As with all policies and procedures, all samples should be reviewed by legal counsel and appropriate medical and hospital personnel before adoption
Blood Alcohol Intake Form:
This sample form demonstrates the type of “probing questions” that CMS expects to occur to assure that a law enforcement test situation does not require EMTALA medical screening. While a form is not required, failure to document all elements may make it difficult to defend against an EMTALA violation or medical malpractice litigation.
It is a sample variation of a system that we have successfully implemented in many plans of correction with CMS. The system must be adapted to the individual hospital capabilities and state law, and must achieve the goal of assuring that no patient who should receive a physician examination falls through the cracks.
DOWNLOAD BLOOD ALCOHOL INTAKE FORM PDF
OB Scoring Protocol:
This system is used in conjuction with a full policy on medical screening in general and OB medical screening in particular. OB nurses must be properly authorized as Qualified Medical Personnel for non-physician screening to implement this system and quality assurance monitoring, education, and medical staff bylaws must support the practice.
This system is typically implemented to avoid having to have an OB or other physician come in to see each presenting patient with contractions or other OB issues.
The system, however, requires that a physician respond promptly to complete the medical assessment of the patient per the criteria regardless of whether the delivery is imminent. The hospital policy must mandate response. Physicians who attempt to avoid response compromise the system and expose the hospital and the physician to EMTALA citations and possible malpractice litigation.
DOWNLOAD OB SCREENING FORM PDF
DOWNLOAD OB SCREENING POLICY PDF
ED Mental Health Assessment
Typical elements that CMS will expect to be documented in a mental health screening exam after first completing the medical screening exam.
DOWNLOAD MENTAL HEALTH SCREENING PDF
EMTALA Transfer Form:
Contains sample elements for documenting transfer information required by EMTALA.
Patient-Requested Transfer Form:
Sample of elements to document when a patient initiates a request for transfer — must be without any direct or indirect suggestion or pressure from the hospital or physician. Suggestions that insurance requests transfer, patient’s primary doctor requests transfer, or that transfer might be more convenient or less expensive for the patient have been deemed to be “coercion” that negates the “patient-initiated” aspect of the transfer.
DOWNLOAD PATIENT REQUESTED TRANSFER FORM PDF
Refusal of Services Form:
Form demonstrates elements necessary to document for the purposes of an “Informed Consent To Refuse” if a patient refuses any services or wishes to leave without completion of the MSE or other services or refusal of ambulance.
I am a registered nurse and have worked in labor and delivery for 30 years and I am revising policies for our unit. I am working on our Obstetric Medical Screening by Qualified Registered Nursing Staff Policy and in the past we have used 41 weeks as our guideline to require a physician’s assessment…where an RN can evaluate between 37 and 41 weeks to rule out labor (EMTALA-assessing for false labor). Do you know of any resource that validates these parameters? The only thing I can think was used to in the initial writing of this policy was the ICD codes. I also noted the OB Scoring tool, but it does not address post dates and under 35 wks requires a physician assessment. Your thougts and help would be appreciated.
Virginia Greene
I am not aware of the 37/47 criteria origin or validation. My position would be that a physician should be involved in the assessment of any post-term presentation.
If Hospital A is called about accepting an inpatient transfer and Hospital B is told there are no beds available at that time but the patient will be placed on a waiting list and will be brought in as soon as a bed is available, is that appropriate? Are any violations being committed? Does EMTALA regulations apply to Inpatients being transferred to another hospital?
In the same scenario Hospital A is called from an Emergency Department at Hospital B and there are no beds available but Hospital A is not on diversion, should Hospital B be told that there are no beds so Hospital B will have the opportunity to call other hospitals for an available bed. Administration at Hospital A does not think other Hospitals should be told there are no beds available. It would seem that Hospital B would want to know there are no beds so the patients can decide if they would want to wait for a bed or try another hospital for admission. Want to do what is in the best interest of the patient. What happens if the hospital is not told they will have to wait hours for a possible bed and the patient’s condition worsens in the ED while waiting transfer.
Please advise
If you are told that your patient is on a waiting list, you have an on-going responsibility to assess whether the patient can withstand the delay. If not, you are obligated to keep searching for a transfer destination. Regardless, the patient must be monitored and maintained during the transfer delay.
“No Beds Available” covers a variety of situations but under EMTALA, the destination hospital must accept an EMTALA patient if they have any beds in the house — not just in the unit requested. If they have EVER had more patients, they must accept. Even if the hospital is on EMS diversion, the EMTALA standard frequently requires them to take transfers. The fact that the hospital is NOT on diversion will make a transfer denial highly suspect.
Is an EMTALA form required for transfer of an acute inpatient to inpatient rehab ?
Not required but may be useful to achieve uniformity