Corporate Compliance

Tip: Guidelines for documenting screening treatment

Compliance Monitor, October 8, 2008

Use the following guidelines when documenting screening treatment, to ensure you are compliant with Emergency Medical Treatment and Active Labor Act (EMTALA):
  • For potential emergency conditions, include all medically indicated screenings, tests, mental status evaluations, impressions, and diagnoses (supported by a history and physician examination, laboratory, or other test results).
     
  • For pregnant women, the medical records should show the screening examination included ongoing evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of the membranes, (e.g., ruptured, leaking, intact).
     
  • For individuals with psychiatric symptoms, the medical records should indicate an assessment of suicide or homicide attempts, or risk; disorientation; or assaultive behavior that indicates danger to self or others.

This tip was adapted from A Practical Guide to EMTALA Compliance. For more information about the book or to order your copy click here

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