Emergency Medical Condition Checklist
Note: This checklist is for chart review purposes only. Patient care must not be delayed to use this resource.
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in—
[select name="Q1" value="YES=1|NO=0"] <-- (i) 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,
[select name="Q2" value="YES=1|NO=0"] <-- (ii) serious impairment to bodily functions, or
[select name="Q3" value="YES=1|NO=0"] <-- (iii) serious dysfunction of any bodily organ or part; or
(B) with respect to a pregnant woman who is having contractions—
[select name="Q4" value="YES=1|NO=0"] <-- (i) that there is inadequate time to effect a safe transfer to another hospital before delivery, or
[select name="Q5" value="YES=1|NO=0"] <-- (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.
RESULT --> [calc memo="interpretation" value="score=(Q1)+(Q2)+(Q3)+(Q4)+(Q5);score>0?'An Emergency Medical Condition is Present':'An Emergency Medical Condition May Not be Present'"]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
[link url="//www.law.cornell.edu/uscode/text/42/1395dd" memo="#1"] US Code EMTALA text
[link url="//www.fpnotebook.com/Manage/Legal/RskMngmnt.htm" memo="#2"] FP Notebook Risk Management
there are 11 form elements
Result - Copy and paste this output: