforcement, they will no longer be required to provide an “At Patient Side” (eTimes.07) time. This removed the requirement of having to obtain patient specific data when your unit provided no direct patient care.
Assist Agency is intended for one agency assisting a separate agency.
Assist Unit is intended for a unit assisting another unit from the same agency.
Assist Public is intended when a public entity requests services other than Medical treatment.
Assist Agency, Unit, and Public are intended when a unit provides assistance but never assumes direct patient care. Equipment and manpower are examples of services that may fit into this description.
Treated/Transported by law enforcement would be utilized when EMS may be called to a scene; however, the patient remains in custody of a law enforcement agency which transports the patient. A unit may show up on scene, but at no time assume direct patient care.
Medical History; Allergies; Current Medications: a patient’s medical history, medication allergies and current medications are important aspects of a patient’s history and physical and for accurate documentation must be completed whenever there is patient contact of any nature. This rule is tied to patient dispositions, so when a disposition equals one of the ones listed below, the provider must document an adequate history, including Medical History (eHistory.08), Allergies (eHistory.06), and Medications (eHistory.12). These rules are activated by the “At Patient Side” (eTimes.07) time and will become active once eTimes.07 or the Incident/ Patient Disposition (eDisposition.12) is documented as follows:
Treated, Transported by this EMS unit;
Treated, Transferred care to another EMS unit;
Treated, Released (per protocol);
Patient Dead as Scene – No Resuscitation Attempted (without Transport);
Patient Dead as Scene – No Resuscitation Attempted (with Transport);
Patient Dead as Scene – Resuscitation Attempted (without Transport);
Patient Dead as Scene – Resuscitation Attempted (with Transport);
These important history questions may not always be available as part of the crew’s history assessment:
When a patient reports that s/he has no Medical History, the Pertinent Negative of “None Reported” remains available and is appropriate to use in this situation.
When a patient refuses to provide the crew with medical history for any reason, the pertinent negative of “Refused” is appropriate and should be documented by the crew.
When a patient is unresponsive and the crew is otherwise unable to obtain medical history from the patient, the pertinent negative of “Unresponsive” is appropriate to use in this situation.
If the crew is otherwise unable to obtain this information, such as a patient who has a diminished mental status, invasive airway procedure, or any alternative means, please document “Unable to Complete” in these fields.
At no point should a provider be utilizing the Not Values of “Not Applicable”,” Not Recorded”, or “Not Reporting.”
Response mode to the scene (eResponse.23) is now a required field and must be completed. The Response to the scene must be completed whenever your agency is activated for a call and the type of service requested is anything but “Other, or Standby.”
Transport mode from scene (eDisposition.17) is now a required field and must be completed. This field must be completed when the disposition for the call requires a transport to a facility. This field is qualified by an “At Patient Side” time (eTimes.07), when the type of response is a “911 Response” and the disposition of the patient is “Treated, Transported by this unit”
Vital Signs: the number of sets of Vital Signs has been modified to require that providers must now document two sets of vital signs when their minimum patient contact time from “At Patient Side” (eTimes.07) and the “Arrival at Destination” time (eTimes.11) is greater than 15 minutes. Providers are reminded that Vital signs should be repeated on critical patients at least every 5 minutes.
At the minimum a Glasgow Coma Score and Respiratory rate should be able to be completed and documented for these patients.
Pertinent Negatives such as “Refused” should a patient not allow the crew to complete them, or “Unable to Complete” may be utilized when the crews is unable to complete a vital sign such as blood pressure or heart rate.