Medical Screening Exam Note (EMTALA)

Date/Time: [Note creation date and time]

Location: [triage / waiting area / EMS bay / resuscitation bay / other ED area]

Patient Arrival Time: [Arrival time, or statement if unavailable with reason]

MSE Initiated: [Date and time MSE initiated or earliest provider contact]

Author: [Author name, credential, role]

QMP Status: [Statement that author is acting as Qualified Medical Personnel per hospital bylaws]

EMTALA Trigger / MSE Status

[Reason EMTALA obligations were triggered: patient request for exam/treatment / EMS request / third-party concern / concerning appearance or behavior] (Identify the source. This section must never be omitted.)

MSE Status: [MSE Initiated (Ongoing—diagnostics pending) / MSE Completed—No EMC Identified / MSE Completed—EMC Identified / MSE Completed—EMC Resolved] — [One-sentence explanation of current status]

Chief Complaint

[Patient's stated reason for visit; if via EMS or third party, note reported complaint and identify historian] (Use patient's own words when brief and clinically useful.)

HPI (Focused)

[Focused narrative of symptom onset, time course, severity, key modifiers, associated symptoms, and pertinent negatives relevant to time-sensitive conditions; information source; limitations in obtaining history if applicable] (Use brief direct quotes only to clarify critical statements such as suicidal ideation, refusal language, or classic symptom descriptors. If history is limited, state why and what alternative sources were used.)

Pertinent History

• Past Medical/Surgical History: [Relevant conditions and surgeries, or unknown with reason]
• Medications: [Current medications, especially anticoagulants, insulin, sedatives; or unknown with reason]
• Allergies: [Allergens with reaction type; NKDA; or unknown with reason]
• Pregnancy Status: [Status if relevant to presentation, or not applicable]

Immediate Safety Assessment

(Include when patient is not immediately placed in a treatment room.)

• General Appearance/Distress: [Appearance, work of breathing, pain or distress level]
• Mental Status/Airway: [Alertness, orientation, airway patency]
• Hemodynamic Impression: [Perfusion status and concerning signs if present]
• Vital Signs: [Current vitals, or not yet obtained with reason and time requested]
• Waiting Area Suitability: [Appropriate to remain in waiting area with return precautions / Requires monitored bed immediately] — [Reasoning]
• Immediate Actions: [Interventions taken: oxygen, IV access, ECG, escalation, urgent bed request]

Exam (Focused)

(Document only systems actually examined. Do not include templated normals for systems not assessed. If an element cannot be performed, state why. Delete unused systems.)

• General/Mental Status: [Appearance, level of consciousness, orientation, affect]
• Airway/Breathing: [Air entry, effort, adventitious sounds, speech]
• Cardiovascular: [Rate, rhythm, perfusion, edema]
• Neurologic: [Focal deficits, cranial nerves, strength, gait, speech]
• Abdomen: [Tenderness, guarding, rebound, distention]
• Musculoskeletal: [Deformity, tenderness, ROM, distal neurovascular status]
• Skin: [Color, temperature, rash, lesions]
• Psychiatric: [Behavior, insight, judgment, SI/HI, hallucinations, capacity] (Include for behavioral presentations.)
• Obstetric: [Contractions, bleeding, fetal movement, gestational age, fetal monitoring] (Include for possible labor or pregnancy-related concerns.)

Diagnostics

(Include when tests are ordered. If EMC determination depends on pending results, reflect this in MSE Status above.)

Ordered: [Tests ordered]

Resulted: [Key findings from available results]

Pending: [Tests awaiting results]

MSE Assessment & EMC Determination

• Primary Working Diagnosis: [Most likely condition with brief rationale]
• Key Differentials: [Time-sensitive conditions considered and why less likely or how being evaluated] (List highest-risk considerations first.)
• Risk Modifiers: [Pertinent positives/negatives affecting risk]

EMC Determination: [EMC present—state condition / No EMC identified at this time / Cannot yet determine EMC status—MSE ongoing pending specific items] — [Supporting explanation referencing history, exam, and diagnostic findings] (This statement is required and must never be omitted.)

Stabilization / Interventions

(Include when treatment is provided or EMC is suspected.)

• Treatments Given: [Medications with dose/route/time, oxygen, fluids, procedures]
• Consults/Activations: [Emergent consults or team activations with times]
• Response: [Objective and subjective response to interventions]
• Behavioral Emergency Measures: [Indication, least-restrictive rationale, restraint/sedation details, monitoring plan] (Include if applicable.)

Reassessment

(Include when patient remains under ED care after initial evaluation. Use timestamped entries.)

• [Time]: [Interval changes, repeat vitals, exam findings, treatment response, new concerns, escalation]

Disposition

(Complete the applicable pathway only.)

Continued ED Evaluation

• Current Status: [Stability and level of care required: waiting area vs monitored bed]
• Pending Items: [Tests, consults, imaging]
• Reassessment Plan: [Time frame for next evaluation]
• Instructions While Waiting: [Return precautions and how to alert staff]

Discharge

• MSE Status: [MSE complete—EMC ruled out / EMC resolved]
• Discharge Diagnosis: [Final diagnosis]
• Return Precautions: [Specific red flags]
• Follow-Up: [Provider or clinic, time frame]

Admission

• EMC Status: [Present / Resolved]
• Reason for Inpatient Care: [Clinical justification]
• Accepting Service: [Service and clinician, time of acceptance]

Transfer

• Reason for Transfer: [Capability or capacity need]
• Condition at Decision: [Clinical status at time of transfer decision]
• Stabilizing Treatments Provided: [Interventions prior to transfer]
• Receiving Facility Acceptance: [Facility name, date/time, accepting clinician or representative]
• Risks/Benefits Discussion: [Discussed with patient or surrogate; certification or patient request as applicable]
• Transport: [Mode and personnel level]
• Records Sent: [ED records, labs, imaging provided]

Refusal / AMA / LWBS

• Refused: [MSE completion / treatment / transfer / admission / diagnostics]
• Capacity Assessment: [Findings supporting capacity or lack thereof]
• Risks/Benefits Explained: [Key points discussed]
• Patient's Stated Reasons: [Patient's explanation]
• Written Refusal: [Obtained / Declined to sign / Unable to obtain with reason]
• Departure: [Patient left voluntarily without suggestion or coercion; vital signs at departure if available]

Authentication

[Electronic signature of responsible clinician], [Date and time]

(When information is unavailable anywhere in the note, document why and what steps were taken to obtain it. Do not leave blank fields that could be interpreted as evaluation not performed.)