Does documentation show patient was stabilized?

Many hospitals have been cited by the Centers for Medicare & Medicaid (CMS) for failure to provide an appropriate medical screening examination for mental health patients, or for discharging these patients in an unstabilized emergency medical condition, notes Barbara E. Person, JD, an attorney at the Omaha, NE-based law firm Baird Holm.

The CMS Interpretive Guidelines make it clear that a patient with suicidal ideation or threats is considered to be having an emergency medical condition. "That means that the patient must be stabilized or admitted. There will be a heavy burden upon the ED to demonstrate stabilization of such a patient," says Person.

Documentation of the patient's positive response to talk therapy, medication, or de-escalation might show stabilization. "However, peer reviewers will presume that an inpatient admission was necessary unless the documentation substantiates a clinical finding of stabilization," says Person.

Historically, with regard to mental health patients, CMS has distinguished between "stable for transfer" and "stable for discharge." "Obviously, chemical restraints would be more effective at stabilizing for transfer than for discharge," says Person. "It may be important to distinguish between those two conditions in documentation."

Here are additional tips from Person to reduce liability risks:

• Review nursing notes and ambulance reports to ensure that the ED physician has not missed a patient or family statement suggesting suicidal intent.

• If your ED has not implemented a mental health assessment protocol already, you should consider one, including prompts designed to identify or rule out a mental health emergency.

• Determine if your electronic health records systems require enhancement for mental health emergencies. "The prompts are often insufficient to prompt the ED physician to document a complete mental health assessment," says Person.

Older physicians who are not fully comfortable with electronic documentation, and typing in particular, should dictate to ensure that sufficient details are recorded to support their clinical decision-making and the ultimate plan of care. "Most EMTALA citations could be avoided by expanded medical record documentation so that the peer reviewer could better understand the attending's logic and rationale for the plan of care," says Person.