Checklist to Evaluate EMTALA Compliance and Tool for Medical-Record Reviews

By Nina Youngstrom

This checklist was developed by Trinity Health, a system based in Livonia, Michigan, to help monitor compliance with the Emergency Medical Treatment and Labor Act. Below is a tool for related medical-record reviews. Contact Andrei Costantino, vice president of integrity and compliance, at costanta@trinity-health.org.  

EMTALA Checklist

YES

NO

N/A

Comments

EMTALA signage posted in the ED and LD, as well as dedicated ED sites besides the hospitals?

Policies current?

Records retention policy

ED and LD registration policy

AMA policy

EMTALA policy

MD on-call policy and on-call list/retention schedule

ED triage policy

ED and hospital transfer policy

ED insurance collection policy

Inappropriate transfer investigation and reporting policy

Physician on-call logs?

Physician bylaw?

Medical screening exam performed by MDs?

Medical screening exam performed by someone other than MD?

Insurance collected before medical screening exam?

Central transfers log available and retained?

AMA/refusal of treatment forms?

Community transport arrangements/agreements?

EMTALA investigations within 12 moths?

Investigation documentation: root cause analysis, defense and corrective action plan

Internal mechanism for reporting EMTALA violations?

Registration process flow in EDs (electronic triggers ED to registration)?

Physician certification form completed prior to every transfer?

Consent prior to transfer out?

EMTALA training provided annually?

Monitoring of EMTALA compliance?

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