EMTALA and pt registration

Dixielee, BSN, RN · Jun 15, 2005

We have them sign a general slip prior to triage that asked name, DOB, SS#, MD, chief complaint. The clerks do a "quick reg" that generates a basic face sheet without insurance info, a hospital number, and name labels. They do go into the computer and we can immediately order labs, supplies, meds, etc. After they have been assessed and deemed medically stable, the clerk will do a more thorough registration which will then give a complete face sheet with the rest of the info on it. That way it does not slow patient care. Even if the patient is a John Doe, they can be assigned a number and labels for the chart, which can be revised later.

The biggest problem we run into is if a patient is seen very quickly, a sore throat, suture removal, etc...sometimes the registration clerks don't see them in time and they leave before getting the rest of the information. We do try to have everyone leaving stop by the discharge window, but sometimes they do not.

I have worked at places that made the NURSE be responsible for notifying the clerk once the patient is stable. That does not work well because we are usually too busy to think about it. We still use a name board even though I understand that is going, but for now, we put the patients last name on the board by their name, but no diagnosis. Once the clerk sees that the patient has been seen (by the fact that lab has been ordered usually), she will see the patient, put a red dot by the name and everyone knows they have been registered.

I worked at one hospital that put little bright purple sticky notes on the corner of each chart when the patients was brought back. This was a reminder to tell registration when the patient was ready. Once the patient was seen, the purple flag was removed and the clerks could glance at the chart and see the flag was gone and they could go in.

There are a number of ways to do it, none of the foolproof or perfect. But we do what we can to satisfy Fed regulations. Good luck.

shadowflightnurse · Jun 15, 2005

I have worked at hospitals where the patient got a "quick registration," was seen, treated, etc. and then the registration was completed. The hospital also used a dry erase board for tracking. There was a space for registration and once completed the clerk would place a check or "x" in the registration box. If we were d/c'ing a pt and there was no check mark we had to physically escort the patient to the registration desk. Kind of a pain, but I figured it took less time to walk the pt to the desk than to sit around and b*tch about it, then have to walk them out anyway. :uhoh3: EMTALA says that the medical screeing exam cannot be DELAYED for the collection of insurance/registration information. If the patient is sitting in the ED waiting room for hours, it is usually ok to have registration speak to the pt. Obviously if there is a specific hospital policy stating no registration until seen by MD, that should be followed. I have seen registration clerks use some "poor tactics" when trying to collect a co-pay or "down payment," to cover their visit.

Home Health Columnist / Guide · Jun 16, 2005

regs:

42 cfr 489.24 -- special responsibilities of medicare hospitals in emergency cases

a) applicability of provisions of this section.

(1) in the case of a hospital that has an emergency department, if an individual (whether or not eligible for medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must-- (i) provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. the examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of 482.55 of this chapter concerning emergency services personnel and direction; and ....

4) delay in examination or treatment.

(i) a participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual's method of payment or insurance status.

(ii) a participating hospital may not seek, or direct an individual to seek, authorization from the individual's insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section.

(iii) an emergency physician or nonphysician practitioner is not precluded from contacting the individual's physician at any time to seek advice regarding the individual's medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. (iv) hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. reasonable registration processes may not unduly discourage individuals from remaining for further evaluation

http://www.emtala.com/law/index.html

interpretation: if they've been screened by triage rn, then ok to ask about insurance. ok for clerk to start asking to fill out forms while awaiting to be seen as long as doesn't delay exam.

MrsWampthang, BSN, RN · Jun 16, 2005

regs:
42 cfr 489.24 -- special responsibilities of medicare hospitals in emergency cases
a) applicability of provisions of this section.
(1) in the case of a hospital that has an emergency department, if an individual (whether or not eligible for medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must-- (i) provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. the examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of 482.55 of this chapter concerning emergency services personnel and direction; and ....
4) delay in examination or treatment.
(i) a participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual's method of payment or insurance status.
(ii) a participating hospital may not seek, or direct an individual to seek, authorization from the individual's insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section.
(iii) an emergency physician or nonphysician practitioner is not precluded from contacting the individual's physician at any time to seek advice regarding the individual's medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. (iv) hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. reasonable registration processes may not unduly discourage individuals from remaining for further evaluation
http://www.emtala.com/law/index.html
interpretation: if they've been screened by triage rn, then ok to ask about insurance. ok for clerk to start asking to fill out forms while awaiting to be seen as long as doesn't delay exam.

thanks for the info. i had no idea where to start looking for that info under the emtala site. i am definitely going to ask about this the next time i see my manager. i know the docs are already grousing because the initial face sheet and stickers aren't coming back with the patient due to printers being slower than the registrars. again, thanks!

pam

bthynn · Jun 21, 2005

At the ED where I work we have a tracking board where registration enters basic info name,dob, and complaint.......then the patient is triaged if the pt is deemed nonurgent by triage they are sent back to registration. If the pt needs immediate attention then they are taken back to a bed triaged at bedside then bedside registration is done. But bedside registration does hold up the ordering of tests......We have one MD who wants all pts brought straight back to a bed and registered at the bedside.....but he does not understand you cannot fillup all the beds with toothaches when you have ambulances on the way. Also we do not have the staffing to use all our beds in the ED so we cannot fill them all up unless it is emergent. Anyone have any ideas how to fix this problem.

Thanks Beth

dewp_63 · Jul 4, 2005

Our hospital uses a "short form" registration, allowing labels and face sheets to be quickly generated and available before pt is triaged. This does not include financial info unless the patient has been to hospital before and the info is already in the computer system. Pt's that come in by EMS are short-formed at the bedside (or at a registration desk in our main ER), with family members providing info when they are available. This does not delay screening by the medical practitioner, and allows us to start protocols when we have to send a patient back to the waiting room. Our policy is that if there is an empty bed, we will fill it - but sometimes we have to kick patients to chairs etc if an ambulance is on the way. We have 11 ER beds, 10 fast track beds and see >3000 month with a very low LWBS rate (~2%). All of our rooms have a computer, but we also have a computer on a rolling stand that they can use (we have a brand new ER, and corporate gave us all the bells and whistles - all beds have TV's, computers and all private rooms!)

Hope this helps! :balloons:

purplemania, BSN, RN · Jul 4, 2005

I think if hospitals tracked how many $$ are walking out the door they would find it feasible to hire someone to work inside the ER to do registration. May with a laptop or notepad or some such.

lil'nurse · Jul 4, 2005

I just reviewed this at work. Insurance info can be collected as long as it doesn't delay tx. Each dx/presenting problem must be given the same minimal tx no matter what pt's ability to pay. Also it is a violation to contact an insurance co. to find out deductibles/amount of coverage prior to tx.

mommatrauma, RN · Jul 4, 2005

I think if hospitals tracked how many $$ are walking out the door they would find it feasible to hire someone to work inside the ER to do registration. May with a laptop or notepad or some such.

We do that now with the laptop, it does help tremendously...However we still have long registration times, sometimes people are there for 2 hours before registration even comes in. Alot of times they don't because the patient has been there before, and they are losing money because the info wasn't verified and the patients have moved or changed insurance since last visit...We really need to revamp our registration system...because the "please stop at the windows on the way out" doesn't work, people that know the deal, know that if they don't stop for registration, they don't pay...We have such a busy ER its hard to get everyone...sometimes our turnover can be so quick that it takes longer for the reg process than the actual treatment...

barefootlady, ADN, RN · Jul 12, 2005

I think Mommatrauma hit the nail on the head. The systems some facilities need to be revamped entirely. I have seen patients, given the tx and teaching and the patient has gone before the "regular" admission papers could be completed. Now a revamp is definately needed in these cases.