DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 1 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
SCOPE: All Company-affiliated 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
Nursing Finance
Hospital Department (on and off campus)
Hospital Based Entity (on campus)
PURPOSE: To require that all patients who come to the dedicated emergency department requesting
emergency services receive an appropriate Medical Screening Examination 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: Any individual who comes to the dedicated emergency department requesting
examination or treatment is entitled to and shall be provided an appropriate Medical Screening
Examination performed by individuals qualified to perform such examination to determine whether
or not an emergency medical condition exists.
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. Hospitals in states with additional requirements must develop policies that address the
state-specific requirements that exceed the requirements of this policy.
PROCEDURE:
I. DEFINITIONS
Appropriate transfer occurs when: (i) the transferring hospital provides medical treatment within its
capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the
health of the unborn child; (ii) the receiving facility has the available space and qualified personnel
for the treatment of the individual and has agreed to accept transfer of the individual and to provide
appropriate medical treatment; (iii) the transferring hospital sends to the receiving hospital all
medical records (or copies thereof) related to the emergency medical condition for which the
individual has presented, available at the time of transfer, including records related to the individual’s
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 2 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
emergency medical condition, observations of signs or symptoms, preliminary diagnosis, treatment
provided, results of diagnostic studies or telephone reports of the studies, and the informed written
consent or certification required, name and address of any on-call physician who has refused or failed
to appear within a reasonable time to provide necessary stabilizing treatment, and that any other
records that are not readily available at the time of transfer are sent as soon as practicable after the
transfer; and (iv) the transfer is effected through qualified personnel, transportation and equipment, as
required, including the use of necessary and medically appropriate life support measures during the
transfer.
Campus means the physical area immediately adjacent to the main hospital, other areas and
structures that are not strictly contiguous to the main buildings but are located within 250 yards of the
main buildings, and any other areas determined on an individual case basis by the Centers for
Medicare and Medicaid Services (CMS) regional office to be part of the main hospital’s campus, but
excluding other areas or structures of the hospital’s main building that are not part of the hospital
such as physician offices, RHCs, SNFs, or other entities that participate separately in Medicare, or
restaurants, shops, or other nonmedical facilities.
Capabilities of a medical facility or main hospital provider means the physical space, equipment,
supplies and services (e.g., trauma care, surgery, intensive care, pediatrics, obstetrics, burn unit,
neonatal unit or psychiatry), including ancillary services available at the hospital. The capabilities of
the hospital’s staff mean the level of care that the hospital’s personnel can provide within the training
and scope of their professional licenses. For off-campus departments, the capability of the hospital as
a whole is included. The obligations of the hospital provider must be discharged within the hospital
as a whole. However, the hospital is not required to locate additional personnel or staff to off-campus
departments to be on call for possible emergencies.
Capacity means the ability of the hospital to accommodate the individual requesting examination or
treatment of the transferred individual. Capacity encompasses number and availability of qualified
staff, beds, equipment and the hospital’s past practices of accommodating additional patients in
excess of its occupancy limits.
Central Log is a log that a hospital is required to maintain on each individual who comes to its
emergency room or any location on the Hospital Property requesting examination or treatment and
the disposition of each individual, whether he or she refused treatment, was refused treatment, or
whether he or she was transferred, admitted and treated, stabilized and transferred or discharged. The
purpose of the central log is to track the care provided to each individual who comes to the Hospital
Property seeking care for an emergency medical condition. The central log includes, directly or by
reference, patient logs from other areas of the hospital, such as the Behavioral Health Unit and/or
Labor and Delivery, where a patient might present for emergency services or receive a medical
screening examination instead of in the emergency department and any location which provides care
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 3 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
under the hospital’s provider’s number.
Comes to the Emergency Department means with respect to an individual who is not a patient, the
individual
1. has presented at a hospital’s dedicated emergency department and requests examination or
treatment for a medical condition, or has such a request made on his or her behalf. In the
absence of such a request by or on behalf of the individual, a request on behalf of the
individual will be considered to exist if a prudent layperson observer would believe, based on
the individual’s appearance or behavior, that the individual needs examination or treatment
for a medical condition;
2. has presented on hospital property other than the dedicated emergency department, and
requests examination or treatment for what may be an emergency medical condition, or has
such a request made on his or her behalf, or if a prudent layperson observer would believe,
based on the individual’s appearance or behavior, that the individual needs emergency
examination or treatment;
3. is in a ground or air ambulance owned and operated by the hospital for purposes of
examination and treatment for a medical condition at a hospital’s dedicated emergency
department, even if the ambulance is not on hospital grounds;
4. is in a ground or air non-hospital-owned ambulance on hospital property for presentation for
examination and treatment for a medical condition at a hospital’s dedicated emergency
department; or
5. an individual in an ambulance owned and operated by the hospital is not considered to have
“come to the hospital’s emergency department” if:
a. the ambulance is operated under community-wide emergency medical service (“EMS”)
protocols that direct it to transport the individual to a hospital other than the hospital that
owns the ambulance; for example, to the closest appropriate facility;
b. the ambulance is operated at the direction of a physician who is not employed or
otherwise affiliated with the hospital that owns the ambulance; or
c. is in a non-hospital-owned ambulance off hospital property even if a member of the
ambulance staff contacts the hospital by telephone or telemetry communications and
informs the hospital that they want to transport the individual to the hospital for
examination and treatment. If the hospital is in diversionary status because it does not
have the staff or facilities to accept any additional emergency patients, it may direct the
ambulance to another facility.
Dedicated Emergency Department means any department or facility of the hospital, regardless of
whether it is located on or off the main hospital campus, that meets at least one of the following
requirements:
1. is licensed by the State in which it is located under applicable State law as an emergency room
or emergency department;
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 4 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
2. is held out to the public (by name, posted signs, advertising, or other means) as a place that
provides care for emergency medical conditions on an urgent basis without requiring a
previously scheduled appointment; or
3. during the calendar year immediately preceding the calendar year in which a determination is
being made, based on a representative sample of patient visits that occurred during that
calendar year, it provides at least one-third of all of its outpatient visits for the treatment of
emergency medical conditions on an urgent basis without requiring a previously scheduled
appointment.
Department of Hospital means a facility or organization or a physician office that is either created
by or acquired by a hospital for the purpose of furnishing health care services of the same type as
those furnished by the hospital under the name, ownership, and financial and administrative control
of the hospital. A department of a hospital may not be licensed to provide health care services in its
own right, may not by itself be qualified to participate in Medicare as a provider and Medicare
Conditions of Participation do not apply to a department as an independent entity. This facility may
be located on or off the hospital campus.
Emergency Medical Treatment and Labor Act (“EMTALA”) refers to Sections 1866 and 1867 of
the Social Security Act, 42 U.S.C. Section 1395dd, which obligate hospitals to provide medical
screening, treatment and transfer of individuals with emergency medical conditions or women in
labor. It is also referred to as the “anti-dumping” statute and COBRA.
Emergency Medical Condition means:
1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe
pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of
immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy;
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any bodily organ or part; or
2. With respect to a pregnant woman who is having contractions:
a. that there is inadequate time to effect a safe transfer to another hospital before delivery; or
b. that transfer may pose a threat to the health or safety of the woman or the unborn child; or
3. With respect to psychiatric patients:
a. that acute psychiatric or acute substance abuse symptoms are manifested; or
b. that individuals are expressing suicidal or homicidal thoughts or gestures and are determined
to be a danger to self or others.
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 5 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
Hospital means a main hospital provider that has entered into a Medicare Provider Agreement,
including a critical access or rural primary care hospital. For the purpose of these policies, hospital
refers to the main building in which the dedicated emergency department is located.
Hospital Based Entity (Provider Based Entity) means a provider of health care services, or a rural
health clinic (RHC), that is either created by, or acquired by, a hospital for the purpose of furnishing
health care services of a different type from those of the hospital under the name, ownership, and
administrative and financial control of the hospital. Note that in the EMTALA regulations, provider-
based entity is distinguished from provider or hospital-based department. (For purposes of
distinguishing the provider-based entity from the hospital-based department, those departments that
are covered by EMTALA are referred to as hospital-based departments.)
Hospital with Emergency Department means a hospital with a dedicated emergency department as
defined above.
Hospital Property means the entire main hospital campus, including parking lot, sidewalk, and
driveway, but excluding other areas or structures of the hospital’s main building that are not part of
the hospital, such as physician offices, rural health centers, skilled nursing facilities, or other entities
that participate separately under Medicare, or restaurants, shops or other nonmedical facilities.
Inpatient means an individual who is admitted to a hospital bed for purposes of receiving inpatient
hospital services with the expectation that he or she will remain at least overnight and occupy a bed
even though the situation may later develop that the individual can be discharged or transferred to
another hospital without actually occupying a hospital bed overnight.
Labor means the process of childbirth beginning with the latent or early phase of labor and
continuing through the delivery of the placenta. A woman is in true labor unless a physician or
qualified medical personnel certifies that, after a reasonable period of observation, the woman is in
false labor.
Medical Screening Examination is the process required to reach with reasonable clinical
confidence, the point at which it can be determined whether or not an emergency medical condition
exists or a woman is in labor. Such screening must be done within the facility’s capability and
available personnel, including on-call physicians. The medical screening examination is an ongoing
process and the medical records must reflect continued monitoring based on the patient’s needs and
must continue until the patient is either stabilized or appropriately transferred. Screening is to be
conducted to the extent necessary, by physicians and/or other qualified medical personnel to
determine whether an emergency medical condition exists. With respect to a psychiatric patient, a
medical screening consists of both a medical screening examination and a psychiatric screening.
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 6 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
Medically Indicated Transfer means the transfer of an individual to a facility with a higher level of
care or to a facility with a service that the transferring facility does not provide in order to provide
further care and treatment to an individual with an emergency medical condition.
Movement from Off-Campus Department means the movement of a patient from an off-campus
department to the main hospital campus, such movement is not considered a transfer.
On-Call List refers to the list that the hospital is required to maintain that defines those physicians
who are “on-call” for duty after the initial medical screening examination to provide further
evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition.
The purpose of the on-call list is to ensure that the emergency department is prospectively aware of
which physicians, including specialists and sub-specialists, are available to provide treatment
necessary to stabilize individuals with emergency medical conditions. If a hospital offers a service to
the public, the service should be available through on-call coverage of the emergency department.
Outpatient means an individual who has begun to receive or is scheduled to receive outpatient
services as part of an encounter other than the visit to the dedicated emergency department for
evaluation of a medical condition or another hospital department for emergency medical care.
(Example: a patient receiving physical therapy pursuant to a physician’s order.)
Physician means: (i) a doctor of medicine or osteopathy; (ii) a doctor of dental surgery or dental
medicine who is legally authorized to practice dentistry by the State and who is acting within the
scope of his/her license; (iii) a doctor of podiatric medicine to the extent that he/she is legally
authorized to perform by the State; or (iv) a doctor of optometry to the extent that he/she is legally
authorized to perform by the State with respect to services related to the condition of aphakia.
Physician Certification refers to written certification by the treating physician ordering the transfer
prior to the patient’s transfer that, based on the information available at the time of transfer, the
medical benefits reasonably expected from the provision of appropriate medical treatment at another
medical facility outweigh the increased risks to the individual and, in the case of a woman in labor, to
the unborn child from effecting the transfer. The certification shall include a summary of the risks
and benefits upon which the certification is based and the reason(s) for the transfer. If a physician is
not physically present at the time of transfer, a qualified medical person can sign the certification as
long as the qualified medical person is in consultation with the physician and the physician is in
agreement with the certification and subsequently, countersigns the certification. The date and time of
such certification should closely match the date and time of the transfer.
Prudent Layperson Observer is a legal standard descriptive of a careful, attentive and diligent
individual who is not a medical professional, who, theoretically, could conclude, based on the
person’s appearance or behavior, that the person needs emergency examination or treatment.
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 7 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
Qualified Medical Person or Personnel means an individual in addition to a licensed physician who
is licensed or certified in one of the following professional categories and who have demonstrated
current competence in the performance of medical screening examinations, for example:
Registered Nurse in Perinatal Services
Psychiatric Social Worker
Registered Nurse in Psychiatric Services
Psychologist
Physician Assistant
Advanced Registered Nurse Practitioner
Certified Registered Nurse Midwife
The above-referenced categories are examples of professionals that may be approved by a hospital’s
governing board as qualified to administer one or more types of medical screening examination and
complete/sign a certification for transfer in consultation with a physician. Each hospital’s governing
board must make such a determination on behalf of the hospital.
Signage refers to the hospital requirement to post signs conspicuously in a dedicated emergency
department or in a place or places likely to be noticed by all individuals entering the dedicated
emergency department as well as those individuals waiting for examination and treatment in areas
other than the dedicated emergency department, (e.g., outpatient departments, on campus hospital
based entities, labor and delivery, waiting room, admitting area, entrance and treatment areas),
informing the patients of their rights under Federal law with respect to examination and treatment for
medical conditions, emergency medical conditions and women in labor. The sign must also state
whether or not the hospital participates in the State’s Medicaid program.
Stabilized with respect to an emergency medical condition means that no material deterioration of
the condition is likely within reasonable medical probability, to result from or occur during the
transfer of the individual from the facility or in the case of a woman in labor, that the woman
delivered the child and the placenta. A patient will be deemed stabilized if the treating physician of
the individual with an emergency medical condition has determined, within reasonable clinical
confidence, that the emergency medical condition has been resolved.
To Stabilize means, with respect to an emergency medical condition to either provide such medical
treatment of the condition as may be necessary to assure, within reasonable medical probability, that
no material deterioration of the condition is likely to result from or occur during the transfer of the
individual from a facility or, in the case of a woman in labor, that the woman has delivered the child
and the placenta. Exception applicable to inpatients: If a hospital has screened an individual and
found that the individual has an emergency medical condition and admits that individual as an
inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 8 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
its special responsibilities with respect to that individual under EMTALA.
Stable for Discharge: A patient is considered stable for discharge when, within reasonable clinical
confidence, it is determined that the patient has reached the point where his/her continued care,
including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or
later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the
discharge instructions. For the purpose of discharging a patient with psychiatric condition(s), the
patient is considered to be stable for discharge when he/she is no longer considered to be a threat to
himself/herself or to others.
Stable for Transfer: A patient is stable for transfer from one hospital to a second hospital if the
treating physician attending to the patient has determined, within reasonable clinical confidence, that
the patient is expected to leave the hospital and be received at the second facility, with no material
deterioration in his/her medical condition; and the treating physician reasonably believes the
receiving facility has the capability to manage the patient’s medical condition and any reasonably
foreseeable complication of that condition. In the case of a patient who is suffering from psychiatric
condition(s), the patient is considered to be stable for transfer when he/she is protected and prevented
from injuring himself/herself or others.
Transfer means the movement (including the discharge) of an individual outside a hospital’s
facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly,
with) the hospital, but does not include such a movement of an individual who has been declared
dead or who leaves the facility against medical advice or without being seen.
Triage is a sorting process to determine the order in which patients will be provided a medical
screening examination by a physician or qualified medical person. Triage is not the equivalent of a
medical screening examination and does not determine the presence or absence of an emergency
medical condition.
II. HOSPITAL POLICIES
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 medical screening process. Such policies should contain the following provisions:
A. General Requirements
The hospital or a department thereof must provide for an appropriate Medical Screening
Examination within the capability of the hospital’s dedicated emergency department, including
ancillary services routinely available to the dedicated emergency department, to determine
whether or not an emergency medical condition exists, or with respect to a pregnant woman
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 9 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
having contractions, whether the woman is in labor when:
1. an individual comes by him or herself or with another person to the hospital’s dedicated
emergency department, and a request is made on the individual’s behalf for examination or
treatment of a medical condition;
2. an individual comes by him or herself or with another person to a location on hospital
property but not a part of the dedicated emergency department and a request is made on the
individual’s behalf for examination or treatment for an emergency medical condition;
3. the appearance or behavior of the individual would cause a prudent layperson observer to
believe that the individual needed such examination or treatment and that the individual
would request that examination or treatment if he or she were able to do so.
B. When a Medical Screening Examination is Required
1. If an individual arrives on the Hospital Property and is not technically in the dedicated
emergency department and requests examination or treatment for an emergency medical
condition, he or she must receive a Medical Screening Examination within the capabilities of
the hospital. Movement of the patient to the hospital’s dedicated emergency department may
be necessary for screening. However, common sense and individual judgment should prevail.
In exercising such judgment, the following factors should be taken into account but are not
necessarily determinative in all situations:
a. Whether the hospital dedicated emergency department has the personnel and resources
necessary to render adequate medical treatment to all existing patients in the dedicated
emergency department and to adequately respond to new patient emergencies that could
arrive at any moment,
b. whether responding to the emergency could send hospital personnel into harm’s way or
unreasonably endanger or jeopardize the lives or health of such personnel, and
c. whether non-hospital paramedics, emergency medical technicians, or other qualified
personnel are present to respond.
The hospital may not establish, maintain or enforce a policy that prohibits personnel from
leaving the hospital to examine and/or treat an individual in need of emergency services on
hospital Property. Furthermore, a hospital may not meet its EMTALA obligations merely by
summoning EMS personnel, but must use EMS in conjunction with hospital personnel to treat
and move an individual who is already on Hospital Property. EMTALA is triggered only if
the hospital’s staff is aware of an individual’s presence in the dedicated emergency
department for examination or treatment for a medical condition.
2. If an individual comes to a hospital’s dedicated emergency department and a request is made
on his or her behalf for examination or treatment for a medical condition, but the nature of the
request makes it clear that the medical condition is not of an emergency nature, the hospital is
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 10 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
required only to perform such screening as would be appropriate for any individual presenting
in that manner to determine that the individual does not have an emergency medical condition.
Example: A patient presents to the dedicated emergency department and tells the triage
nurse that she just needs the stitches removed from her small laceration, but does not have
an emergency. Brief questioning by qualified medical personnel to establish that the
patient has no pain, fever, swelling or redness and does not believe an emergency medical
condition exists, would be sufficient to establish that there is no emergency condition.
The hospital’s EMTALA obligations would be satisfied after the qualified medical person
completed the documentation.
3. If an individual presents to a dedicated emergency department and requests services that are
not examination or treatment for a medical condition, such as preventive care services, the
hospital is not obligated to provide a screening under EMTALA.
Example: An individual presents to the dedicated emergency department and tells the
clerk that she needs her flu shot because it is now flu season. The hospital is not obligated
to provide a medical screening under EMTALA because the request for a flu vaccine is a
preventive care service.
4. An individual in a ground or air ambulance owned and operated by the hospital is not
considered to have “come to the emergency department” if the ambulance is operated under
community-wide emergency medical service (EMS) protocols or EMS protocols “mandated
by State law” that direct it to transport the individual to a hospital other than the hospital that
owns the ambulance.
5. An individual in a ground or air ambulance owned and operated by the hospital is not
considered to have “come to the emergency department” if the ambulance is operated at the
direction of a physician who is not employed or otherwise affiliated with the hospital that
owns the ambulance or if the physician’s direction of the destination of the ambulance is
subject to community-wide protocols that require the individual to be transported to a
hospital other than the hospital that owns the ambulance.
6. An individual in a nonhospital-owned ground or air ambulance on Hospital Property is
considered to have come to the hospital’s emergency department. An individual in a non-
hospital-owned ambulance not on the hospital’s property is not considered to have come to
the hospital’s emergency department even if the ambulance personnel contact the hospital by
telephone or telemetry communications. A hospital may deny access to patients when it is in
“diversionary” status because it does not have the staff or facilities to accept any additional
emergency patients at that time. However, if the ambulance disregards the hospital’s
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 11 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
instructions and brings the individual on to hospital property, the individual has come to the
emergency department.
7. Should a hospital that is not in diversionary status fail to accept a telephone or radio request
for transfer or admission, the refusal could represent a violation of other Federal or State
requirements.
8. Sanctions under EMTALA for an inappropriate transfer during a national emergency do not
apply to a hospital with a dedicated emergency department located in an emergency area.
C. The Location in Which the Medical Screening Examination Should Be Performed
1. The Medical Screening Examination and other emergency services need not be provided in a
location specifically identified as a dedicated emergency department. If an individual arrives
at the hospital and is not technically in the dedicated emergency department, but is on
Hospital Property and requests emergency care, he or she is entitled to a Medical Screening
Examination. The hospital may use areas to deliver emergency services which are also used
for other inpatient or outpatient services. Medical Screening Examinations or stabilization
may require ancillary services available only in areas or facilities of the hospital outside of the
dedicated emergency department.
2. Patients may be directed to other hospital-owned facilities that are contiguous (i.e., any area
within the hospital or a hospital-owned facility on land that touches land where a hospital
emergency department sits) or is part of the hospital’s “campus” and is owned by the hospital,
and is operated under the hospital’s provider number. However, the hospital should not
move the patient to an off-campus facility for the Medical Screening Examination or other
emergency services.
In order for the patient to be directed to the hospital-owned on-campus facility, three
conditions must be met:
a. all persons with the same medical condition are moved to this location regardless of their
ability to pay for treatment,
b. there is a bona fide medical reason to move the patient, and
c. qualified medical personnel accompany the patient.
Should an individual come to an off-campus hospital-based department that does not offer
services for emergency medical conditions, EMTALA does not apply. The department must
call an EMS if it is incapable of treating the patient and provide whatever assistance it can to
the individual while awaiting the arrival of EMS personnel. The hospital must have
appropriate written guidelines in place for provision of medical screening for individuals who
present to departments on hospital property other than dedicated emergency departments and
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 12 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
request emergency care and services.
D. How to Provide the Medical Screening Examination
1. Hospitals are obligated to perform the Medical Screening Examination to determine if an
emergency medical condition exists. It is not appropriate to merely “log in” a patient and not
provide a Medical Screening Examination.
2. In providing a Medical Screening Examination, the hospital shall not discriminate against any
individual because of diagnosis (e.g., labor, AIDS), financial status (e.g., uninsured,
Medicaid), race, color, national origin, or handicap.
3. Triage is not equivalent to a Medical Screening Examination. Triage merely determines the
“order” in which patients will be seen, not the presence or absence of an emergency medical
condition.
4. The Medical Screening Examination must be the same Medical Screening Examination that
the hospital would perform on any individual coming to the hospital’s dedicated emergency
department with those signs and symptoms, regardless of the individual’s ability to pay for
medical care.
5. A medical screening examination may be performed by an emergency department physician,
another physician, or a non-physician practitioner who is qualified to conduct such
examination (“qualified medical personnel”) and approved by the hospital’s governing board.
6. A Medical Screening Examination is the process required to reach within reasonable clinical
confidence, the point at which it can be determined whether an emergency medical condition
does or does not exist. The hospital must apply in a non-discriminatory manner (i.e., a
different level of care must not exist based on payment status, race, national origin, etc.) a
screening process that is reasonably calculated to determine whether an emergency medical
condition exists.
7. Depending on the patient’s presenting symptoms, the Medical Screening Examination may
range from a simple process involving only a brief history and physical examination to a
complex process that also involves performing ancillary studies and procedures such as (but
not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests
and procedures.
8. A Medical Screening Examination is not an isolated event. It is an on-going process. The
record must reflect continued monitoring according to the patient’s needs and must continue
until he/she is stabilized or appropriately transferred. There should be evidence of this
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 13 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
evaluation documented in the medical record prior to discharge or transfer.
9. The extent of the necessary examination to determine whether an emergency medical
condition exists is generally within the judgment and discretion of the physician or other
qualified medical personnel performing the examination.
E. No Delay in Screening or Examination
1. There shall be no delay in providing a Medical Screening Examination or follow-up treatment
for an emergency medical condition in order to inquire about the patient’s method of payment
or insurance status.
2. For patients who are enrolled in a managed care plan, prior authorization from the plan shall
NOT be required or requested before providing an appropriate Medical Screening
Examination and initiating any further medical examination and necessary stabilizing
treatment. Neither the performance of the Medical Screening Examination nor the provision
of stabilizing treatment will be conditioned on a patient’s completion of a financial
responsibility form, an advance beneficiary notification form, or payment of a co-payment for
any services rendered.
3. Patients who inquire about financial responsibility for emergency care should receive a
response by a staff member who has been well trained to provide information regarding
potential financial liability. Patients will be encouraged to delay such discussion until after
the completion of the Medical Screening Examination and any necessary stabilizing
treatment. The staff member who provides information on potential financial liability should
clearly inform the patient that the hospital will provide a Medical Screening Examination and
any necessary stabilizing treatment, regardless of his or her ability to pay. Patients who
believe that they have an emergency medical condition should be encouraged to remain for
the medical screening examination.
4. An emergency physician or non-physician practitioner may contact the individual’s physician
at any time to seek advice regarding the individual’s medical history and needs that may be
relevant to medical treatment and screening of the patient, so long as this consultation does
not inappropriately delay services.
5. The hospital may follow reasonable registration processes for individuals for whom
examination or treatment is required, including asking whether the individual is insured, and
if so, what that insurance is, as long as the inquiry does not delay screening or treatment or
unduly discourage the individual from remaining for further evaluation.
6. If a patient withdraws his or her request for examination or treatment or refuses further
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 14 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
examination or treatment, an appropriately trained individual from the emergency department
staff will discuss the medical issues related to a voluntary withdrawal. In the discussion, the
emergency department staff member will:
a. offer the patient further medical examination and treatment as may be required to identify
and stabilize an emergency medical condition;
b. inform the patient of the benefits or the examination and treatment, and of the risks of
withdrawal prior to receiving the examination and treatment;
c. take all reasonable steps to secure the individual’s written informed consent to refuse or
withdraw from such examination and treatment; and
d. complete a Refusal to Permit Further Care or Withdrawal of Consent to Permit for Further
Medical Examination and Treatment for Emergency Medical Condition (a sample form is
attached to LL.EM.003); and
e. describe, in the medical record, the examination and treatment that was refused or the
request for treatment was withdrawn.
7. If the patient refuses to sign the form, the written document should indicate that the person
has been informed of the risks and benefits of the examination and/or treatment.
8. If a patient leaves the hospital without notifying hospital personnel, this should be
documented. The documentation must reflect that the patient had been at the hospital and the
time the patient was discovered to have left the premises. Triage notes and additional records
must be retained. See the Collection of Financial Information in the Emergency Department
Policy, GOS.BILL.002, for further guidance on billing compliance issues.
F. Who May Perform the Medical Screening Examination
1. A medical screening examination may be performed by:
a. A qualified physician with appropriate privileges;
b. A qualified licensed independent practitioner with appropriate privileges; and/or
c. A non-physician staff member who:
i. is qualified to conduct such an examination (“Qualified Medical Personnel”) either
through appropriate privileging or demonstrated competencies;
ii. is functioning within the scope of his or her license and in compliance with state law
and applicable practice acts (e.g., Medical or Nurse Practice Acts);
iii. is performing the screening examination based on medical staff approved guidelines;
and
iv. is approved by the hospital’s governing board as set forth in a document such as the
medical staff rules and regulations, approved by the governing body of the hospital.
It is not acceptable for the hospital to allow informal personnel appointments that
could change frequently.
12/2003
DEPARTMENT: Legal POLICY DESCRIPTION: EMTALA –
Medical Screening
PAGE: 15 of 15 REPLACES POLICY DATED: Jan. 1, 1999;
Jan. 1, 2001
EFFECTIVE DATE: January 30, 2004 REFERENCE NUMBER: LL.EM.001
2. When non-physician personnel perform Medical Screening Examinations, the hospital’s
Board of Trustees should approve, based upon recommendations of the medical executive
committee, specific screening guidelines that outline the examination and/or diagnostic work-
up required to determine if an emergency medical condition exists. These guidelines will
normally be complaint specific and will be limited to those presenting complaints that lend
themselves to screening by such non-physician personnel.
3. The competencies for any non-physician personnel performing Medical Screening
Examinations should be documented and validated by a qualified physician. There should
also be an education plan for measuring and developing core competencies in medical
screening.
4. Facilities must establish a process to ensure that a physician examines all patients whose
conditions or symptoms require physician examination.
5. Facilities must establish processes to ensure that: 1) an emergency department physician on
duty is responsible for the general care of all patients presenting themselves to the emergency
department; and 2) the responsibility remains with the emergency department physician until
the patient’s private physician or an on-call specialist assumes that responsibility, or the
patient is discharged.
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 Federal Register 489.24(a) and 489.24(c), Special Responsibilities of Medicare Hospitals in
Emergency Cases
Medicare Conditions of Participation, Section 489.24 (a)
EMTALA - Stabilization Policy, LL.EM.002
EMTALA - Transfer Policy, LL.EM.003
EMTALA - Signage Policy, LL.EM.004
EMTALA - Central Log Policy, LL.EM.005
EMTALA - Duty to Accept Policy, LL.EM.006
EMTALA - Provision of On-Call Coverage Policy, LL.EM.007
EMTALA – Hospital Dept both On & Off Campus and On-Campus Hosp Based Entities, LL.EM.008
12/2003