FR-M-201 INCIDENT REPORTING.pdf

TO: ALL PALM BEACH COUNTY FIRE RESCUE PERSONNEL FROM: REGINALD K. DUREN FIRE RESCUE ADMINISTRATOR PREPARED BY: FIRE RESCUE PPM COMMITTEE SUBJECT: INCIDENT REPORTING PPM #:...

TO: ALL PALM BEACH COUNTY FIRE RESCUE PERSONNEL FROM: REGINALD K. DUREN FIRE RESCUE ADMINISTRATOR PREPARED BY: FIRE RESCUE PPM COMMITTEE SUBJECT: INCIDENT REPORTING PPM #: FR-M-201 ISSUE DATE EFFECTIVE DATE August 9, 2019 August 23, 2019 PURPOSE: To provide a standard for documenting incident reports in the department computer system and to assure patient confidentiality is maintained. UPDATES: Future updates to this PPM are the responsibility of the Division Chief of BOSS, in conjunction with the PPM Committee, under the authority of the Fire Rescue Administrator. AUTHORITY:  Fire Rescue Administrator  Fire Rescue Medical Director  National Fire Incident Reporting System (NFIRS)  Florida Administrative Code 64E-2.013(2)  Florida State Statutes 401.30 (3)  Florida Fire Incident Report (FFIR)  Incident Management System, 2013  Florida EMS Tracking and Reporting System (EMSTARS)  National EMS Information System (NEMSIS), as may be amended. SCOPE: This policy applies to all Palm Beach County Fire Rescue personnel and reservists. ATTACHMENTS: Attachment A: Fire Incident Narrative Attachment B: Fire CAD Protocols Attachment C: EMS CAD Protocols Attachment D: Incident Reporting Tutorial Attachment E: Risk Management Report Guide POLICY: After each emergency and non-emergency incident, the Lieutenant or Operational Captain shall ensure that the incident report is documented in the appropriate incident reporting system. If the incident reporting system is not available, the Operational Captain shall ensure the incident is documented on a field report and entered as soon as the system is available for use. FR-M-201/Page 1 of 6 PROCEDURE: Fire Rescue employees shall utilize National Fire Incident Reporting System (NFIRS) software and electronic Patient Care Report (ePCR) software for post incident documentation. After returning from an incident, personnel delegated the responsibility for documenting the incident shall complete that documentation with the most accurate information available at the time. If personnel return from an incident after 0730, they may receive overtime to complete the documentation, provided it is completed in a timely manner and verified by the Operational Captain. 1. Fire Incident: a. All reports shall be completed in accordance with the National Fire Incident Reporting System (NFIRS) Handbook. b. The incident information shall be entered as soon as possible into the applicable NFIRS program after returning from the incident. The person(s) entering the information shall sign the report in the appropriate field. c. All incidents where the Situation Found is identified as a fire (NFIRS situation found codes 100–173) shall have an incident narrative entered in the applicable NFIRS program. The purpose of the “Incident” Narrative is to give a comprehensive description of the entire incident and shall be completed by the individual with the most overall knowledge of the incident. In most cases this will be the Incident Commander but may sometimes be the first-in unit on smaller incidents. The individual with the most overall knowledge of the incident shall also be responsible for completing all fire related pages. The highest ranking Incident Commander shall be responsible for designating who shall complete the above data entry. d. The “Incident” Narrative shall be completed by the Incident Commander on any incident (not already identified in 1.c. above) where command was established. e. The “Incident” Narrative shall also be used for any other non-medical incident not already identified in paragraphs 1.c. and 1.d. above, (i.e., elevator incident, fire alarms, etc...). f. Any unit that arrives on any non-EMS incident (i.e., fire, hazardous materials, motor vehicle accident, etc.,) shall be responsible for entering a “Unit” Narrative. This narrative should not be in D.A.R.E.V.E.N.T. format. The “Unit” Narrative should describe the specific activities and assignments of that individual unit and the personnel assigned under them; not the overall incident. (On single unit incidents it is acceptable to enter the unit information in the “Incident” Narrative if the actions of the unit are adequately described in that narrative). When an Investigator arrives on scene, the Investigator shall direct the crews as to which sections of the applicable NFIRS program they can leave blank. The Investigator shall complete those specific sections of the report. Fire Rescue personnel are always required to complete the narratives as described within this policy. g. Before the end of the shift, the Operational Captain from the first arriving suppression unit shall be responsible for reviewing each report for completeness and correctness. The Operational Captain shall verify that they have reviewed the report by documenting the review in the applicable NFIRS program. A Lieutenant or Operational Captain shall not review a report when they are the primary writer of that report. In this case, they should notify the next level supervisor who shall review the report. Writing only a “Unit” Narrative does not disqualify a Lieutenant or Operational Captain from reviewing that report. FR-M-201/Page 2 of 6  h. The Battalion Chief is responsible for reviewing all fire incidents occurring in their battalion (situation found codes 100-173). Each shift, a report shall be sent to the printer at the Battalion Headquarters listing the incidents from the previous shift. The Battalion Chief shall review these incidents for completeness and correctness prior to the end of the shift. In the event a correction or addition needs to be made, the reviewing Battalion Chief shall notify the appropriate Operational Captain via email. It shall be the Operational Captain’s responsibility to make the correction to the report before the end of their next duty day. When the report has been corrected, the Operational Captain shall email the Battalion Chief that the correction(s)/addition(s) have been made. The Battalion Chief shall then document the review in the applicable NFIRS program to indicate that the report is complete and correct. i. The Fire Continuous Quality Improvement (CQI) Officer shall review all fire incidents (situation found codes from 100-173) in accordance with Continuous Quality Improvement (PPM FR-T-303). j. The Supervisor of Investigations is responsible for reviewing all fire reports in which an Investigator from the Investigations Division handled the incident. k. The Battalion Chief, or designee, is responsible for checking all missing reports, and/or incomplete reports. 2. Hazardous Material Incident: a. The appropriate Hazardous Materials Incident sections shall be completed by Special Operations on all incidents where they utilize expendable materials and/or utilize a third party for research or clean-up. b. The Battalion Chief assigned to Special Operations is responsible for reviewing all incidents in which a Hazardous Materials Incident page/section is completed. The incident shall be reviewed for completeness and correctness. Any discrepancies noted shall be returned for correction. The Battalion Chief assigned to Special Operations shall verify that the report has been reviewed by documenting the review in the applicable NFIRS program. 3. Medical Incident: a. For the purposes of this policy, report writing will be in accordance with the DISPATCHED call type code. b. “Medical Incidents” are incidents which have a CAD call type code of 100-999 (except for medical alarms with no patient) or any other incident where there is a patient. A list of the call type codes can be found searching PBCFR CAD Protocols on the Fire Rescue Intranet (SharePoint). There are two tabs at the bottom of the PBCFR CAD Protocols excel sheet, Fire and EMS. c. Medical Alarms with no patients shall be documented in the applicable NFIRS program. d. All medical reports are to be completed in accordance with this policy, the applicable SOGs, Fire Rescue EMS Protocols, procedures performed and ePCR “User’s Manual”. e. Medical incidents where the patient or emergency is unfounded shall be documented in the applicable ePCR program as “No Patient Found (Canceled on Scene)”. f. Any unit that arrives on any medical incident shall be responsible for entering a “Unit” Narrative in the applicable NFIRS program if the crew performed any action that was outside the scope of that which was documented in the applicable ePCR program (i.e., FR-M-201/Page 3 of 6  a crew performed extrication on a MVA that is not noted in detail within the medical report). g. All non-medical conditions encountered during a medical incident (i.e., a car fire at an MVA) shall be documented on the appropriate pages in the applicable NFIRS program. h. The incident information shall be entered as soon as possible. Any member of the crew may enter medical reports into the applicable ePCR program. However, medical reports shall be finalized and submitted consistent with the author’s level of training and certification. i. Refusal of Medical Treatment and/or Transport (i.e., particular treatment, closer appropriate hospital, etc.,) shall be determined and documented as outlined in SOG 520-03 Patient Refusal. j. The “Report Author” form shall be signed by the crew member completing the medical report on all medical reports. k. The “Privacy Practices Acknowledgement” form shall be signed by all patients that were either not transported or refused care. l. The following applies to patients who are transported: i. If the patient is physically and mentally capable of signing, the “I. Patient Signature” form shall be signed by the patient. ii. If the patient is not physically or mentally capable of signing, and a patient representative is available to sign, the “II. Patient Authorized Representative Signature” form shall be signed by the patient representative. iii. If the patient is not physically or mentally capable of signing, the “III A. Ambulance Crew Signature” form shall be signed by a crew member of the transporting unit. iv. On all transports, the “Transfer of Care (Hospital)” form shall be signed by a hospital staff member. m. At a minimum, a Medical Report Account Number (MRN) shall be obtained from all hospital facilities to which the patient was transported. Every effort shall be made to obtain a Social Security Number and insurance information (i.e., medical, auto, etc...). Additional follow-up to the hospital facility may be required to obtain all information. n. All students (i.e., Paramedic, EMT, etc…) and observers shall be properly documented in the applicable ePCR program. o. Before the end of shift, the Operational Captain shall ensure all medical reports are complete and compliant with the current Fire Rescue EMS protocols. The Operational Captain shall record the review in the applicable ePCR program. p. The medical report review process shall be done in accordance with both the applicable ePCR “User Manual” and Continuous Quality Improvement (PPM FR-T- 303). 4. Firefighter and Civilian Casualties: a. The Firefighter Casualty page shall be completed in the applicable NFIRS program if an Employee, Reservist or cadet is injured, killed or exposed in the line of duty. This includes all casualties that occur while on-duty, in conjunction with an incident as well as non-incident events. A casualty is either an injury, fatality or exposure. b. When a Reservist casualty occurs, the immediate supervisor shall use the following in the applicable NFIRS program: i. RESERVE1 as the employee ID # FR-M-201/Page 4 of 6  ii. PBCFR as the user’s first name iii. RESERVIST as the user’s last name iv. The reservist’s name shall be added to the comments section c. The Civilian Casualty page shall be completed if a civilian is injured or killed at a fire scene or as the result of being exposed to fire. This includes Fire Rescue Cadets or Law Enforcement Officers not employed by Fire Rescue. d. Any time a Firefighter Casualty page is completed, a medical report shall also be completed in the applicable ePCR program if they were evaluated, treated and/or transported to the hospital. e. Injuries to Employees shall also be documented as outlined in Work-Related Injuries/Returning to Work (PPM FR-H-302). 5. Public Assist: a. In order to determine the incident qualifies as a Public Assist (refer to SOG 500-01 Determining if a Patient Exists and SOG 510-01 Public Assists). If determined to be a Public Assist (59), the incident report shall be entered in the applicable NFIRS program. 6. Vehicle Accidents: a. All persons from all vehicles (drivers and passengers) who are denying injuries and who, in the opinion of the paramedic, demonstrate no apparent injury and in the opinion of the paramedic there is no mechanism sufficient enough to cause an injury shall have their demographic information completed in the applicable ePCR program. 7. Mass Casualty Incidents: a. All incidents declared as an “MCI” (Mass Casualty Incident) shall be documented as such in the applicable ePCR program. During a Level 1 or 2 MCI, an abbreviated medical report may be completed containing only: i. The patient’s name ii. Date of birth iii. Phone number iv. Brief narrative b. During a Level 3 or greater MCI an abbreviated medical report may be completed for any patient containing only: i. The Metag number ii. Basic information obtained at the scene iii. Any medical care rendered c. Crews should make every attempt after an MCI to obtain any missing information for their medical reports. 8. Patient Confidentiality: a. All patient confidentiality issues shall be in compliance with Health Insurance Portability and Accountability Act and Security Standard (PPM FR-A-401). b. Only personnel authorized with an appropriate security clearance may access, view, print or handle patient information or records in any way. These authorized personnel have demonstrated a bonafide need to have access to this information for the performance of their duties under normal conditions. FR-M-201/Page 5 of 6  ______________________________ REGINALD K. DUREN FIRE RESCUE ADMINISTRATOR Supersession History 1. PPM#FR VI-02, issued 11/11/1985 2. PPM#FR VI-02, issued 05/11/2016 3. PPM#FR VI-02, issued 11/01/2016 4. PPM#FR VI-02, issued 12/12/2017 5. PPM#FR M-201, clerical 03/01/2018 6. PPM#FR M-201, issued 6/25/2018 7. PPM#FR M-201, issued 04/22/2019 8. PPM#FR-M-201, issued 06/21/2019 9. PPM#FR M-201, issued 8/9/2019 10. PPM#FR M-201, attachment E added 10/24/19 FR-M-201/Page 6 of 6