Department of Public Health and Human Services
Public Health & Safety » EMS and Trauma Systems » Example Encounter Forms
Example Encounter Forms
EMSTS Provides An Example Encounter Form
Effective April 1st, changes to 37.104.212(12) ARM included updated requirements to assure patient information is available to emergency room providers. In addition to decreasing the time that patient care records must be provided (no later than 24 hours), this rule requires that an encounter form must be provided in instances where the PCR cannot be left at the time the patient is dropped off at the emergency room. These requirements are in support of the essential need for EMS information about the patient in the continuity of the patient's care. The history of the incident, the patient's medical history, complaints and symptoms, as well as what emergency care was provided are essential to implementing a treatment plan for the patient's care.
Several EMS services have requested an example of an Encounter Form. Included below is one example that services are free to download and use as they wish. It is provided in both pdf and Excel versions. The excel file can be easily modified to fit other needs if an EMS service wishes to change it. This form utilizes NEMSIS terms and format and also helps with data entry purposes.
Many services are already using other forms of Encounter Forms and we would be happy to also post copies of these if provided to us. Either mail to our office or email to firstname.lastname@example.org.