Healthcare Facility Compliance 14 items
Emergency Department & EMTALA Compliance Audit
Audit checklist for hospital emergency departments to verify compliance with EMTALA medical screening, stabilization, transfer, and on-call obligations.
EMTALA 42 CFR 489.24CMS 42 CFR 482.55SOM Appendix V
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Medical Screening & Central Log
- Does every individual who comes to the ED requesting examination receive an appropriate medical screening exam (MSE) within the hospital's capability? *
- Is the MSE performed by a qualified medical person designated in the medical staff bylaws? *
- Is a central log maintained recording each individual who presents, whether refused, treated, admitted, transferred, or discharged? *
- Is the MSE provided regardless of the patient's insurance status or ability to pay, with no delay to inquire about payment? *
Stabilizing Treatment
- Is stabilizing treatment provided within the hospital's capability for any individual with an emergency medical condition? *
- For patients in labor, is 'stabilized' defined as delivery of the child and placenta? *
- Are patients not transferred or discharged until the emergency medical condition is resolved or stabilized? *
Appropriate Transfers
- For unstable patients, is a physician certification of the medical benefits vs. risks of transfer completed and signed? *
- Does the receiving facility have available space, qualified personnel, and agreement to accept the transfer? *
- Are medical records, imaging, and test results sent with the patient at the time of transfer? *
- Is transfer effected through qualified personnel and appropriate transportation equipment? *
On-Call Coverage & Signage
- Does the hospital maintain an on-call physician list to provide further evaluation and treatment necessary to stabilize patients? *
- Is signage conspicuously posted in the ED and areas likely to be noticed specifying rights under EMTALA? *
- Are EMTALA-related records (transfers received and effected) retained for five years? *
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