EMTALA requires hospitals to provide an appropriate medical screening examination (MSE) to any

person requesting emergency treatment or an examination for a specific medical condition. EMTALA
obligation begins, therefore, when a patient presents at a hospital's Emergency Department and any
of the following occurs:

 The patient requests examination or treatment for a medical condition

 Someone accompanying the patient makes the request on behalf of the patient

 In the eyes of a prudent layperson, the patient appears to have a medical condition requiring
an MSE and possible subsequent care

EMTALA defines a dedicated Emergency Department (DED) as any department or

facility of the hospital, regardless of whether it is located on or off the main hospital
campus, that meets at least one of the following requirements:

 It is licensed by the state in which it is located, under applicable state law, as an

Emergency Room or Emergency Department

 It is held out to the public - by name, posted signs, advertising or other means -
as a place that provides care for emergency medical conditions on an urgent
basis without requiring a previously scheduled appointment

 At least one-third of outpatient visits were for emergency medical conditions

without scheduled appointments in the previous calendar year

EMTALA's clinical and administrative requirements can extend to hospital departments,

such as Labor and Delivery, a Psychiatric Unit or any other department, if it meets one
of the three definitions for a DED. Most hospital Labor and Delivery Departments fit this
criteria.

If an individual comes to a hospital-owned facility or department, which is off-campus and operates

under the hospital's Medicare provider number, EMTALA will not apply to that facility or department
unless it meets the definition of a DED.

Should such a department or facility not meet the definition of a DED, it still must screen and
stabilize the patient to the best of its ability or execute an appropriate transfer if necessary to another
hospital or to the hospital on whose Medicare provider number it is operated. There is also no
obligation to be staffed to handle emergency medical conditions.

The EMTALA law applies to any area of the hospital campus within 250 yards of the main hospital
building.

It does not include nonmedical businesses close to the hospital, such as shops and restaurants or
physician offices that have a separate Medicare provider number from the hospital.

Which patients are covered under EMTALA? Any patient who:

  Presents to a hospital Emergency Department or an off-campus dedicated Emergency
Department operating under the hospital's Medicare provider number for an examination or
treatment of a medical condition

 Presents either to the Emergency Department or the Labor and Delivery Department of a
hospital having contractions

 Is on the hospital campus and requests or needs an examination or treatment for what may
be an emergency medical condition
 Medical emergencies may happen in areas of the hospital that are not equipped for handling
them. For example, you may be in a nonclinical area of your hospital, such as a hallway, an
entrance or an administrative office, when an individual says that he or she has an
emergency or exhibits signs of an emergency.
 When a medical emergency occurs in areas that are not dedicated Emergency Departments,
call the appropriate code according to your hospital's policies to alert the Rapid Response
Team immediately. This is a widely recognized best practice. It enables a First Responder
Team to arrive quickly and transport the patient to the appropriate dedicated Emergency
Department in a timely manner.
 Posting the number to call and the appropriate code(s) to alert the Rapid Response Team in
nonclinical as well as clinical areas of the hospital is another best practice.
 EMTALA obligations end when a patient is stable and well enough for release from the
dedicated Emergency Department or the patient is admitted for inpatient care.
 An inpatient is defined as a person who has been admitted to a hospital for purposes of
receiving care. A person being kept for observation in a dedicated Emergency Department is
not an inpatient.
 Inpatient status does include admitted patients who are boarded in the Emergency
Department waiting for a hospital bed that is anticipated to become available.

Emergency Department (ED) employees and physicians have responsibilities under EMTALA.
Examples of ED employees with EMTALA responsibilities include registration staff, nurses, applied
practice nurses, medical students or physicians.

Federal regulations require EDs to post signage conspicuously in hospital public entrances, as well
as waiting, treatment and registration areas of the ED to inform individuals of their rights under
EMTALA. Signage must also state if the facility does or does not participate in Medicaid.

Signage at entrances must be visible from a distance of twenty feet and also be posted in any
dominant foreign language spoken by a sizeable population treated by the facility.

The hospital's responsibility includes periodically reevaluating the signage effectiveness and
modifying signage that is not effective in notifying individuals of their rights under EMTALA.

EMTALA also requires EDs to maintain a physician on-call list and central log of all patients who
come to the hospital seeking care for a medical condition in the ED and in Labor and Delivery. The
on-call list and central log must be maintained for at least five years – longer if required by state law.

Likewise, records of transfers must be maintained for at least five years – longer if required by state
law.
Documentation of the performance of a medical screening examination (MSE) for each presenting
patient is required.

Under EMTALA, an MSE is the process required to reach, with reasonable clinical confidence, a
determination as to whether the patient has an emergency medical condition (EMC) or not.

Any patient who comes to the hospital and requests emergency care must receive an MSE. Also,
patients who come to the Emergency Department and request medical care, whether for an
emergency or not, must receive an MSE.

Depending on the patient's presenting signs and symptoms, an MSE may involve a wide spectrum of
actions. The MSE could be a simple process involving only a brief history and physical examination.
It could also be a complex process that involves performing ancillary studies and procedures, such
as, but not limited to, lumbar punctures, clinical laboratory tests, CT scans and/or other diagnostic
tests and procedures.

Although triage may be the beginning of an MSE, triage is not an MSE under EMTALA.

An MSE must be provided regardless of the patient's ability to pay, source of payment, diagnosis,
race, color, national origin or disability.

Only a physician or appropriately credentialed health professional may perform an MSE. An

appropriately credentialed health professional is an individual whose state license includes
performing MSEs as part of his or her scope of practice.

Other important provisions of EMTALA are:

 Emergency Department physicians can contact a patient's regular physician at any time for
information relevant to treating the patient, as long as the phone call does not inappropriately
delay services

 Hospitals can have a reasonable registration process — including asking whether the patient
is insured — as long as it does not delay the medical screening exam and stabilizing
treatment

 If pre-authorization is part of the reasonable registration process and the insurer denies
authorization for the stabilizing treatment, the hospital is still obligated under EMTALA to
provide the necessary stabilizing treatment if it has the necessary capabilities

The following types of vulnerable patients should not leave the hospital Emergency Department (ED)
unless authorized by an appropriate party:

 Non-emancipated minors without consent of parents or legal guardians

 Patients lacking capacity to understand their medical conditions

 Patients who are a danger to self or others

If one of these types of patients attempts to leave, ED staff should notify hospital security
immediately upon discovery.
For all other patients, if one leaves the ED before the medical screening examination (MSE) without
informing ED staff, they must document that the patient walked out and attempt to contact the
patient.

If a patient refuses initiation of an MSE and treatment and informs staff, a triage nurse must

 Inform the patient of the risks of leaving and the benefits of receiving the MSE and treatment

 Encourage the patient to stay

If the patient still refuses the MSE and treatment, the triage nurse must

 Document the patient's informed refusal in the medical record

 Request that the patient sign a refusal of care form

Patient refusal to sign the form must be documented in the medical record.

The triage nurse must also notify the charge nurse or other staff member designated by the
organization.

If a patient refuses completion of an MSE and treatment and wishes to leave against medical advice
(AMA), an ED nurse or physician must inform the patient of his or her right to have the full MSE,
risks of leaving without the full MSE and benefits of receiving the full MSE. The nurse or physician
must encourage the patient to stay.

The ED nurse or physician must document in the medical record that the patient was informed of
specific benefits of obtaining a full MSE and specific risks in leaving before the MSE was completed.
Each of the specific risks must be documented.

The nurse or physician must ask the patient to sign a refusal of medical care statement in the
medical record. The person obtaining the patient's signature must sign as a witness in the medical
record. Patient refusal to sign the statement must be documented in the medical record.

Generally, the transfer of a patient to another hospital may only occur after the patient's medical
condition has been stabilized, and only when your hospital does not have the capability and capacity
to provide the best medical or surgical care for the patient.

Stabilizing a patient means providing the medical treatment of the condition that is necessary to
ensure, within reasonable medical probability, that no material deterioration of the condition is likely
to result from, or occur during, the transfer of the patient from your hospital to another facility. In the
case of a pregnant woman having contractions, the medical condition is considered stabilized when
both the neonate and placenta have been delivered.

The term capability means that a hospital has the physical space, equipment, supplies and service -
for example, trauma care, surgery, intensive care, pediatrics, obstetrics or neonatal unit - needed. It
also means the level of care that the staff can provide is within the training and scope of their
profession.
The term capacity means the ability of a hospital to accommodate the patient, including the
availability of qualified staff, beds and necessary equipment.

A transfer of a patient with an emergency medical condition that has not been stabilized
may only occur if your hospital does not have the capability and capacity to stabilize the
patient, or the patient requests the transfer.

For example, if a patient with a severe burn presents at your Emergency Department
(ED) and your hospital does not have a burn unit, it is appropriate to transfer the patient
to a hospital with a burn unit. Your ED is required to stabilize the patient before the
transfer only if it has the capability and capacity to do so.

A patient may request a transfer to another hospital whether or not his or her medical
condition is stable. Thorough documentation of the patient's request for, and consent to,
the transfer is necessary to support that it was a valid transfer under EMTALA.

If the patient is able, obtain his or her signature consenting to the transfer. Otherwise,
obtain physician certification outlining the risks and benefits of the transfer. Physician
certification is especially important if the patient is unstable for discharge.

The following are steps to take when transferring a patient to another hospital:

 Provide medical treatment within the capability and capacity of your hospital to minimize the
risks to the patient

 Obtain agreement from the receiving facility that it has the capability and capacity to receive
the patient and it is willing to accept the transfer

 Use qualified personnel and transportation equipment to effect a safe transfer

 Send a copy of the MEDICAL RECORDS with the patient to the receiving facility

Select the bold, capitalized words for more information about medical records to send with the
patient.

Medical Records to Send with the Patient

The medical records that should accompany the patient include:

 The medical record, including an Advanced Directive if it is in the possession of your hospital
 A written request for and consent to the transfer, or physician certification
 Certification outlining the risks and benefits of the transfer if the patient is unstable for
discharge
 Patients presenting to the ED with psychiatric illnesses should receive a medical screening
examination (MSE). Once medically cleared, either admit the patient to a psychiatric unit of
your hospital or transfer the patient to an appropriate psychiatric facility.
  If a psychiatric illness is diagnosed, but the patient's condition makes a transfer impossible or
there is no bed available at an appropriate facility, monitor the patient continuously in the ED
until an accepting facility can be found.
 Document all attempts, successful and unsuccessful, at getting the patient transferred to an
appropriate psychiatric facility.
 Your hospital has a duty to accept transfers if it has: 1) the specialized capability that the
patient requires, and 2) the capacity to accept the patient's transfer.
 A transfer must be accepted regardless of the patient's ability to pay, source of payment,
race, age, religion, diagnosis or disability. In other words, no form of discrimination is allowed
in the transfer acceptance decision-making.
 A transfer cannot be refused based on a patient's instability or stability. If there is
disagreement between the physicians in the two hospitals, the receiving physician should
defer to the medical judgment of the transferring physician to avoid any appearance of an
EMTALA violation.

You have a duty to report suspected EMTALA violations to your Compliance Department.

If you believe a patient's transfer to another facility is in violation of EMTALA, you must report it.

If you believe your hospital has received a patient's transfer from another hospital in violation of
EMTALA, you must report it.

If you believe your hospital has denied a patient's transfer from another hospital in violation of
EMTALA, you must report it.

Under no circumstances will any adverse action be taken against a physician, or other qualified
medical personnel, who refuses to transfer a patient with an emergency medical condition based on
a belief that the transfer would violate EMTALA.

In addition, under no circumstances will any adverse action be taken against an employee who
reports a suspected violation of the EMTALA requirements.

The Office of Inspector General (OIG) - the enforcement arm of the Department of Health and
Human Services - provides Congress with a semi-annual report on enforcement activities. The
report includes actions taken against EMTALA violators.

A recent case involved a major west coast hospital that paid a $40,750 fine for an EMTALA violation.
The hospital failed to provide an appropriate medical screening examination to a patient who
presented to the Emergency Department with severe abdominal pain and symptoms. After waiting
for more than six hours, the patient elected to leave and seek care at another hospital where he was
diagnosed with acute appendicitis and a large peritoneal abscess, requiring an immediate
appendectomy.

Another example involved a southeastern hospital that entered into a $45,000 settlement
agreement with the OIG for an EMTALA violation. This troubling case concerned a 3-week-old
baby whose parents brought it to the Emergency Department due to a low oral temperature of 91,
blue lips, a body that felt cold and poor eating.
The Emergency Department staff failed to address the low temperature, did no further testing
and deemed the baby stable. On the way home, however, the baby became unresponsive and
required critical care at a second hospital for necrotic bowel, which led to cardiac arrest, kidney
injury and potential hypoxic brain injury.

Violations of EMTALA are subject to a variety of penalties:

 Both hospital and individual physicians can be fined

 Termination from Medicare and Medicaid participation

 Potential lawsuit for civil damages

 Potential civil rights violations

 Publication of the violation and other penalties

 A recent study of EMTALA investigations concluded the majority of settlements were for
failing to provide medical screening examinations and stabilization.
 According to the study, the primary reason for patient dumping was due to a patient's level of
insurance coverage or financial status and ability to pay.

 The Privacy Rule became effective April 14, 2003, and the Security Rule became effective
April 21, 2005. Since these dates, both rules have been amended and strengthened several
times.
 You may have heard of the Enforcement Rule, the Omnibus Rule, the HITECH Act or
the Breach Notification Rule, all of which were additions to clarify or modify the original
Privacy and Security Rules.
 The purpose of the Privacy and Security Rules is to provide guidelines for keeping protected
health information (PHI) confidential. The Rules also provide guidance regarding disciplinary
actions that could be imposed for those who fail to keep patient information confidential.

Having an understanding of the requirements for protecting patient information will assist you in

 Complying with your organization's privacy and information security related policies and
procedures

 Protecting patient information

 Recognizing your duty in reporting potential privacy or security breach incidents

 HIPAA's Privacy and Security Rules have been in place for more than a decade, and no
doubt there are few who have never heard of HIPAA.
 Most people would say they have a general idea of what HIPAA means, probably something
like, "keeping medical records confidential;" however, many of the details regarding the
actual requirements of the Privacy and Security Rules remain unknown to most.
 Let's learn what several healthcare workforce members have to say about their individual
roles in Privacy and Information Security.
 ETHAN (LABORATORY TECH): Hi, I'm Ethan from the Lab. I see all types of sensitive
patient results but must always remember the Minimum Necessary requirements.


 OLIVIA (ENVIRONMENTAL SERVICES TECH): Olivia here, from
Environmental Services. No matter how famous the patient, I must keep it to myself – I
can't tell anyone!
 ISABELLA (STAFF NURSE): Hello, I'm Isabella – a staff nurse. I have to constantly remind
myself to log out when I walk away from the electronic medical record to keep it safe from
prying eyes.
 LILY (BILLING CLERK): Oh hi, I'm Lily from Billing. Do I really know who is on the other end
of the phone when I get a call asking for patient information?
 NADIA (NUTRITION SERVICES TECH): Nadia here, from Nutrition Services. I have to be
so careful that the paperwork on the patient tray doesn't end up in the trash. There's PHI on
here!
 DANIEL (RECEPTION CLERK): I'm Daniel, one of the clerks here. I must remember to
check the directory carefully before responding to anyone about a patient. Patients have a
right to total confidentiality.
 SIENNA (IMAGING SERVICES TECH): Hello! I'm Sienna from Imaging Services. No matter
what I see in an X-ray, I must maintain the patient's privacy.
 DOCTOR VEENA PATEL (PLASTIC SURGEON): Hi folks. Around here they call me Doc
Patel. I have to constantly remind myself that the patient may not want his or her family or
visitors to hear our conversations. It's the patient's choice, and I must ask before every
disclosure.
 DOCTOR VEENA PATEL (PLASTIC SURGEON): Hi folks. Around here they call me Doc
Patel. I have to constantly remind myself that the patient may not want his or her family or
visitors to hear our conversations. It's the patient's choice, and I must ask before every
disclosure.
 ZANDER (CASE MANAGEMENT MANAGER): Oh hi, I'm Zander from Case Management.
Sending patient information by email is common practice for me, but I must remember to
send it encrypted.
 DEBI (PRIVACY OFFICER): My name is Debi, and I am a Privacy Officer. What you have
just learned from these workforce members is a fraction of what everyone must know
regarding their roles in the privacy and security of patient information. It is important to take
these HIPAA courses seriously. We are depending on you!
 Rarely a day goes by that a violation or breach of an individual's protected health
information does not show up in the news, and that breach typically involves thousands of
individuals – not just one.
 How can such breaches occur with HIPAA laws in place?
 Unfortunately, the lack of workforce awareness continues to rank number one when it
comes to threats to health data privacy and security.
 As you explore these HIPAA-related courses and the examples of protected health
information, think of the information as your own.
 How would you want your own health information treated? Perhaps, think about the old
saying, "Do unto others as you would have them do unto you."
 If you are exposed to protected health information in your job, treat that information with
respect, just as you would treat the owner of that information – the patient. Treat protected
health information as if it were your own.
DR. MARK BALDWIN (EMPLOYED PHYSICIAN): Oh, hi Elaine! Thanks for your help with the
patient in 4052. Sure feels good to be doing what I've spent years training for! I just want to get my
patients back to their real lives – oh, and by the way, Mrs. Berry should be going home soon.

ELAINE NEWTON (NURSE MANAGER): Well, that's good news – she'll be glad to get out of here.
Yes, it must be good to finally be on this side of the fence – no longer a resident, but now a real
practicing professional!

DR. MARK BALDWIN: Umm… Elaine, I'm looking at a reminder email that just popped up \u2013
says I need to finish my compliance training?

I thought we went through this in orientation?

ELAINE NEWTON: Well, you likely got an introduction to it, but the laws governing health care are
complicated so additional compliance training is required for all new employees. We sure don't want
to end up in trouble and in the news like Marcus Medical!

I'm guessing you've heard about their multi-million dollar fine and now they have a Corporate
Integrity Agreement with the government? It's big news - not to mention the damage to their
reputation.

The primary purpose of documentation is to support the provision of high quality care for your
patients. Documentation facilitates the communication of information among the many different
healthcare professionals and entities that may encounter a patient along the continuum of care.
Additionally, revenues are directly impacted since coding, and subsequently billing and
reimbursement, are highly dependent upon the practitioner's documentation in the medical record.
In an outpatient setting, evaluation and management (E/M) services are the most common category
of services provided. They refer to visits with, and consultations by, physicians. Medical record
documentation for E/M services must be anchored by three key components: problem-focused
history, problem-focused physical examination and medical decision-making.

Your coder, billing specialist or contracted coding source relies upon your documentation to assign
an E/M code that accurately reflects the level of complexity of the patient's problem and the
service(s) you provided. It is important, therefore, to remember the old adage, "If it wasn't
documented, it wasn't done."

Let's review each of these three components in further detail.

Documentation begins with obtaining the patient's medical history. A history should include the chief
complaint (CC), history of the present illness, review of systems and the patient's past, family and/or
social history. The amount of information collected in the history will depend upon the complexity of
the patient's complaint and your clinical judgment.

The history of present illness (HPI) includes the following elements:

 Anatomical location

 Quality - for example, a description of the discomfort

 Severity - on a 1 to 10 scale
  Duration

 Timing or frequency

 How it occurred

 Modifying actions, such as "improves with ibuprofen"

 Signs and symptoms

The number of bullet points documented in the history affects the level of service that can be billed.

A review of systems (ROS) is an inventory of body systems obtained by questioning the patient
about his or her symptoms. The fourteen recognized symptom areas are:

 Constitutional symptoms such as fever or weight loss

 Eyes

 Ears, nose, mouth and throat

 Cardiovascular

 Respiratory

 Gastrointestinal

 Genitourinary

 Musculoskeletal

 Integumentary

 Neurological

 Psychiatric

 Endocrine

 Hematologic and/or lymphatic

 Allergic and/or immunologic

 The past, family and/or social history (PFSH) is another important component in the overall
patient history. The PFSH consists of a patient's past medical history with illnesses,
surgeries, injuries and treatments. It includes the patient's family history, such as diseases or
hereditary conditions, and the patient's social history. An age-appropriate review of past and
current relevant activities, such as the use of tobacco or alcohol, is also included.
 For the physical examination, the physician or other healthcare professional must document
either a general multisystem or a single-organ system examination. The extent of the
 examination is based upon the history, nature of the problem and physician's or other
healthcare professional's clinical judgment.
 In an effort to reduce the burden of duplicative documentation by providers, The Centers for
Medicare and Medicaid Services (CMS) has relaxed the rules for recording E/M services.
These rules went into effect January 1, 2019.
 For established patients in an office or outpatient setting, when relevant information is
already noted in the medical record, practitioners may choose to focus their documentation
on what is new or changed since the last visit. Or, they may focus on relevant items that
have not changed. Practitioners need not rewrite the list of required elements if there is
evidence it was already reviewed and updated. However, there is still a need to review prior
data, update it as necessary and note in the record that they have done so.
 For E/M office or outpatient visits for new and established patients, practitioners will not be
required to reenter the patient's chief complaint and history if it has been previously
documented by ancillary staff or the patient. However, the practitioner will need to document
that such information was reviewed and verified.
 healthcare professionals to recall prior findings and actions relating to the patient. Rather,
documentation works to support the rationale for the decisions made by the physician or
other healthcare professional. Such documentation should include the number of diagnoses
and management options available, the amount and/or complexity of the data to be reviewed
and the risk of complications and/or morbidity or mortality.
 In the treatment plan, notate orders for each diagnostic test or study and indicate the location
where these are to be performed. Any need for additional diagnostics may support a higher
level of medical complexity. It is also important to note the patient's capacity to participate in
their own care in the treatment plan.
 Finally, ensure that medical necessity for your treatment plan is clearly evident with the use
of clarity and specificity in your documentation, and avoid the use of cryptic notations.
 For example, do not use "pain" alone for a diagnosis. Rather, note whether it is dull, sharp,
or throbbing, where it is located, the conditions surrounding onset, duration, the rating on an
intensity scale of one to ten, how and when the pain is exacerbated, and any other pertinent
symptoms to support medical decision-making.
 The hospital is often a physician's and other healthcare professional's partner in caring for
his or her patients. And, yet, many physicians and healthcare professionals do not realize, or
fully appreciate, the impact their hospital record documentation has on the hospital's ability to
comply with CMS' coding and billing requirements.
 Accurate and complete documentation that supports legitimate hospital billing is actually not
difficult but may require more time to meet specificity requirements. The benefit to the
physician and healthcare professional is that the same documentation that supports hospital
billing also supports his or her billing. Nowhere is this mutual benefit more evident than in
documenting the correct patient status through hospital record documentation.
 Additionally, accurate and complete documentation helps to ensure that the patient receives
his or her appropriate insurance or CMS benefit. If documentation is not appropriate, the
patient may have additional out-of-pocket expenses.
 CMS implemented the two-midnight rule for inpatient admissions. That is, a patient could not
be formally admitted unless the admitting physician expects the stay to span two midnights.
Since then, the rule has been eased to allow shorter stays in certain circumstances.
 Medicare maintains the two-midnight benchmark for inpatient coverage and that admission is
supported by documentation as reasonable and necessary. However, certain stays of less
than two midnights may be covered on a case-by-case basis on the judgment of the
admitting physician and supporting documentation.
 Because CMS continues to target short stays for review, physicians should be mindful in
their documentation of the inclusion of evidence for medical severity, adverse consequences
 and the need for diagnostic studies that may be more appropriately conducted in an
outpatient setting.
 Documentation is effective when it includes the five Ws – Who, What, When, Where and
Why. That is, who performed the service, what service was performed, where the service
was provided, when it was provided and why the service was medically necessary.
 The documentation should reflect that professional standards of care were met and that the
care was provided in an appropriate level of care setting.
 It may be necessary to also indicate that specific guidelines or protocols were followed.
 We believe in the pursuit of excellence in education, research, patient care, and community
service with integrity, ethical behavior and respect for all.
 We take pride in the dedication and commitment of our compassionate healthcare providers,
talented educators, internationally recognized researchers and hard-working staff who make
countless contributions at RBHS everyday.
 We value humanism and compassion for all people.
 We are committed to working collaboratively with our University colleagues, partners and
communities to fulfill our Mission.
 In all aspects of University life we will foster professionalism, fairness, honesty, sincerity,
collegiality and an open exchange of ideas. We will ensure high standards that will nurture
faculty, students and staff in a vibrant environment.
 As a statewide asset, we embrace our responsibility to the people of New Jersey.

COURSE MENU
 The Code of Conduct is an expression of our shared commitment to the university
mission of providing for the instructional needs of New Jersey's citizens, conducting
cutting-edge research, and performing public service.
 Rutgers is dedicated to teaching that meets the highest standards of excellence, to
conducting research that breaks new ground, and to providing services, solutions,
and clinical care that help individuals and the local, national, and global
communities where they live.
 These principles comprise our core values. They express our commitment to ethical
conduct and adherence with laws, regulations and policies. All of us are accountable for
putting these core values into action on a daily basis between one another, with our
patients, and for our communities.
 We will continue to do the right things daily, and ask that you use our Code of Conduct
as both a roadmap AND a gauge of our success.
 We are all RESPONSIBLE for reading, understanding and complying with the Code of
Ethics: General Conduct, as well as other rules, policies, procedures and regulations
that affect our jobs.
 Questions about the Code of Ethics: General Conduct may be directed to the University
Ethics Office.

The Code of Ethics: General Conduct is intended to:

 Convey expectations of workplace behavior to the Rutgers community

 Highlight Rutgers' commitment to compliance with laws, regulations, contractual obligations

and standards of care consistent with community standards
  Familiarize all staff, faculty, researchers, scientists, students, vendors, volunteers with the
basic legal principles and ethical standards of behavior expected throughout the university
 The Code of Ethics: General Conduct is the Rutgers commitment to acting with honesty and
truthfulness in all our interactions with patients, employees, the medical staff, our volunteers,
vendors, the government, and members of the communities we serve.
We must all:

 Know the rules which apply to our jobs

 Follow them at all times

 Speak up when we become aware of an ethical / compliance issue

The strength of the individual is in the choices he or she makes.

When in doubt, SPEAK UP!

Reporting Resources include:

 Supervisor

 School/Unit Compliance Officer

 Ethics Compliance Hotline 1-800-215-9664