DEPARTMENT: Risk & Insurance
PAGE: 1 of 4
APPROVED: December 18, 2000
EFFECTIVE DATE: January 1, 2001
POLICY DESCRIPTION: EMTALA –
Hospital Departments both On and Off Campus
and On-Campus Hospital Based Entities
REPLACES POLICY DATED:
REVISED:
REFERENCE NUMBER: RI.008
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
Ancillary Services
Admitting/Registration
Employed Physicians
Hospital owned Medical Office Buildings
Hospital owned emergency vehicles
Nursing
Hospital Department (on and off campus)
Hospital Based Entity (on campus)
Administration
Quality Management
Risk Management
Emergency Department
Urgent Care Centers/Clinics
Ambulatory Care Facilities
Finance
PURPOSE: To ensure that all individuals with potential emergency conditions, who present to a
department of the hospital located on or off campus and On-Campus Hospital Based Entities, receive
an appropriate medical screening examination and any necessary treatment and stabilization.
POLICY: Any individual who presents to a department of the hospital located on or off campus and
On-Campus Hospital Based Entities and requests examination and treatment for a potential
emergency medical condition, will receive an appropriate medical screening within the capability of
the Hospital, including ancillary services routinely available to the emergency department, to
determine whether or not an emergency medical condition exists.
PROCEDURE: Please refer to the EMTALA - Medical Screening Policy, RI.001, for a complete
list of definitions pertaining to this policy.
1. Medical Screening Examination for individuals presenting to a department of the hospital located
on or off campus and On-Campus Hospital Based Entities:
a. Any individual who presents to a department of the hospital located on or off campus and OnCampus Hospital Based Entities and requests examination and treatment for a potential
emergency medical condition must be provided an appropriate medical screening examination
to determine if an emergency medical condition exists.
b. Any individual who comes to the department of the hospital located on or off campus and OnCampus Hospital Based Entities for medical purposes which do not involve potential
emergency medical conditions will not be provided an emergency medical screening
examination.
12/2000
DEPARTMENT: Risk & Insurance
PAGE: 2 of 4
APPROVED: December 18, 2000
EFFECTIVE DATE: January 1, 2001
POLICY DESCRIPTION: EMTALA –
Hospital Departments both On and Off Campus
and On-Campus Hospital Based Entities
REPLACES POLICY DATED:
REVISED:
REFERENCE NUMBER: RI.008
c. The capability of the department of the hospital located on or off campus and On-Campus
Hospital Based Entities to provide screening, treatment and stabilization for emergency
medical conditions includes the capability of the Hospital as a whole, not just the capability of
the department of the hospital located on or off campus and On-Campus Hospital Based
Entities.
d. The Hospital is not required to add additional personnel or staff to a department of the
hospital located on or off campus and On-Campus Hospital Based Entities to be on standby
for possible emergencies.
e. The Hospital must establish protocols for screening of individuals with potential emergency
conditions at a department of the hospital located on or off campus and On-Campus Hospital
Based Entities.
i) Personnel at a department of the hospital located on or off campus and On-Campus
Hospital Based Entities must have direct contact with the emergency department physician
or other emergency department personnel at the Hospital.
ii) The Hospital may, when deemed appropriate by the emergency physician and the
administrator-on-call, dispatch practitioners from the main campus to the department of
the hospital located on or off campus and On-Campus Hospital Based Entities to provide
screening or stabilization services.
2. For a department of the hospital located on or off campus and On-Campus Hospital Based
Entities that are urgent care centers, primary care centers or other facilities that are routinely
staffed by physicians, RNs or LPNs:
At least one individual on duty at the department of the hospital located on or off campus and OnCampus Hospital Based Entities during its regular hours of operation must either be a physician
or be designated by the Hospital governing board as a qualified medical person for the purposes
of performing a medical screening examination and necessary stabilization.
a. If there is a physician on duty, the physician will perform the screening examination on any
individual who presents to the department of the hospital located on or off campus and OnCampus Hospital Based Entities and requests screening and/or treatment for a potential
emergency medical condition.
b. If the designated qualified medical provider is a registered nurse, protocols must be
established by the medical staff and approved by the Hospital governing board for conduct of
12/2000
DEPARTMENT: Risk & Insurance
PAGE: 3 of 4
APPROVED: December 18, 2000
EFFECTIVE DATE: January 1, 2001
POLICY DESCRIPTION: EMTALA –
Hospital Departments both On and Off Campus
and On-Campus Hospital Based Entities
REPLACES POLICY DATED:
REVISED:
REFERENCE NUMBER: RI.008
the medical screening examination.
c. Necessary education, training and validation of competence of the qualified medical provider
must be conducted and documented.
d. The physician or qualified medical provider must initiate the screening of any individual who
comes to the department of the hospital located on or off campus and On-Campus Hospital
Based Entities and requests screening or treatment for a potential emergency medical
condition.
e. With consultation from the Hospital emergency physician, the physician or qualified medical
person must either complete the screening and provide any necessary stabilizing treatment at
the department of the hospital located on or off campus and On-Campus Hospital Based
Entities, or move the patient to the hospital or arrange an appropriate transfer to another
facility.
3. For a department of the hospital located on or off campus and On-Campus Hospital Based
Entities such as physical therapy, radiology, or other departments not routinely staffed with
physicians, RNs, or LPNs:
a. Protocols must be established directing the department’s personnel to contact emergency
personnel at the Hospital for direction.
b. At a minimum, personnel in the department of the hospital located on or off campus and OnCampus Hospital Based Entities must:
i) Contact the Hospital emergency department and speak to the individual responsible for
conversing with Emergency Medical System personnel.
ii) Describe patient appearance.
iii) Report all symptoms.
iv) At the direction of the emergency physician on the Hospital, either arrange for
transportation of the individual to the Hospital or assist in the appropriate transfer of the
individual to another hospital.
v) If the movement of the individual to Hospital would not significantly jeopardize the life or
health of the individual, the personnel at the department of the hospital located on or off
campus and On-Campus Hospital Based Entities must assist in arranging this movement
(which is not considered a transfer).
vi) If the transfer of an individual with a potential emergency condition to a medical facility
other than the Hospital is warranted, either because the Hospital does not have the
12/2000
DEPARTMENT: Risk & Insurance
PAGE: 4 of 4
APPROVED: December 18, 2000
EFFECTIVE DATE: January 1, 2001
POLICY DESCRIPTION: EMTALA –
Hospital Departments both On and Off Campus
and On-Campus Hospital Based Entities
REPLACES POLICY DATED:
REVISED:
REFERENCE NUMBER: RI.008
specialized capability or facilities required by the individual, or because the individual’s
condition is deteriorating so rapidly that movement to the Hospital would significantly
jeopardize the life or health of the individual, personnel at the department of the hospital
located on or off campus and On-Campus Hospital Based Entities must assist in arranging
an appropriate transfer of the individual to a medical facility other than the Hospital.
vii) The Hospital must establish transfer agreements with other hospitals or medical facilities
in the area of the department of the hospital located on or off campus and On-Campus
Hospital Based Entities.
viii) The physician or qualified medical provider must initiate the transfer in accordance with
the provisions for transfer delineated in the EMTALA Transfer Policy, RI.003.
REFERENCES:
EMTALA Medical Screening Policy, RI.001
EMTALA Stabilization Policy, RI.002
EMTALA Transfer Policy, RI.003
EMTALA Signage Policy, RI.004
EMTALA Central Log Policy, RI.005
EMTALA Duty to Accept Policy, RI.006
EMTALA Provision of On-Call Coverage Policy, RI.007
12/2000