THE "20 Commandments" OF COBRA/EMTALA

1. THOU SHALL: Log in every patient who presents, together with complaint/diagnosis and disposition. A patient has "presented" when they enter onto the premises, campus (and 250 yard zone around the hospital), "provider based" remote sites and ambulances owned by the hospital without regard to means or ability to pay.

2. THOU SHALL: Provide a medical screening examination [by physician, preferably], beyond triage, to all patients regardless of acuity who present in the hospital and/or "provider-based" locations (including movement to the main hospital ED as necessary to complete the MSE);

3. THOU SHALT NOT: delay the Medical Screening Examination or attempt to secure verification or authorization from third party payor, nor attempt to influence the patient by drawing payor status issues to the patient's attention prior to completion of Medical Screening Exam and initiation of stabilizing care;

4. THOU SHALL: Provide necessary testing, including on-call services, as needed to exclude the presence of an legally defined emergency medical condition (does NOT equate to emergent patient);

5. THOU SHALL: To the extent of the capabilities of the hospital and/or "provider-based" location, provide stabilization, such that the patient is not likely to deteriorate from or during transport or discharge -- in the case of OB patients with contractions present, until stabilized by delivery of baby and placenta -- and make a medically appropriate transfer if the patient exceeds hospital or "provider-based" location capabilities. ;

6. THOU SHALL: Provide on-call coverage schedule listing on-call physicians by individual name for all medical specialties represented on the medical staff, provider policies and procedures for occasions where the on-physician is not available, and maintain the list of the individuals on-call for five years. On-call physicians are not at liberty to decline patients;

7. THOU SHALL: Require on-call specialists respond to the hospital to attend the patient (including transfer patients and in-house emergencies), in timely manner and provide legally defined stabilizing care and/or definitive treatment in the hospital without regard to means or ability to pay;

8. THOU SHALL: Transfer COBRA/EMTALA patients for only for services or care not available at your facility or upon patient request documented to EMTALA requirements and accept transfers for all those patients where the intended receiving hospital is better able to care for the patient than the hospital requesting transfer;

9. THOU SHALL: Provider MSE to OB patients and treat patients with contractions as unstable emergency patients per the law;

10. THOU SHALL: Obtain and document advance acceptance from the receiving hospital;

11. THOU SHALL: Provide medically appropriate vehicles, personnel, and life support equipment for all COBRA/EMTALA transfers. Private vehicles are not appropriate transfer vehicles and may not be used without written refusal of ambulance;

12. THOU SHALL: Provide a physician certification with clearly stated risks and benefits of transfer for all COBRA/EMTALA transfers;

13. THOU SHALL: Provide medical records, labs, reports and consultation records to accompany the patient on all COBRA/EMTALA transfers;

14. THOU SHALL: Include the name of any on-call physician who refused to respond or failed to make a timely response in the transfer records of any COBRA/EMTALA patient transferred as a result of that refusal or lack of timely response;

15. THOU SHALL: Obtain written refusal of services by a patient or responsible party that refuses exam, treatment, or transfer that documents the specific risks of refusal associated with the individual case, or document the reasonable efforts by the hospital to obtain written refusal;

16. THOU SHALL: Obtain written consent to transfer from the patient or responsible party, or document the reasonable justification for not obtaining the written consent;

17. THOU SHALL: Document in the medical record sufficient specific data and information to substantiate the appropriate nature of the actions taken in the individual case. Failure to document is a potential violation, even without adverse outcome;

18. THOU SHALL: Obtain full vitals on all presenting patients and maintain documented vitals at appropriate frequency during the stay, and in ALL CASES obtain discharge vitals or vitals at the time of discharge or transfer, and document such in the record.

19. THOU SHALL: Post COBRA/EMTALA signs in all public entrances, waiting areas, registration and care areas. Signs that conflict with the intent and purpose of COBRA/EMTALA shall not be posted. Signs must be easily visible and readable from a distance of 20 feet or the position of the patient and must appear in non-english languages common to the patient population.

20. THOU SHALL: Report any possible violations of COBRA/EMTALA by another facility within 72 hours of receipt of the patient.

For informational and educational purposes only. Be certain to consult your hospital counsel for legal advice regarding policies, procedures, and legal obligations under this and other laws. Copyright 1996-2002--Frew Consulting Group, Ltd. Loves Park, IL. Reprinted with permission of the author, Stephen A. Frew, J.D., Frew Consulting Group. For more valuable articles and information about COBRA or other issues please visit Frew Consulting.

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