Emergency Medicine

A patient's condition before discharge may be documented through repeat vital signs, reassessments, response to treatment, laboratory and imaging results, nursing observations, and discharge instructions. When relevant, documentation of ambulation, oral intake, mental status, pain, oxygenation, or other clinical findings may also show the patient's condition when the discharge decision was made.

Resuscitation decisions may be reviewed using code records, cardiac rhythm documentation, medication administration times, airway records, CPR documentation, laboratory findings, and records of return of spontaneous circulation. These records can help establish the sequence and timing of interventions and the clinical findings available during the resuscitation.

EMTALA generally requires a covered hospital emergency department to provide an appropriate medical screening examination to determine whether an emergency medical condition exists. If an emergency medical condition is identified, the hospital must provide stabilizing treatment within its capabilities or arrange an appropriate transfer when required.