PAGE:1 of 3 / REPLACES POLICY DATED: 1/1/99; 1/1/01; 1/30/04; 8/1/04; 11/15/04 RETIRED 7/15/2008
EFFECTIVE DATE: February 1, 2005 / REFERENCE NUMBER: LL.EM.005
SCOPE: All Company-affiliated facilities including, but not limited to, the following hospital departments:
All Clinical Departments Hospital Departments on campus
Administration Hospital owned emergency vehicles
Admitting/Registration NursingAmbulatory Care Facilities Patient Account Services
Ancillary Services Quality Management
Dedicated Emergency Departments Risk Management
Employed Physicians Urgent Care Centers/Clinics
Finance
PURPOSE:
To require that a hospital with an emergency department track the care provided to each individual seeking care in a dedicated emergency department for a medical condition or seeking care in areas on hospital property other than a DED for an emergency medical condition, as required by the Emergency Medical Treatment and Active Labor Act (“EMTALA”), 42 U.S.C., Section 1395 and all Federal regulations and interpretive guidelines promulgated thereunder.
POLICY: Each hospital that provides emergency services must maintain a Central Log to include information on each individual who comes to the DED seeking examination or treatment for a medical condition or who comes on to the hospital property requesting evaluation or treatment for what may be an emergency medical condition.
Logs from areas of the hospital other a DEDare hereby incorporated by reference into the Central Log. [Each facility is required to create an addendum to be attached to their “Central Log” policy, which provides information on where each log component of the Central Log is located within the hospital.]
Some states have separate emergency services laws that may apply additional legal requirements to the Medical Screening Examination, diagnostic testing, stabilizing emergency medical treatment or maintenance of the Central Log. Consult with your Operations Counsel to identify and comply with any such additional legal mandates. Hospitals in states with additional requirements must develop policy addenda that address the state-specific requirements which exceed the requirements of this policy.
PROCEDURE:
Please refer to the EMTALA - Medical Screening Policy, LL.EM.001, for a complete list of definitions and additional guidance pertaining to this policy. Each hospital that participates in the Medicare program and provides emergency medical services must develop policies and procedures to insure compliance with EMTALA requirements relating to the maintenance of the Central Log. Such policies should contain the following provisions
1.Each hospital must maintain a Central Log to track the care provided to each individual who comes either to the dedicated emergency department seeking evaluation or treatment for a medical condition or presents on hospital property other than in a DED seeking care for an emergency medical condition.
Each hospital has the discretion to maintain the Central Log in a form that best meets the needs of its patients. An electronic template that includes all federal requirements for EMTALA is available on Meditech for each market or division to customize.
2.The Central Log includes, directly or by reference, logs of all individuals protected under EMTALA regardless of the point of entry.
3.If the logs in other departments are not directly referenced (i.e., the DED log includes patients from other departments), the facility may choose to reference the separate logs. Examples of referencing include defining which departments maintain a log of emergent patients in policy (i.e., DED-Emergency Services, DED-Labor and Delivery Services, etc.), and referencing the department logs by changing the report “header” in Meditech, or placing a label on the log referencing other facility logs.
4.All ancillary logs incorporated into the Central Log by reference are maintained in the same manner and with the same central core of information that is maintained in all logs.
5.The Central Log and all ancillary logs of individuals seeking care in the DED for a medical condition or seeking care in areas on hospital property other than a DED for an emergency medical condition must contain at a minimum, the name of the individual and whether the individual:
- refused treatment
- was refused treatment
- was transferred
- was admitted and treated
- was stabilized and transferred, or
- was stabilized and discharged.
6.A log entry for all individuals protected under EMTALA should be made at the first point of contact whether that contact is by a greeter, registration clerk, sign-in sheet, nurse, or other individual. Further, in those departments of the hospital that are not DEDs, where an individual may present with an EMC, the department will provide the necessary information from the point of contact to the DED for logging purposes.
7.The Central Log, including any ancillary logs of individuals protected by EMTALA, will be available within a reasonable amount of time for surveyor review.
8.The Central Log (including any ancillary logs of individuals protected under EMTALA) must be retained for EMTALA purposes for a minimum of five years from the date of disposition of the individual.
REFERENCES:
Social Security Act, Section 1867, 42 U.S.C. 1395dd, Examination and Treatment for Emergency
Medical Conditions and Women In Labor
CMS Site Review Guidelines, State Operations Manual
42 CFR 489.20(r), Special Responsibilities of Medicare Hospitals in Emergency CasesRecords Management Policy, EC.014
EMTALA - Medical Screening Policy, LL.EM.001
EMTALA - Stabilization Policy, LL.EM.002
EMTALA - Transfer Policy, LL.EM.003
EMTALA - Signage Policy, LL.EM.004
EMTALA - Duty to Accept Policy, LL.EM.006
EMTALA - Provision of On-Call Coverage Policy, LL.EM.007
12/2004