The Emergency Medical Treatment and Labor Act (EMTALA) governs how patients are transferred from one hospital to another. When a patient requests a transfer to another hospital, they make that request in writing using an EMTALA form after being informed of the hospital’s obligations and the risks of transfer. But is it acceptable to sign EMTALA forms electronically?
Can You Sign EMTALA Forms Electronically?
For providers, CMS tag A-0450 permits electronic patient signatures. This tag is silent on whether the patient (informed refusal) may sign electronically, but patients are permitted to sign procedure-related informed consent forms electronically so it would make sense that they could also sign the informed refusal form electronically.
(Rev. 47, Issued: 06-05-09, Effective/Implementation: 06-05-09)
482.24(c)(1) – All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.
Interpretive Guidelines §482.24(c)(1)
All entries in the medical record must be legible. Orders, progress notes, nursing notes, or other entries in the medical record that are not legible may be misread or misinterpreted and may lead to medical errors or other adverse patient events.
All entries in the medical record must be complete. A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers. With these criteria in mind, an individual entry into the medical record must contain sufficient information on the matter that is the subject of the entry to permit the medical record to satisfy the completeness standard.
All entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided.
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