"Medical Clearance" for jail

[migm]

I looked back and haven't seen a thread on this. At my shop unless I write "medically cleared for jail" in the dc note they get bounced back to the ED. In my opinion it's not my job to medically clear anybody. I write I performed a medical screening exam, no emergency, blah blah safe for discharge. Anyone else encounter this scenario? I feel like the jail is trying to get me to stick my neck out for them - I'm not willing.

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[GeneralVeers]

I just write "medically cleared" or fill out whatever form needed. It's not worth worrying about, honestly. Most of these prisoners just need a quick eyeball exam, and then off to jail for whatever antisocial trangressions they have committed.

 

[southerndoc]

If they can't take the discharge paperwork as proof that they are medically cleared, then someone needs to talk with your police, sheriff, etc. The discharge paperwork is good enough fro somebody to go home so it should be good enough to go to jail.

I have never -- nor will I ever -- write "medically cleared for jail." If they expect me to do that, then they will be paying an officer to stay in the patient's room until his charges are brought before a judge or they succumb to taking them to jail.

 

[TooMuchResearch]

One county in my area has everyone come through the ED on their way to jail.

They also get a little feisty on the occasion that I have to admit someone brought in for clearance.

If they can't take the discharge paperwork as proof that they are medically cleared, then someone needs to talk with your police, sheriff, etc. The discharge paperwork is good enough fro somebody to go home so it should be good enough to go to jail.

I have never -- nor will I ever -- write "medically cleared for jail." If they expect me to do that, then they will be paying an officer to stay in the patient's room until his charges are brought before a judge or they succumb to taking them to jail.

 

[thegenius]

I looked back and haven't seen a thread on this. At my shop unless I write "medically cleared for jail" in the dc note they get bounced back to the ED. In my opinion it's not my job to medically clear anybody. I write I performed a medical screening exam, no emergency, blah blah safe for discharge. Anyone else encounter this scenario? I feel like the jail is trying to get me to stick my neck out for them - I'm not willing.

I'm with ya.

I have a little blurb macro saying what I've done. Something like "they have been evaluated for all medical emergencies, there are none, the patient is safe to be discharged. blah blah" Just like what you wrote.

Next time they want you to write "Medically Cleared For Jail"
discharge them and tell them if they come back to have the jail bring you a detailed definition of what "Medical Clearance" means, and you'll determine if you can fulfill that definition given the scope of your medical training and being in an ER.

Or
Just discharge them. They can sit around in the lobby with the police office watching them.



So the problem with these kinds of things is that you'll end up winning at the end of the day, but you'll piss off a lot of police officers in your county. You wanna live like that?

 

[thegenius]

If they can't take the discharge paperwork as proof that they are medically cleared, then someone needs to talk with your police, sheriff, etc. The discharge paperwork is good enough fro somebody to go home so it should be good enough to go to jail.

I have never -- nor will I ever -- write "medically cleared for jail." If they expect me to do that, then they will be paying an officer to stay in the patient's room until his charges are brought before a judge or they succumb to taking them to jail.

Why won't you write medically cleared for jail?

 

[deleted836128]

I won’t say anyone is “medically cleared.” That isn’t our job in the ER and what does that even mean? I just say something like “no emergent conditions, safe for discharge.”

 

[DeadCactus]

"No contraindication to discharge or detainment identified."

 

[southerndoc]

Because you do not need a medical clearance to go to jail. Thankfully we don't get cops bringing people routinely to the ER unless they've been assaulted, altered mental status, etc.

Where would I write it? In the chart? The cops do not get a copy of that when the patient is discharged. They get a copy of the Epic discharge instructions, patient follow-up information, etc.

Do you write "medically cleared for discharge," "medically cleared for taxi," or "medically cleared to take the bus?" No, your discharge from the ER is attesting to the fact that the patient doesn't have a medical emergency and is safe for discharge.

 

[GeneralVeers]

It's stupid. But IMO it's not the hill to die on. PD around here are great about hauling off patients/ family members who take things too far, and I prefer to make their lives easy on this stuff and keep the nice relationship. I scratch their back, they scratch mine.

I agree. I want to make the lives of PD as easy as possible in case I ever have to deal with them in the future. I also want their crazies/inmates out of my ED as quickly as possible. Fighting them over "medical clearance" is a sure way to make a violent inmate stick around in your department longer, not to mention it will really piss off the nurses.

 

[p1acebo]

Cops where I am do this too. I can see why it could be a liability saying something as vague as “medically cleared,” which could mean anything. However my question is has anyone ever actually been sued because they “medically cleared” a patient for jail and some bad outcome occurred at jail?

 

[deleted109597]

I just write "medically stable for transport to jail".
Nobody has ever questioned it or asked for anything else.

 

[RustedFox]

The only bugaboo that I run into of this flavor is that the local behavioral health shops want me to write: "Medically cleared" in the chart before they accept the Baker Act. (or 5150, if you're in CA.... God Bless Van Halen). Nobody else puts up a fight.

Yes. Cooperate with the local constabulary, a la Veers.

This is probably unwritten rule #13 of working in the ER.

... wait ...

Unwritten rules of the ER... thread?

 

[GeneralVeers]

The only bugaboo that I run into of this flavor is that the local behavioral health shops want me to write: "Medically cleared" in the chart before they accept the Baker Act. (or 5150, if you're in CA.... God Bless Van Halen). Nobody else puts up a fight.

Yes. Cooperate with the local constabulary, a la Veers.

This is probably unwritten rule #13 of working in the ER.

... wait ...

Unwritten rules of the ER... thread?

Sounds like we need to hear the rest of Fox's unwritten rules......

 

[RustedFox]

Sounds like we need to hear the rest of Fox's unwritten rules......

I say that you write the "unwritten rules of the ER", because I am revising and double-revising the "My Jackpot Lawsuit!" original post right now.

 

[RustedFox]

Unwritten rule #3 of the ER: - Do NOT sign out any procedure that needs to be done. If you think that an LP or a pelvic exam or a central line should be placed: then you need to ruck-up and do it.

ONLY EXCEPTION: If you're a non-EM boarded guy working in the ER, or an ER doc that went UC and is now back in the fray (I have one of each in my present main-gig), then sign-out the patient to me so I can [generally] conclude that the procedure doesn't need to be done, or [that] I can do it far better than you could.

*** I have seriously wrested care from FM dickhead twice this month because he didn't recognize that this patient was going to die without a central line, pressors, and a STAT trip to the OR. ***

 

[RustedFox]

Unwritten Rule #1: Nobody says the words "quiet" or "slow" in the ER. If you say these words, or any derivative; then you can see all the patients that come after you uttered that curse.
Unwritten Rule #2: Bull**** patients get signed-into, but they wait. Oops. I signed into that "sore throat/URI", but I heard that there was a stroke alert coming in on the radio. Good thing they went to the other hospital, with the comprehensive stroke whatever. You waited that long? Oh, well, ten minutes more won't hurt you. Do yourself a favor: shut-up. Go away. There is no reason for you to be in the ER.k

Grrrrr.

#NewThreadComingUp.

 

[southerndoc]

It's stupid. But IMO it's not the hill to die on. PD around here are great about hauling off patients/ family members who take things too far, and I prefer to make their lives easy on this stuff and keep the nice relationship. I scratch their back, they scratch mine.

I already have a great relationship with them. I'm the EMS medical director for the county and work with the SWAT team as a tactical physician for high-risk callouts.

I'm lucky that we have armed security guards 24/7 (4-5 on-duty at any one time) with an off-duty police officer also on-duty 24/7.

 

[southerndoc]

Unwritten Rule #1: Nobody says the words "quiet" or "slow" in the ER. If you say these words, or any derivative; then you can see all the patients that come after you uttered that curse.
Unwritten Rule #2: Bull**** patients get signed-into, but they wait. Oops. I signed into that "sore throat/URI", but I heard that there was a stroke alert coming in on the radio. Good thing they went to the other hospital, with the comprehensive stroke whatever. You waited that long? Oh, well, ten minutes more won't hurt you. Do yourself a favor: shut-up. Go away. There is no reason for you to be in the ER.k

Grrrrr.

#NewThreadComingUp.

It's slow as crap tonight. I will say slow, slow, slow all day long. I like volume. I'm paid based on RVU and the night goes by quicker when I'm busy.

 

[BoardingDoc]

It's slow as crap tonight. I will say slow, slow, slow all day long. I like volume. I'm paid based on RVU and the night goes by quicker when I'm busy.

100% this. I complain that it's slow all the time. Hard not to when you're paid by RVU not by hour.

 

[BAM!]

Because you do not need a medical clearance to go to jail. Thankfully we don't get cops bringing people routinely to the ER unless they've been assaulted, altered mental status, etc.

Where would I write it? In the chart? The cops do not get a copy of that when the patient is discharged. They get a copy of the Epic discharge instructions, patient follow-up information, etc.

Do you write "medically cleared for discharge," "medically cleared for taxi," or "medically cleared to take the bus?" No, your discharge from the ER is attesting to the fact that the patient doesn't have a medical emergency and is safe for discharge.

What are you afraid of?

 

[GonnaBeADoc2222]

100% this. I complain that it's slow all the time. Hard not to when you're paid by RVU not by hour.

Love hourly pay when it's slow. One overnight I got paid 3k to see 6 patients. Watched like 4 movies. When the movieatient ratio approaches 1 you know it's an awesome night.

 

[GonnaBeADoc2222]

Agree. Just write it and get them out of the department.

What are you afraid of?

 

[thegenius]

I’m not opposed nor really care about southern docs not putting in on the discharge papers. I was just curious. As I wrote at the end of the day, we would win a position on this issue if it ever went to court or whatever.

We have 20 docs more or less where I work, and if 19 put it in their discharge papers and I don’t, then the nurses and everybody else will be regularly asking why not, you are going to answer the same question over and over....and eventually it will be accepted that there is one doc who does it differently than others.

It might be a little different though with psych clearance. We ship 5150s to a county crisis center that is a mile away from the ER. They have a contract to manage psychiatric crises in our county, but as far as I know they are not bound by EMTALA. They regularly refuse patients because of minimally abnormal labs (e.g. Cr 1.3, K+ 3.2,....) or they delay for inordinate periods of time accepting transfer. Sometimes 8 hours. Sometimes they say they are on diversion. And they always want the chart to say “medically cleared for psychiatric care" or some nonsense. If we don't put it in, they just won't accept the patient. We have regular meetings with them and nothing really seems to change.

 

[Tenk]

Ummm... there is absolutely no legal difference between discharging someone in police custody to jail and writing on a paper medically clear for jail. None. Zip. Zilch. Nada.

They are the exact same thing. You can get sued either way if you are wrong. Doesn’t matter. There are far, far, far more important things to get your panties in a bunch over.

 

[southerndoc]

My point is that it's unnecessary additional statements. By discharging the patient, you are saying the patient is medically cleared.

I try not to do something twice when once suffices. Just a style statement. Probably allows me to be more productive. You're right, it's not a huge amount of work to write it, but where are you writing it? The patient doesn't go home with a copy of their chart. Do you write it on the discharge paperwork? The one where you've marked them as stable for discharge?

 

[thegenius]

yes, the paperwork that they go home with, or to jail with. The discharge papers. It is stupid I agree.

For our crisis center, our staff actually prints out our EMR chart (whether complete or not) and faxes it to them.

 

[Birdstrike]

To the person you're writing the statement for, "Medically cleared for _____," translates to, "If anything goes wrong after this moment, you can blame me, not ______."

 

[Groove]

Yeah, we get this sort of thing when we d/c our patients to psych down the hall. We have to put "medically cleared and clinically sober" or they won't take them.

What's even more frustrating is that the psychiatrists on call over there have apparently forgotten 100% of their basic medicine and the social workers will send the pt back over to the ED 8 hours later for elevated BP because nobody administered the pt's daily anti-HTN meds.

 

[thegenius]

What's even more frustrating is that the psychiatrists on call over there have apparently forgotten 100% of their basic medicine and the social workers will send the pt back over to the ED 8 hours later for elevated BP because nobody administered the pt's daily anti-HTN meds.

I love it (actually hate it) how psychiatrists and crisis centers do not have to help some of these patients for the dumbest of medical problems, even though some of them are in real dire need of psychiatric stabilization.

They just punt them back to the ED, where they sit around for hours because of a BP of 165/90.

 

[migm]

My concern is the gross negligence of jail staff in recognizing apparent medical emergencies. I am not a prophet. When I see and discharge a pt, they are safe to go and come back if something changes. My concern is staff at jail will say "well the doc said he was fine" and not treat the unknown ingestion of heroin in a baggy that finally ruptured.. is that on me? I dont know. I usually write, medically stable for discharge, if condition changes please return to the ED. That patient got bounced back to the ED because of the the last statement I **** you not.

 

[Birdstrike]

My concern is the gross negligence of jail staff in recognizing apparent medical emergencies.

Is there likely plenty of incompetence and even negligence?
Sure. But I'm sure they're also sick to the gills of inmates faking illness to get out of jail and put in a soft warm ED bed where customer satisfaction is King.

My concern is staff at jail will say "well the doc said he was fine" and not treat the unknown ingestion of heroin in a baggy that finally ruptured.. is that on me? I dont know.

I think if someone eats a baggy of heroin, unknown to you, and dies, that's not "on you." It's on the eater. Sorry, but eating condoms full of heroin and not telling anyone has consequences.

I usually write, medically stable for discharge, if condition changes please return to the ED. That patient got bounced back to the ED because of the the last statement I **** you not.

ER Doc: "Why the *!!$*#&@!!! did this patient come back?!"

Patient: "Because your discharge instruction told me to."

 

[Groove]

I love it (actually hate it) how psychiatrists and crisis centers do not have to help some of these patients for the dumbest of medical problems, even though some of them are in real dire need of psychiatric stabilization.

They just punt them back to the ED, where they sit around for hours because of a BP of 165/90.

Yeah, it's ******ed. I refused the pt and told the social workers to have the psychiatrist on call manage the guys BP as we needed the beds for our patients. The psychiatrist calls me all huffing and puffing about how he "doesn't manage BP....I'm a psychiatrist" at which point I laughed at him and told him he was an idiot for not being able to handle basic hypertension. I told him I could call up a general surgeon who would have enough common sense to handle simple blood pressure maintenance. I said "You may be a psychiatrist...but you're a doctor, right? I know you have basic medical management training otherwise you would have never made it through residency. How on earth did you forget how to take care of some of your patients most basic medical needs? You guys do admission orders and routine medical management for the pt's you admit in residency so don't tell me you don't know how. You just forgot....That's pathetic, Doctor. How sad is it that I have a waiting room full of ER patients with potential emergencies who need a room that your pt will be taking up because you don't know how, or don't care enough to take care of a basic medical problem I could entrust to a 3rd year medical student." He gasped and I hung up on him.

It was a busy day and I was not in a great mood. He called the CMO on me claiming I had denigrated his role as a psychiatrist and insulted him. Luckily, our CMO saw it for what it was and I didn't really get into any trouble for it. These things happen with regularity over there and it drives me crazy. What's sad is that they have an NP working for them that does medical admissions and is trained in psych and works for both departments. How hard would it be to staff your psychiatric evaluation center with one of those NPs if you can't find an MD "comfortable" handling these things or a nurse who can administering medications over there? Grrr, I'm getting steamed just talking about it again.

I told our medical dir to figure out a better policy with psych because what we currently have is ridiculous.

 

[hundreddaysoff]

Love hourly pay when it's slow. One overnight I got paid 3k to see 6 patients. Watched like 4 movies. When the movieatient ratio approaches 1 you know it's an awesome night.

This is literally 30% of all my shifts... $3K to see less than 10 pts and sleep at least 4 hours in our FSEDs. I'm not complaining, mind you. I just keep wondering when HCA is gonna throw down the hammer, realize they're losing money, and close the FSEDs, and I'll be back to being a normal busy 100% main-ER jockey.

 

[GonnaBeADoc2222]

I love you

Yeah, it's ******ed. I refused the pt and told the social workers to have the psychiatrist on call manage the guys BP as we needed the beds for our patients. The psychiatrist calls me all huffing and puffing about how he "doesn't manage BP....I'm a psychiatrist" at which point I laughed at him and told him he was an idiot for not being able to handle basic hypertension. I told him I could call up a general surgeon who would have enough common sense to handle simple blood pressure maintenance. I said "You may be a psychiatrist...but you're a doctor, right? I know you have basic medical management training otherwise you would have never made it through residency. How on earth did you forget how to take care of some of your patients most basic medical needs? You guys do admission orders and routine medical management for the pt's you admit in residency so don't tell me you don't know how. You just forgot....That's pathetic, Doctor. How sad is it that I have a waiting room full of ER patients with potential emergencies who need a room that your pt will be taking up because you don't know how, or don't care enough to take care of a basic medical problem I could entrust to a 3rd year medical student." He gasped and I hung up on him.

It was a busy day and I was not in a great mood. He called the CMO on me claiming I had denigrated his role as a psychiatrist and insulted him. Luckily, our CMO saw it for what it was and I didn't really get into any trouble for it. These things happen with regularity over there and it drives me crazy. What's sad is that they have an NP working for them that does medical admissions and is trained in psych and works for both departments. How hard would it be to staff your psychiatric evaluation center with one of those NPs if you can't find an MD "comfortable" handling these things or a nurse who can administering medications over there? Grrr, I'm getting steamed just talking about it again.

I told our medical dir to figure out a better policy with psych because what we currently have is ridiculous.

 

[GonnaBeADoc2222]

This is literally 30% of all my shifts... $3K to see less than 10 pts and sleep at least 4 hours in our FSEDs. I'm not complaining, mind you. I just keep wondering when HCA is gonna throw down the hammer, realize they're losing money, and close the FSEDs, and I'll be back to being a normal busy 100% main-ER jockey.

These shifts are nice.the problem is, if you work too many of these, I think your skills will definitely start to degrade.

 

[Merely]

Yeah, we get this sort of thing when we d/c our patients to psych down the hall. We have to put "medically cleared and clinically sober" or they won't take them.

What's even more frustrating is that the psychiatrists on call over there have apparently forgotten 100% of their basic medicine and the social workers will send the pt back over to the ED 8 hours later for elevated BP because nobody administered the pt's daily anti-HTN meds.

Yeah, it's ******ed. I refused the pt and told the social workers to have the psychiatrist on call manage the guys BP as we needed the beds for our patients. The psychiatrist calls me all huffing and puffing about how he "doesn't manage BP....I'm a psychiatrist" at which point I laughed at him and told him he was an idiot for not being able to handle basic hypertension. I told him I could call up a general surgeon who would have enough common sense to handle simple blood pressure maintenance. I said "You may be a psychiatrist...but you're a doctor, right? I know you have basic medical management training otherwise you would have never made it through residency. How on earth did you forget how to take care of some of your patients most basic medical needs? You guys do admission orders and routine medical management for the pt's you admit in residency so don't tell me you don't know how. You just forgot....That's pathetic, Doctor. How sad is it that I have a waiting room full of ER patients with potential emergencies who need a room that your pt will be taking up because you don't know how, or don't care enough to take care of a basic medical problem I could entrust to a 3rd year medical student." He gasped and I hung up on him.

It was a busy day and I was not in a great mood. He called the CMO on me claiming I had denigrated his role as a psychiatrist and insulted him. Luckily, our CMO saw it for what it was and I didn't really get into any trouble for it. These things happen with regularity over there and it drives me crazy. What's sad is that they have an NP working for them that does medical admissions and is trained in psych and works for both departments. How hard would it be to staff your psychiatric evaluation center with one of those NPs if you can't find an MD "comfortable" handling these things or a nurse who can administering medications over there? Grrr, I'm getting steamed just talking about it again.

I told our medical dir to figure out a better policy with psych because what we currently have is ridiculous.

The psychiatrist hasn’t managed blood pressure in probably 15 years so I don’t blame him for punting the patient back to you so if anything goes wrong the liability is on you because he could argue it’s outside his scope

 

[GeneralVeers]

The psychiatrist hasn’t managed blood pressure in probably 15 years so I don’t blame him for punting the patient back to you so if anything goes wrong the liability is on you because he could argue it’s outside his scope

I don't manage blood pressure either. The psychiatrists should be sending these people to a primary care doctor's office.

 

[Groove]

The psychiatrist hasn’t managed blood pressure in probably 15 years so I don’t blame him for punting the patient back to you so if anything goes wrong the liability is on you because he could argue it’s outside his scope

Who's fault is that? They certainly learn how to do it in residency. If psychiatrists want to give up everything that made them an MD in the first place in order to focus purely on psychiatry, then they really have no business requiring an MD degree for the profession. When you can't treat a skin abrasion or administer a person's daily HTN meds or know how to order sliding scale insulin for a diabetic and feel the need to order a medicine consult for all of the above...you really have no business being a doctor anymore. Move over and let the psychologists take over the profession if that's going the be the case.

I just have such a low opinion of a doctor who sends over a pt with asymptomatic hypertension for me to simply administer his daily anti-hypertensive meds and then send him back simply because he feigns ignorance on how to treat said condition. He wants to take up an emergency room bed for that? Disgusting.

 

[RustedFox]

...then they really have no business requiring an MD degree for the profession. When you can't treat a skin abrasion or administer a person's daily HTN meds or know how to order sliding scale insulin for a diabetic and feel the need to order a medicine consult for all of the above...you really have no business being a doctor anymore. Move over and let the psychologists take over the profession if that's going the be the case.

I have also thought about this sooo many times.