Health Information Technologies and Processes

Surgery, Anesthesia, ED/EMTALA Registers in an electronic health record world

  • 1.  Surgery, Anesthesia, ED/EMTALA Registers in an electronic health record world

    Posted 07-06-2020 16:06
    I am wondering how facilities are handling the requirement for a permanent Surgery/Anesthesia register or Emergency Room/EMTALA register in the electronic health record environment?   Are you running reports for a specific time period and archiving them?   Or do you just run a report when it is needed/requested (as the data is available in the electronic health record)?

    Looking for a best practice in maintaining this type of register information.

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    Melinda Prachar
    HIM Director
    LifeCare Medical Center
    Roseau MN
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  • 2.  RE: Surgery, Anesthesia, ED/EMTALA Registers in an electronic health record world

    Posted 07-07-2020 08:34
    Even though this is supposed to maintain in our system indefinitely, we have opted to run the ED daily log report and download it to a shared folder on our network drive. The report is scheduled so no one actually has to perform the duties. The ED Core Team leader for our system will log in once a month or so and verify that all the dates are present. We went Live on a new system 2.5 years ago and even though we still have our old system available, it's nice to have the data all in one secure place regardless of the system.

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    Kathryn Wood, RHIA
    Assist Dir of Information Systems/Privacy Officer
    War Memorial Hospital
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  • 3.  RE: Surgery, Anesthesia, ED/EMTALA Registers in an electronic health record world

    Posted 07-07-2020 12:07
    I'm embarrassed to ask, but could you point me in the direction of information on a permanent surgery/anesthesia register.  I'd like to understand what this is and find out if I'm missing something or misunderstanding what we're talking about.  Many thanks!

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    Joyce Adams
    Him Manager/Privacy Officer
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  • 4.  RE: Surgery, Anesthesia, ED/EMTALA Registers in an electronic health record world

    Posted 07-07-2020 15:15
    This is a really good question!   I work in a critical access hospital - so my source is CMS's Conditions of Participation for Critical Access Hospitals.   In the past, we had a bound book/register that we would enter surgical cases into.   When we transitioned to the EHR in our surgical services, we no longer kept the bound book/binder.   Here's a snip from the CMS Conditions of Participation for Critical Access Hospitals:


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    Melinda Prachar
    Director Him
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  • 5.  RE: Surgery, Anesthesia, ED/EMTALA Registers in an electronic health record world

    Posted 07-07-2020 15:17
    Thank you!  Great advice!

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    Melinda Prachar
    Director Him
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  • 6.  RE: Surgery, Anesthesia, ED/EMTALA Registers in an electronic health record world

    Posted 07-07-2020 17:36
    Thank you for this information.  I was able to look into this and we are automatically curating the info from intraoperative e-forms each day. It happens so automatically that I wasn't aware of it.

    Now I feel much better!

    Thanks,
    Joyce

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    Joyce Adams
    Him Manager/Privacy Officer
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  • 7.  RE: Surgery, Anesthesia, ED/EMTALA Registers in an electronic health record world

    Posted 07-07-2020 09:13
    This is where some EHR systems can be a welcome solution...and sometimes a headache.  It is not uncommon for some facilities to need to run the "EMTALA" log each day and then reconcile what is on the report with additional data.  Once the report is reconciled, these revised reports are then stored in a designated location for retrieval as needed, such as during a CMS investigation regarding EMTALA.

    In those rare instances where the EMTALA log is needed for the same date of the investigation, I have learned that this EMTALA log reconciliation process does not take too long and easily allows for a copy of the log to be presented to the auditors well within the time requirements of a CMS survey.

    When I ask folks if this is a "pain"...I get the response that it is but that the current log from the EHR may not necessarily be complete...AND...this also allows for the log to be checked for accuracy as errors in data entry into the EHR may occur.

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    Frank Ruelas
    Compliance Professional
    Arizona
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