CENTRAL IOWA HEALTHCARE Marshalltown, Iowa ADMINISTRATIVE POLICY & PROCEDURE Policy Number: 144 Subject: Purpose: Policy: Central Iowa Healthcare Physio (Rehab) Medical Screening Exams and Transfers To establish a procedure for the examination, treatment and transfer, as necessary, of individuals seeking unscheduled examination or treatment in the hospital-licensed physical therapy clinic in Toledo. Each individual who seeks examination or treatment on hospital-licensed premises at the Central Iowa Healthcare Physio Clinic ( Rehab Clinic ) shall be offered a medical screening examination to determine whether an emergency medical condition exists, and shall not be transferred from the clinic except upon a request for transfer, and a physician s certification that the benefits of transfer outweigh the risks or upon refusal of further examination or treatment. Procedures: A. Transfers, Generally. For any individual who seeks examination or treatment at the Rehab Clinic, and who is subsequently transferred to a medical facility other than CIH, which provides an acute level of care, a Patient Rights and Transfer Consent form, and a Transfer Requirements, Condition and Orders form shall be completed. B. Medical Screening Examination. For any individual who comes to the Rehab Clinic and on whose behalf a request for unscheduled examination or treatment for a medical condition is made, an appropriate medical screening examination shall be provided within the capabilities of the Tama Clinic to determine whether or not an emergency medical condition exits. C. Qualified Health Professionals. A physician, physician assistant, or nurse practitioner shall participate in any medical screening examination, performing the medical screening examination personally. If a PA or NP determines that an emergency medical condition exists and transfer to a medical facility other than CIH is recommended, the physician must be consulted to order transfer and/or transport. 1. Physicians. Any physician employed or contracted to provide medical services in any of CIH s rural health clinics is authorized to perform medical screening examinations. 2. Physician Assistants. Any physician assistant employed or contracted to 1
provide medical services in any of CIH s rural health clinics is authorized to perform medical screening examinations in the Rehab Clinic, consistent with scope of practice and guidelines established by the supervising physician. 3. Nurse Practitioners. Any nurse practitioner employed or contracted to perform medical services in CIH s rural health clinics is authorized to perform medical screening examinations in the Rehab Clinic, consistent with protocols and practice agreements. D. No Delay. Provision of the medical screening examination may not be delayed in order to inquire about the individual s method of payment or insurance status. E. Further Examination and Treatment. If the individual has an emergency medical condition, further examination, and treatment within the capabilities of CIH s staff and facilities must be provided as required to stabilize the emergency medical condition. If such examination and treatment is necessary, emergency transport to CIH should be requested. F. Refusal of Treatment. If the individual or a person acting on the individual s behalf refuses further examination and treatment, the individual must be informed of the risks and benefits of such examination and treatment. If consent to further examination and/or treatment is still withheld, a Refusal of Exam/Treatment form must be prepared and placed in the medical record to document the individual s (or other person s) written informed refusal for examination and treatment. The Refusal of Exam/Treatment form shall be documented with a description of the examination and/or treatment refused by or on behalf of the individual, and the fact that the individual has been informed of the risks and benefits of refusing examination, treatment or both. The individual (or other person) should be requested to sign the Refusal of Exam/Treatment form after it has been completed, or the reason why the individual refuses to sign the form. G. Permissible Transport to Hospital. If an individual has sought examination or treatment at the Rehab Clinic, and has been determined to have an emergency medical condition or qualified health personnel are unavailable to provide a medical screening examination, the individual should be transported by ambulance to CIH. If the individual refuses such transport, the individual or a responsible person acting on the individual s behalf shall be requested to sign a Refusal of Exam/Treatment or the reason why the individual refuses to sign the form. H. Permissible Transfer to Another Medical Facility. Transfer of an individual with an emergency medical condition to a medical facility other than CIH is appropriate under the following circumstances: 1. Stabilized. The emergency medical condition has been stabilized; or 2
2. Unstabilized/Patient Request. The individual s emergency medical condition has not been stabilized, but the individual (or a legally responsible person acting on the individual s behalf) requests in writing a transfer to another medical facility. After having been informed of CIH s obligation to provide further examination and treatment and of the risk of transfer. a. Document a request for transfer, including the reason for the request, on the Patient Rights & Transfer Consent form. The form should be signed by the individual or a legally responsible person on his or her behalf and placed in the medical record. 3. Unstabilized/Physician Certification. The individual s emergency medical condition has not been stabilized, but a physician has signed the certificate on the Patient Rights and Transfer Consent form stating that, based upon the information available to him or her at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment in another medical facility outweigh the increased risks to the individual and, in the case of labor, to the unborn child from effecting a transfer (the risks and benefits of transfer must be summarized) to CIH. For individuals transferred pursuant to a physician certification, the individual or a legally responsible person shall be requested to sign the Consent to Transfer section of the form. If such a signature cannot be obtained the reason should be documented on the form. I. Refusal of Transfer. If the individual refuses a recommended transfer to a medical facility other than CIH after having been informed of the risks and benefits to the individual of the transfer, all reasonable steps must be taken to secure the individual s written informed refusal (or that of a person acting on his or her behalf) on the Patient Rights & Refusal of Transfer form. Transport to CIH may be offered as an alternative to the recommended transfer. The Refusal of Transfer form must otherwise be documented and signed by the individual or a person on his or her behalf, with a description of the transfer refused, the reasons for the refusal and a statement that the individual was informed of the risks and benefits of transfer. The completed form shall be placed in the medical record. J. Request for Transfer. In the event that an individual in an emergency medical condition (or a legally responsible person acting on the individual s behalf) requests a transfer to another medical facility, the Patient Rights & Transfer Consent form will be completed and submitted for the individual s (or legally responsible person s) signature. K. Effecting Transfer. Transfer of an individual in an unstable emergency medical condition to a medical facility other than CIH requires the following: 1. Medical treatment must be provided to minimize the risks to the individual s health and, in the case of a woman in labor, the health of the unborn child. 3
2. The receiving facility must be contacted to verify that there is available space and qualified personnel for treatment of the individual, and to obtain the receiving facility s agreement to accept transfer. 3. All medical records relating to the individual s emergency medical condition must be sent along with the transferred individual, including records relating to the emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment(s) provided, test results, and the Patient Rights and Transfer Consent form including the individual s written consent to transfer and the physician s certification. 4. Qualified personnel and transportation equipment must be used for the transfer, including any necessary and medically appropriate life support measures. L. Central Log. A central log shall be maintained on each individual who comes to the Rehab Clinic seeking assistance, recording whether he or she refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred or was discharged. Original logs will be sent monthly to the Director of QI at CIH for centralization, even if there were no entries for the month. The Rehab Clinic will retain copies of the monthly log forms. M. Maintenance of Records. Medical records and other records relating to individuals transferred to or from the Rehab Clinic shall be maintained for a period of five years from the date of transfer. N. Signs. A sign shall be posted conspicuously in the Rehab Clinic specifying the rights of individuals under Social Security Act #1867 with respect to examination and treatment for emergency medical conditions. Responsibilities: A. CIH Physio (rehab) Therapist Manager. 1. If an individual seeks unscheduled examination or treatment at the Rehab Clinic, escort the individual to Tama Clinic for medical screening unless the individual s physical condition prevents it. If escort is not possible, contact Tama Clinic and request that a physician, PA, or NP comes to the Rehab Clinic to perform a medical screening examination. 2. If an individual (or a person acting on his or her behalf) refuses medical screening, discuss the individual s right to receive examination and treatment at CIH and/or an appropriate transfer to another medical facility. 4
3. As circumstances dictate, prepare the Refusal of Exam/Treatment, Patient Rights & Refusal of Transfer, and Patient Rights and Transfer Consent forms (with the exception of the physician certification and the summary of risks and benefits). 4. In the case of transfer to a medical facility other than CIH: a. Contact the receiving facility to confirm that space and qualified personnel are available to treat the individual and to confirm that transfer will be accepted. b. Prepare copies to send with the individual of all records related to the emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of tests, the Refusal of Exam/Treatment, Patient Rights & Refusal of Transfer, Transfer Requirements, Condition and Orders, Transfer Checklist, Labor Assessment Record and Patient Rights & Transfer Consent forms, and (if applicable) the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. c. Confirm that qualified personnel and transportation equipment are used to transfer the individual, including any necessary life support equipment. 5. In the case of transport to CIH, no transfer records are required. 6. Maintain a central log on each individual who comes to the Rehab Clinic seeking assistance and whether he or she refused treatment, was refused treatment, was transferred, was transported to CIH, stabilized and transferred or discharged. B. Physicians at Tama Clinic and CIH ER 1. Provide medical screening examination to individuals seeking unscheduled examination or treatment at the Rehab Clinic. 2. When considering transfer to a medical facility other than CIH of an individual with an unstable emergency medical condition, weigh the medical benefits reasonably expected from the provision of appropriate medical treatment at the receiving facility against the increased risks to the individual (and in the case of labor, to the unborn child) from effecting the transfer. 3. If transfer is indicated (but has not been requested by the patient), document the risks and benefits of transfer in the Patient Rights & Transfer Consent 5
Definitions: form, recommend transfer to the patient and discuss the risks and benefits with the individual or a person acting on his or her behalf. Sign the physician certification in the Patient Rights & Transfer Consent form. 4. If an individual (or a person acting on his or her behalf) refuses a recommended transfer, discuss the individual s right to receive examination and treatment at CIH facilities and/or an appropriate transfer to another medical facility. 5. If an individual (or a person acting on his or her behalf) refuses examination or treatment, discuss the individual s right to receive examination and treatment at CIH and/or an appropriate transfer to another medical facility. 6. If an individual (or legally responsible person) requests a transfer to a medical facility other than CIH, inform the individual (or legally responsible person) of CIH s obligation to provide further examination and treatment and of the risk of transfer. 7. In the case of transfer to a medical facility other than CIH: a. Contact the receiving physician to confirm acceptance of transfer. b. Determine mode of transportation and qualified accompanying personnel. c. Complete the Transfer Requirement, Condition, and Orders form. C. Physician Assistants and Nurse Practitioners at Tama Clinic and CIH ER fulfill the responsibilities set out above for Physician, except that a physician s certification requires consultation with a physician and countersignature of such certification. A. Emergency Medical Condition. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical condition could reasonably be expected to result in: 1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, 2. Serious impairment to bodily functions, or 3. Serious dysfunction of any bodily organ or part, 6
Or with respect to a pregnant woman who is having contractions: 1. That there is inadequate time to effect a safe transfer to another hospital before delivery, or 2. That transfer may pose a threat to the health or safety of the woman or the unborn child. B. Stabilized. 1. With respect to an emergency medical condition other than a woman in labor, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility. 2. With respect to a woman in labor, that the woman has delivered, including the placenta C. Transfer. The movement (including the discharge) of an individual outside the facility at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) CIH, that does not include such a movement of an individual who has been declared dead or leaves the facility without permission. Other related Policies: Policy No. 140 -Transfer and Emergency Examination Policy No. 145 - Obstetrical Medical Screening Exams and Transfers Policy No. 143 - MAPS Medical Screening Exams and Transfers Originated by: Administration Effective date: February 19, 1996 Authorized by: Review date: 8/01, 3/04, 2/08, 3/09, 3/12, 7/15 T:\Data\Policies\AdminNew_2\adm144r2crk.doc 7