The Role of Medical Records in Defending Against an EMTALA Complaint (42 CFR § 489.24(i))

Accurate and complete medical records are the most powerful defense against an EMTALA complaint. Under 42 CFR 489.24(i), surveyors rely heavily on a hospital’s documentation to determine whether an appropriate medical screening examination, stabilizing treatment, or compliant transfer occurred. Small practices that interface with hospitals, whether through ED call rotations, outpatient departments, or provider-based clinics, must understand that documentation failures create EMTALA exposure even when clinical care was appropriate. This article explains how records support compliance, what elements matter most, and how small practices can build a defensible EMTALA documentation framework with minimal resources.

EMTALA enforcement is based on evidence. When CMS investigates a potential violation, surveyors review medical records before interviewing staff, examining logs, or requesting witness accounts. If documentation is incomplete, contradictory, or missing essential details, CMS may presume noncompliance even if the hospital’s clinical decisions were correct.

Small clinics working within hospital-owned networks face heightened risk. Their clinicians may participate in ED call schedules, provide stabilizing services, or perform evaluations tied to EMTALA obligations. Poor documentation at the clinic level can jeopardize both the hospital and the practice. This article explores the role of medical records in defending an EMTALA case and provides practical guidance for ensuring documentation meets the standards established by 42 CFR 489.24(i).

Understanding Legal Framework & Scope Under 42 CFR 489.24 i

1. What 42 CFR 489.24(i) Requires

This section mandates that hospitals:

• Maintain medical and transfer records for individuals examined or treated for emergency medical conditions.

• Ensure records support the actions taken to comply with EMTALA obligations.

• Produce records during CMS investigations and surveys.

Although written for hospitals, these requirements affect small practices when they:

• Provide services to stabilize an emergency condition,

• Perform an exam under hospital direction, or

• Contribute documentation used in transfer decisions.

2. Records as Evidence of Compliance

Surveyors evaluate whether:

• The patient received an appropriate medical screening examination.

• The provider documented symptoms and vital signs.

• Tests, clinical decisions, and interventions were recorded.

• The rationale for transfer, refusal, or stabilizing treatment was clearly justified.

• The record reflects timeliness of actions.

Without this documentation, CMS cannot verify compliance, and the presumption shifts toward violation.

3. Federal vs State Documentation Requirements

State laws set general medical record mandates, but EMTALA imposes additional obligations tied specifically to emergency care and transfers. When documentation gaps arise, EMTALA standards prevail.

4. Why Documentation Matters for Small Practices

Small practices contribute to EMTALA-related documentation when:

• Their physicians cover the ED call panel.

• They operate as provider-based departments.

• They stabilize patients prior to transfer.

• They document interactions that influence EMTALA decisions.

Incomplete documentation from an outpatient clinic can trigger liability for the entire system.

5. Operational Impact

Understanding 42 CFR 489.24(i) reduces risk by ensuring:

• Clear clinical decision-making records

• Traceable timelines

• Defensible transfer justifications

• Reliable evidence for CMS surveyors

Enforcement & Jurisdiction

CMS investigates EMTALA complaints primarily through a documentation-heavy process. OIG handles penalties, but CMS determines compliance by:

• Reviewing ED logs

• Analyzing medical records

• Evaluating transfer documentation

• Comparing record timestamps to reported events

• Identifying inconsistencies between staff accounts and chart entries

Common Documentation Failures Leading to Enforcement

• Missing vital signs despite symptomatic presentation

• Incomplete documentation of medical screening examinations

• Missing rationale for transfer

• Inconsistent timelines

• No record of stabilizing interventions attempted

• Absence of documentation showing physician involvement

For small practices supporting hospital care, missing documentation can implicate the hospital in EMTALA violations.

These controls help small clinics support EMTALA-compliant documentation within the broader hospital system. Each action ties directly to 42 CFR 489.24(i) and includes implementation guidance, evidence expectations, and low-cost options.

1. EMTALA Documentation Packet

A structured packet ensures complete records for EMTALA-related events.

• Implementation: Include templates for screening exams, interventions, timelines, and transfer notes.

• Evidence: Completed packet filed with clinical record.

• Low-cost option: Printable PDF stored on shared drive.

2. Timestamp Accuracy Protocol

EMTALA investigations rely heavily on timing.

• Implementation: Require staff to document all key events with real-time timestamps.

• Evidence: Time-stamped notes, vitals, interventions, and communications.

• Low-cost option: Automatic timestamping in EHR or time-synchronized wall clocks.

3. Clinical Rationale Documentation Process

Every major decision must have documented justification.

• Implementation: Document why a transfer was necessary, why an intervention was chosen, or why immediate physician involvement was required.

• Evidence: Clear statements linking clinical decision to patient’s condition.

• Low-cost option: Single-line prompts embedded in notes.

4. Standardized Medical Screening Examination Form

When small-practice clinicians perform screening examinations under hospital protocol, the form ensures completeness.

• Implementation: Use a structured template covering symptoms, vitals, exam findings, and tests.

• Evidence: Completed form attached to record.

• Low-cost option: Paper form with checkboxes.

5. Transfer Documentation Checklist

If a clinic participates in sending patients to a hospital ED or higher-level care, documentation must show EMTALA-compliant transfer steps.

• Implementation: Include medical necessity, acceptance by receiving facility, and means of transport.

• Evidence: Transfer checklist signed by staff.

• Low-cost option: One-page printed checklist.

6. Call Coverage Documentation

When small-practice physicians respond to hospital requests, documentation of call involvement is critical.

• Implementation: Record the time contacted, type of communication, actions taken, and arrival time if applicable.

• Evidence: Call log entry in the record.

• Low-cost option: Shared spreadsheet or EHR quick-note template.

7. Immediate Post-Event Documentation Rule

Documentation performed immediately is significantly more defensible.

• Implementation: Require staff to complete major event documentation before ending the shift.

• Evidence: Timestamped notes demonstrating timely entry.

• Low-cost option: End-of-shift checklist.

These controls create stronger records that form a reliable defense during EMTALA investigations.

Case Study

A small orthopedic practice affiliated with a hospital provided call coverage for ED fractures. A 34-year-old man arrived at the ED after an accident. ED staff called the orthopedic PA for evaluation. The PA assessed the patient but failed to document the exam thoroughly. The ED note recorded only that “orthopedics consulted,” but no screening details, findings, or rationale for transfer were documented.

Later, the patient filed an EMTALA complaint alleging delayed stabilization. CMS reviewed the documentation and found:

• No record of a complete exam

• No documented rationale for transfer

• Inconsistency between staff accounts and documentation

• No timestamps identifying physician engagement

Since medical records were insufficient to demonstrate compliance with EMTALA obligations, CMS presumed noncompliance.

Consequences

• Hospital cited for inadequate EMTALA documentation under 42 CFR 489.24(i)

• Orthopedic practice ordered to implement corrective training

• Transfer process required revision

• Heightened scrutiny during next CMS survey

How the Operational Playbook Would Have Prevented This

If the PA had used the standardized exam form, documented timestamps, and filled out the transfer checklist, the record would have clearly shown compliance and protected both the clinic and the hospital.

Common Audit Pitfalls to Avoid Under 42 CFR 489.24 i

Medical record deficiencies are the most common source of EMTALA findings.

• Missing timestamps, creating doubt about timeliness of screening or treatment.

• Incomplete symptom and exam documentation, making screening appear insufficient.

• No transfer rationale, leaving CMS unable to verify medical necessity.

• Inconsistent notes between departments, suggesting inaccurate or retrospective entries.

• Absence of call documentation, making physician involvement unverifiable.

• Failure to document receiving facility acceptance, undermining lawful transfer requirements.

Correcting these documentation gaps strengthens EMTALA defenses and reduces enforcement risk under 42 CFR 489.24(i).

A culture of defensible documentation requires consistent leadership. Clinics supporting hospital EMTALA functions should assign a documentation champion responsible for maintaining templates, monitoring compliance, and reviewing cases monthly. Regular training should emphasize accuracy, completeness, and timeliness. Clinics should monitor metrics such as missing documentation rates, incomplete forms, and late entries. Governance focused on verification and accountability ensures that clinical decisions are recorded in a way that aligns with EMTALA expectations.

Medical records serve as the foundation of EMTALA compliance. Under 42 CFR 489.24(i), CMS uses documentation as the primary evidence in determining whether the hospital or its affiliated clinicians met EMTALA obligations. Small practices can support compliance by implementing simple, standardized, low-cost documentation tools that create complete and defensible records.

Next Steps

1. Deploy an EMTALA documentation packet across all clinical areas.

2. Require real-time timestamps for all key clinical decisions.

3. Use standardized exam and transfer templates.

4. Document call responses and physician involvement thoroughly.

5. Conduct monthly documentation audits to verify compliance.

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.

• EMTALA Regulations – 42 CFR 489.24
  

• CMS State Operations Manual, Appendix V – EMTALA Guidelines
  

• Emergency Medical Treatment and Labor Act (42 USC 1395dd)
  

• Federal Register EMTALA Interpretive Guidance
  

• HHS Office of Inspector General – Civil Monetary Penalties Law Guidance