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.
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.
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.
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.
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.