12VAC5-31-1140. Provision of patient care documentation.

A. EMS personnel and EMS agencies shall provide the receiving medical facility or transporting EMS agency with a copy of the prehospital patient care report for each patient treated at the time of patient transfer. Should EMS personnel be unable to provide the full prehospital patient care report at the time of patient transfer, EMS personnel shall provide an abbreviated documented report with the critical EMS findings and actions at the time of patient transfer and the full prehospital patient care report shall be provided to the accepting facility within 12 hours.

B. The signature of the prescriber, as defined in § 54.1-3401 of the Code of Virginia, who assumes responsibility for the patient shall be included on the prehospital patient care report for an incident when a drug is administered, or self-administration is assisted (excluding oxygen), or an invasive procedure is performed. EMS personnel shall not infer that the prescriber's signature denotes approval, authorization or verification of compliance with protocol, standing orders or medical control orders.

The receiving prescriber signature requirement above does not apply to drugs that are maintained by EMS personnel during transport of patients between healthcare facilities, provided adequate documentation of ongoing drugs are transferred with the patient by the sending facility.

If a patient is not transported to the hospital or if the attending prescriber at the hospital refuses to sign the prehospital patient care report, the PPCR shall be signed by the agency's operational medical director within seven days of the administration and a signed copy delivered to the hospital pharmacy that was responsible for any drug kit exchange.