DEPARTMENT: Risk & Insurance / POLICY DESCRIPTION: EMTALA - Central Log
PAGE: 1 of 2 / REPLACES POLICY DATED:
APPROVED: November 12, 1998 / RETIRED:
EFFECTIVE DATE: January 1, 1999 / REFERENCE NUMBER: RI.005
SCOPE: All Company facilities including hospitals and any entities operating under the hospital’s Medicare Provider Number including, but not limited to, the following:
All Clinical Departments Administration
Ancillary Services Quality Management
Admitting/Registration Risk Management
Employed Physicians Emergency Department
Hospital owned Medical Office Buildings Urgent Care Centers/clinics
Hospital owned emergency vehicles Ambulatory Care Facilities
Health Information Management Nursing
PURPOSE:
To track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition.
POLICY:
Each facility that provides emergency services will maintain a central log to include information on each individual who comes to the hospital requesting treatment, including those patients presenting to Labor and Delivery, the Emergency Department and other areas where emergency medical conditions are treated.
Some states have separate emergency services laws that may apply additional legal requirements to the Medical Screening Examination, diagnostic testing, or stabilizing emergency medical treatment. Consult with your Operations Counsel to identify and comply with any such additional legal mandates.
PROCEDURE:
Please refer to the EMTALA - Medical Screening Policy, RI.001, for a complete list of definitions pertaining to this policy.
1. Each hospital must maintain a central log to track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition.
2. Each hospital has the discretion to maintain the central log in a form that best meets the needs of its patient.
3. The central log includes, directly or by reference, patient logs from other areas of the hospital such as pediatrics and labor and delivery, where a patient might present for emergency medical services or received a medical screening examination instead of in the emergency department.
4. All logs must be available at the time in a timely manner for surveyor review.
5. The log must contain:
·  the name of the individual seeking assistance; and
·  the disposition (permitted dispositions include: 1) patient refused treatment, 2) was refused treatment by the facility, 3) transferred, 4) admitted and treated, 5) stabilized and transferred, or 6) discharged)
The log entry should be made at the first point of contact. This would normally take place at triage.
REFERENCES:
Social Security Act, Section 1867, 42 U.S.C. 1395dd, Examination and Treatment for Emergency Medical Conditions and Women In Labor
HCFA Site Review Guidelines, State Operations Manual
42 Federal Register 489.20(r), Special Responsibilities of Medicare Hospitals in Emergency Cases
EMTALA Medical Screening Policy, RI.001
EMTALA Stabilization Policy, RI.002
EMTALA Transfer Policy, RI.003
EMTALA Signage Policy, RI.004
EMTALA Duty to Accept Policy, RI.006
EMTALA Provision of On-Call Coverage Policy, RI.007