Central Log Requirements: Documenting All Individuals Who “Come to the ED” (42 CFR § 489.24(k))

A compliant emergency department central log is the backbone of EMTALA transparency. Under 42 CFR 489.24(k), hospitals must maintain an accurate, contemporaneous record of all individuals who come to the ED and the outcomes of their visits. The rule applies regardless of insurance, ability to pay, or whether an individual ultimately receives a medical screening exam or leaves before evaluation. For small hospitals, a well-designed log that auto-pulls from triage and transport data reduces omissions, accelerates survey responses, and demonstrates good-faith compliance. Consistent, time-stamped logging paired with shift reconciliation is the simplest way to avoid citations and penalties linked to gaps or selective documentation.

Central log duties are deceptively simple: record everyone who presents and what happened next. In practice, omissions often occur at the margins, patients who leave before triage, ambulance diversions, parking-lot encounters, or individuals redirected to urgent care without an EMTALA-compliant assessment. For lean teams, the safest approach is to automate capture at the earliest reliable signal (triage badge swipe, ambulance radio notification, or security timestamp) and to reconcile the log against multiple sources at every shift change. Doing so not only meets federal requirements; it also gives operations a reliable dataset to manage throughput, boarding, and diversion decisions tied to patient safety.

Understanding Legal Framework & Scope Under 42 CFR 489.24(k)

What the regulation requires. The hospital must maintain a central log that identifies each individual who comes to the emergency department and indicates whether the individual refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged. The log must be organized to easily track an individual’s care and disposition over time (42 CFR 489.24(k)). The statute underlying EMTALA (42 U.S.C. 1395dd) sets the duty to provide an appropriate medical screening exam and stabilizing treatment; the central log provides auditable evidence of whether the hospital recognized and recorded the presentation in the first place.

Who is included. “Comes to the emergency department” is interpreted broadly and includes individuals on hospital property within the ED’s dedicated footprint, as well as those that present elsewhere on the campus requesting emergency care. It covers ambulance arrivals even if diverted, walk-ins, drop-offs, and individuals who refuse triage or leave before being seen. It does not depend on registration being completed or insurance being checked.

Minimum content. The regulation does not prescribe a single form, but surveyors expect, at minimum: unique identifier, presentation date/time, mode of arrival (e.g., ambulance, walk-in), chief complaint or brief reason for visit, MSE start time (if applicable), disposition (admit, discharge, transfer, LWBS, eloped, AMA, refused treatment), and key times (e.g., left time, transfer acceptance time).

Retention and organization. The central log must be maintained in a manner that allows ready retrieval by date/time and patient identifier for survey and enforcement purposes. Most facilities retain logs consistent with medical record retention schedules and EMTALA interpretive guidance expectations.

How this reduces denials, penalties, and friction. A robust log allows you to quickly prove that every presentation was recognized and handled in line with screening and stabilization duties. It is the fastest path to resolving complaints, limiting enforcement exposure, and explaining unusual events (e.g., mass casualty, system downtime) without prolonged back-and-forth.

CMS, through State Survey Agencies, reviews central logs when investigating EMTALA complaints. Logs are compared with triage sheets, EHR encounter lists, ambulance run sheets, security and CCTV timestamps, and diversion records to identify omissions or selective documentation. If CMS finds that individuals who presented were not logged, or that dispositions are incomplete or inconsistent with other records, the hospital risks citations. Confirmed violations can be referred to the HHS Office of Inspector General for civil monetary penalties linked to EMTALA noncompliance. Surveyors focus intensively on patients who left without being seen, ambulance diversions, and psychiatric presentations because those categories are historically prone to under-documentation.

Below is an operational playbook tailored for small hospitals to meet 42 CFR 489.24(k) requirements with minimal cost. Each control states how to implement it, what evidence to retain, a low-cost approach, and the regulatory anchor.

1) Single Source of Truth Central Log

• Implement: Keep one central log for the ED, not parallel spreadsheets. Configure EHR/bed board so that any arrival signal (triage badge scan, ambulance radio entry, security timestamp) creates a pending row that cannot be deleted, only dispositioned.

• Evidence: System configuration screenshot; data dictionary; audit trail showing row creation on signal events.

• Low-cost: Use your EHR’s tracking board with a “pre-encounter” status; if no EHR, a locked spreadsheet with auto time-stamp macro and versioning.

• Authority: 42 CFR 489.24(k) requires a central log of each individual who comes to the ED.

2) Presentation Triggers Map

• Implement: Define precise triggers for “comes to the ED”: ambulance arrival on hospital grounds, walk-in desk contact, triage verbal request, security call from parking lot about a person seeking help, and intercom/panic-phone requests. Each trigger must launch a log row.

• Evidence: Policy appendix listing triggers and the field autofilled at row creation; staff training sign-off.

• Low-cost: One-page laminated flowchart at triage and security stations.

• Authority: Broad scope of “comes to the ED” supports inclusive logging (42 CFR 489.24(k)).

3) Disposition Taxonomy With Clear Definitions

• Implement: Standardize and train on discrete dispositions: Admitted, Discharged, Transferred, LWBS (left without being seen), Eloped (after triage), AMA (after MSE/treatment), Refused Triage, and “Refused Treatment, No MSE.”

• Evidence: Disposition dictionary with examples; periodic chart audits comparing clinical notes to log disposition.

• Low-cost: EHR drop-down list with hover hints; if paper, printed key on the log form.

• Authority: Log must show whether the individual refused or was refused treatment, transferred, admitted, stabilized and transferred, or discharged (42 CFR 489.24(k)).

4) Shift Reconciliation Across Three Sources

• Implement: At each shift end, a charge nurse or house supervisor reconciles the central log against: (a) triage queue, (b) EMS run sheets or radio logs, and (c) security event log. Investigate mismatches immediately.

• Evidence: Reconciliation checklist with signatures; a monthly variance trend report.

• Low-cost: Simple printed checklist with three columns and a space for variance notes.

• Authority: Ensures completeness of “each individual” requirement (42 CFR 489.24(k)).

5) Minimal-Data Logging for Sensitive Cases

• Implement: For psychiatric, sexual assault, or high-sensitivity cases, log a minimal, legally sufficient descriptor (e.g., “Behavioral health concern”) rather than detailed narratives; ensure the central log remains identifiable and auditable while respecting privacy norms.

• Evidence: Policy excerpt on minimal logging; examples reviewed with compliance.

• Low-cost: EHR quick-pick chief complaint list with privacy-friendly terms.

• Authority: 42 CFR 489.24(k) requires inclusion in the log; it does not mandate sensitive detail beyond identifiability and disposition.

6) Diversion Integrity Check

• Implement: When on diversion, continue to log ambulance requests that contact the ED or arrive on property, noting diversion status and final destination. If a patient is on campus, they must be logged regardless of diversion.

• Evidence: Diversion logs cross-referenced to central log entries; policy clarifying diversion does not suspend logging.

• Low-cost: A “diversion” checkbox column with auto-insert of diversion reason and time window.

• Authority: Individuals who come to the ED must be logged, even during diversion (42 CFR 489.24(k)).

7) EHR Downtime “Paper First” Protocol

• Implement: Maintain a pre-printed paper log with identical fields in red clipboards at triage and security. During downtime, record entries immediately, then back-enter into the EHR within 24 hours; staple all paper sheets to a downtime packet.

• Evidence: Downtime packet with paper logs, downtime start/stop times, and staff initials; IT incident ticket number.

• Low-cost: Photocopy packets stored in a marked wall bin; simple “back-entry” stamp.

• Authority: The duty to maintain a central log is continuous (42 CFR 489.24(k)).

8) Time Discipline: Four Clocks

• Implement: Capture four times for every row where applicable: arrival or first contact, triage start, MSE start, and disposition time. Require “not applicable” only when there is no MSE (e.g., refused triage).

• Evidence: Log export showing time fields; random audits ensuring reasonable intervals.

• Low-cost: EHR auto-stamp for triage and MSE orders; if paper, synchronized wall clock checks each shift.

• Authority: Organized log that allows tracking of care and outcomes over time (42 CFR 489.24(k)).

9) Refusal/Elope Pathway With Witnessing

• Implement: When individuals refuse triage or elope, obtain a witnessed note documenting a simple, non-coercive offer for evaluation and the time they left; link that note to the log row and select the correct disposition code.

• Evidence: Witness statements or brief notes; weekly tally of LWBS/eloped with reasons.

• Low-cost: A half-page “refusal/elope” slip that scans to the chart.

• Authority: The log must show whether the individual refused treatment and final disposition (42 CFR 489.24(k)).

10) Monthly Compliance Review and Feedback Loop

• Implement: Compliance or quality reviews a random sample of 30 log entries monthly to verify completeness, accuracy of dispositions, and presence of supporting documents. Send service-line feedback within five business days.

• Evidence: Review summary, corrective actions, and re-education logs.

• Low-cost: Standard auditing template; 30-minute monthly huddle.

• Authority: Ongoing oversight ensures durable adherence to 42 CFR 489.24(k).

Wrap-up: These targeted controls make the central log both easy to complete at the bedside and credible during survey file pulls, satisfying the “each individual” requirement without adding headcount.

Case Study

Event: On a stormy evening, EMS radios that they are bringing a 58-year-old chest pain patient. The hospital is on ED diversion due to boarding, but the ambulance reports they are already on hospital property because of road closures.

What happened: Security cameras show the ambulance turning into the campus and stopping at the ED bay for five minutes while dispatch reroutes. The unit ultimately leaves for a neighboring facility. The triage desk did not create a log entry because “we never registered them” and believed diversion excused logging.

Compliance analysis: Because the ambulance came onto hospital property requesting emergency care, the individual “came to the ED.” Under 42 CFR 489.24(k), an entry should have been created with arrival time, diversion status, and disposition “transfer/redirected prior to MSE.” During the CMS complaint investigation, the hospital can point to security logs and radio records, but the absence of a central log entry suggests selective documentation.

Fix and outcome: The facility updates the “presentation triggers map” to require automatic pending-row creation on any ambulance radio contact when the unit crosses property line, with diversion status pre-checked. Shift reconciliation now includes the security log as a hard requirement. In the follow-up review, no further gaps are found, and the hospital demonstrates sustained compliance.

Wrap-up: These six checks directly prove that the central log is complete, time-disciplined, and reliable under EMTALA.

Common Audit Pitfalls to Avoid Under 42 CFR 489.24(k)

The following pitfalls repeatedly appear in survey findings. Avoiding them will tighten your central log and reduce enforcement risk.

• Assuming diversion suspends logging obligations. Diversion does not negate logging when the individual or ambulance is on hospital property requesting emergency care; failures lead to citations for incomplete central logs. Consequence: Deficiency for missing entries during diversion periods.

• Not logging “left before triage” or parking-lot presentations. Individuals who seek help but depart before formal registration must still be captured. Consequence: Inability to prove recognition of presentations; pattern appears as selective documentation.

• Collapsing refusal categories. Mixing LWBS, AMA, eloped, and refused triage under one code obscures risk patterns. Consequence: Poor quality oversight and surveyor doubt about data integrity.

• Omitting key timestamps. Missing arrival or disposition times undercuts your ability to demonstrate timely MSE or disposition decisions. Consequence: Findings that your log is not “organized” to track care over time.

• Failing to reconcile with EMS and security logs. Without cross-checks, edge-case presentations slip through. Consequence: Discrepancies that trigger broader EMTALA scrutiny beyond the log.

• Deleting pending rows when patients leave. Rows must be dispositioned, not deleted; deletion is a red flag in audit trails. Consequence: Allegations of after-the-fact record cleansing.

Wrap-up: Treat logging as an inclusive capture activity, not a registration byproduct; correct coding and reconciliation convert edge cases into defensible data.

Ownership. The ED Director owns day-to-day integrity of the central log; the House Supervisor ensures shift reconciliation; Compliance owns monthly audits and trend reporting. IT supports automation, downtime tools, and audit trails. Medical Staff leadership reinforces that complete logging is everyone’s responsibility, including physicians.

Training. New staff receive a 20-minute module on presentation triggers, refusal taxonomy, and four timestamps. Quarterly refreshers use anonymized cases from recent variances. Include EMS partners and security in a brief annual drill focused on how early signals create pending log rows.

Metrics. Track three KPIs: (1) percentage of EMS/security events matched to a log row; (2) percentage of rows with complete four timestamps, when applicable; (3) ratio of LWBS/eloped to total presentations with trend-by-hour to inform staffing. Share results to the quality committee and close the loop with targeted micro-trainings where needed.

Policy alignment. Align your central log policy with EMTALA screening, diversion, security reporting, and downtime policies. Consistency prevents gaps during survey interviews and ensures staff can answer “what happens when…” questions with confidence.

The central log is the first proof that your ED recognized and responded to every presentation. Under 42 CFR 489.24(k), completeness and organization are the keys: inclusive capture at first signal, simple disposition codes, four timestamps, and routine reconciliation. Small hospitals can meet the standard with modest tools and disciplined processes. The payoff is significant, fewer survey surprises, faster complaint resolution, and stronger clinical operations.

Immediate, concrete next steps

1. Publish a one-page “presentation triggers map” and add an auto-create pending row on the earliest reliable signal (triage, EMS radio, or security).

2. Standardize dispositions with a refusal/elopement taxonomy and update EHR drop-downs to match.

3. Implement shift reconciliation across triage, EMS, and security logs; require signatures and variance notes.

4. Stand up downtime “paper-first” clipboards and a 24-hour back-entry rule; run a tabletop drill this week.

5. Launch monthly audits of 30 random rows for four timestamps and coding accuracy, then share findings with staff in a 10-minute huddle.

Recommended compliance tool

A shared “Medicare Plan Interaction” log and policy folder on your existing network or EHR, used to store scripts, training records, and any sponsor correspondence about beneficiary communications.

Advice:

Before the next open enrollment, walk through your clinic as an auditor would and remove or rewrite anything that could be interpreted as recommending one Part D plan over another.

• eCFR: 42 CFR 489.24 — Special responsibilities of Medicare hospitals in emergency cases
  

• eCFR: 42 CFR 489.24(k) — Central log requirements
  

• United States Code: 42 U.S.C. 1395dd — Examination and treatment for emergency medical conditions and women in labor
  

• CMS State Operations Manual, Appendix V — Interpretive Guidelines for EMTALA
  

• HHS OIG — Civil Money Penalties Authorities Related to EMTALA
  

• Federal Register — Clarifying Policies Related to EMTALA Responsibilities (Final Rule)