Appropriate Use of the Emergency Room 101

first-aid-1146983_960_720Have you recently been to the ER? What for? If you faced a true medical emergency, then you used the emergency room resource appropriately.

The list below will show a number of appropriate reasons for visiting the Emergency Department.

Please note: If you are in an emergency, call 911. You should call your PCP, a nurse hotline if you need medical advice. This article is not meant to be used as a means to diagnose any medical condition – only a qualified medical practitioner, such as a doctor, can help you to determine this. This article gives loose examples of situations that may warrant a visit to the ER: please use your best judgement in your prudent lay understanding of health and medicine.


Open Wounds & Active Bleeding

Did you get an open wound injury? Are you actively bleeding?


Allergic Reaction

Did you eat something that you shouldn’t have? If you have swelling, hives, or any other allergic reaction to the food you ate or some other element, it’s a good bet you should go to the ER.


Sudden Illness

Did you suddenly feel dizzy or short of breath at school or work? Sudden onset illness can be an indicator of a more serious condition.


Altered Behaviour

Are you or someone acting very strangely from their normal behaviour? For example: slurring words, unable to speak coherently or at all. It could be a sign of something more serious.


Abuse & Assault

If you have been assaulted or abused, please go to the ER immediately.


Threats of Abuse

If you are being threatened with physical or sexual abuse, call 911 or go to a police station.


Sports Injuries and Motor Vehicle Accidents

Were you in a sports related incident? Were you in a car accident? These are all reasons to go to the emergency room for a checkup for broken bones and other injuries. Even if you feel fine right after the incident, it’s good to go to the ER for a checkup. People who don’t go to the ER immediately can sometimes exhibit more post-accident conditions days later and so should also go to the ER.

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Anyone who is going through a cataleptic event or just did should go to the ER for a checkup as soon as possible. During a seizure a person can get further injuries that can and should be prevented.


Sudden and/or Severe Headache

A headache may not seem like an emergency to some, but they can be dangerous to people operating a car. If you are experiencing a very severe headache (worst in your life-type), then you should go to the ER. Sudden onset headaches are also serious and should be checked on by a doctor. If a headache has been moderate but chronic, spanning weeks and alternating in intensity – this could also warrant a visit to the ER and followed up with your PCP.


Torn Stitches and Medical Devices

Any stitches that have torn or medical devices that have been dislodged? You should be brought to the ER where a doctor or nurse can assist.


Severe Burns

If you have a severe burn, please go to the ER immediately.


Foreign Object

Children who have swallowed marbles, pennies and any kind of foreign object should go to the ER. Adults who have a foreign object should also go to the ER for help.


Severe Constipation / Urinary Issues

If your body isn’t working the way it should and you’re feeling heavy and ill from not being able to go to the bathroom, this is a very severe condition needing emergency attention.


Abnormal Bleeding

Ladies who have severe bleeding that is out of the ordinary for them, or any other urinary dysfunction.


Illness in Infant or Premature Infant

If your baby is ill and you have no other means to get health care, it is okay to bring your baby in. Premature infants should especially be brought in as they may be more susceptible to illness.


Unwitnessed Falls (Infants and Elderly)

Any fall or other injury that may or may not have occurred out of the sight of the parents or caregivers should be brought to the ER.



If you are very ill and continue to vomit without getting better, it is time to see the ER.


Severe Abdominal Pain – Stomach Pain

If you are experiencing severe sharp pains in your stomach region, then it is worth checking it out at the ER. Sometimes it can be the stomach flu, but it is worth checking.

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Anyone experiencing numbness of limbs, vision loss or alteration of vision, loss of feeling should go to the ER.


Severe Withdrawal

If you are addicted to any drug that is causing painful withdrawal, you should go to the ER for assistance. They may be able to redirect you to resources or help you there.


Chronic Conditions Exacerbated

Anyone with a chronic condition that has suddenly worsened should go to the emergency department for care. Whether that’s back pain or a recent rash, if it has gotten worse – go.


Self Harm

Anyone causing or considering causing injury to themselves should come to get care at the ER. They will be able to provide assistance and protection to you.


Shortness of Breath, Faintness and Dizziness

An alteration to your breathing, such as shortness of breath, faintness, fainting, dizziness and giddiness all need to go to the ER. They can be symptoms of a more serious condition.



The list above has broadly illustrated a set of situations where it may be appropriate to visit the Emergency Department. However, there are many more cases where you should go to the ER. How can you tell if it is a true emergency? Make your best judgement of the situation and get care. If you aren’t sure you may need medical advice – your PCP may have their line available, give them a call. Another option is a nurse hotline, where a certified trained nurse can help determine if you need to go to the ER right away.

Please use your best judgement in your prudent lay understanding of health and medicine.

  • “Would I suffer loss of life or limb if I didn’t go to the ER?”
  • Seek medical advice from a qualified medical practitioner, a doctor or nurse for example.
  • Call a nurse hotline if needing advice.
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What is a Prudent Lay Person?


A Prudent Lay Person (or Layperson, abbreviated PLP) is a standard for deciding if an Emergency Room visit is necessary and presenting condition(s) of the patient reasonably warrant immediate attention.

The standard defines an emergency as a condition that a prudent lay person, “who possesses an average knowledge of health and medicine” expects, may result in:

1. Serious medical harm, or:

2. Serious impairment of bodily function, or:

3: Serious dysfunction of any bodily organ.

Prudent Layperson standard laws were “spurred by incidents of patients with genuine acute illness who delayed care for fear of being stuck with the hospital bill, said John C. Nelson, MD, president-elect of the American Medical Association.” (



In some states like Oregon, there is a profession called the Prudent Lay Reviewer or Prudent Person, created for the evaluation of Emergency Room claims based on the PLP standard. It is a health insurance occupation.

The Prudent Lay reviewer “possesses an average knowledge of health and medicine” fulfilling the Prudent Layperson standard (McGraw-Hill Concise Dictionary of Modern Medicine, 2002). Their average knowledge helps them to apply the Prudent Lay Standard to ER claims payment decisions.

The prudent lay profession is uncommon. Certain state(s) employ the prudent lay professional, but many still don’t.
No prudent layperson profession in some states.

Typically Emergency Room claims payment is based on a pairing of CPT codes (99281, 99282, 99283, 99284, 99285) and the Diagnosis code for the ER visit, using partially or fully automated adjudication software. These systems may not perform a comprehensive review of the ER claim based on the Prudent Lay standard, so claims over-payment results due to upcoding and mistakes on the part of the claim-submitting provider.


What does a Prudent Lay Person do?

A Prudent Lay Person (or ‘Prudent Lay Reviewer’) looks over Emergency Department chart notes to determine whether the emergency room visit was a “true medical emergency” requiring full reimbursement by the health insurance company. In almost all cases, the ER claim will be paid some amount.

The PLP reviewer can issue a lesser payment to a health care provider, such as a hospital or ER clinic, if the ER visit was not a true medical emergency (a mild “cough”, a “general health checkup”).

A greater amount can be issued based on the PLP reviewer’s decision, if it is indeed a true medical emergency warranting immediate attention in the Emergency Department (“motor vehicle accident”, “shortness of breath”, “chest pain”, “sudden allergic reaction”).

It is a profession which requires case by case evaluation of ER claims based on documentation of the Emergency Room visit. The documentation provided is used by the reviewer to make a determination on the amount paid on each ER claim.

About payment of ER claims: Health insurance companies are required to pay all ER claims. But in certain states, there is a lesser amount called Pay Triage, or some variation of the term, meaning, “the lesser amount”. This lesser amount may be paid by health insurance companies. There may be different rules in your state.

You can learn more about the term ‘Triage’ here: History of Triage on Wikipedia


How ER Claims are Reviewed by a Prudent Layperson Reviewer

The one element that weighs most heavily on a PLP reviewer’s decision is 1) documentation and 2) the perceived severity of the initial condition from the standpoint of the patient.

Last, the Prudent Layperson reviewer will often ask “Would I, possessing an average knowledge of health and medicine, go into the Emergency Room for this condition?”, in order to make a final ER claims payment decision.


Prudent Lay Review Decisions are based primarily on:

1) Chart notes: The most critical element in a prudent lay review decision is the detailed description of the Emergency Room event found in the History of Present Illness note, a standard description of prior conditions and the patient’s reason(s) for going to the Emergency Room. The initial presenting symptoms are the most important detail weighed by the PL reviewer within the HPI.

2) The initial symptoms and the patient’s perception of the severity of the emergency room visit, as well as their charted behavior.

3) The Prudent Layperson Reviewer’s own best judgement: “Would I, possessing an average knowledge of health and medicine, go into the Emergency Room for this condition?”

Note: Health insurance companies may employ different review structures, however, if the Prudent Lay standard is being used as the template for ER claims reviews, then initial presenting symptoms will be the primary element used on a claims payment determination, wherever the PLP reviewer positions exist.


What kind of decisions do Prudent Layperson Reviewers make?

Full payment of an Emergency Room claim
Partial or Lesser payment of an Emergency Room claim *
Request for additional chart notes from the provider on an Emergency Room claim
Denial of an Emergency Room claim for not meeting one or a set of state requirements, such as timely filing of claim *
* Different state rules: Not all states have the same guidelines and rules.


Why is the Prudent Lay Person Profession necessary?

In certain states, a health insurance company may employ a Prudent Layperson reviewer in order to review the medical necessity of ER visits and issue appropriate payment of ER claims, based on the PLP standard set by State and Federal government, as defined earlier in this article.

Do all states have a Prudent Layperson Reviewer Profession?
No. However, the Prudent Layperson standard itself is widespread and growing in popularity.

In states where the Prudent Lay Person standard is in effect, Emergency Room claims may be reviewed case by case. But this is not always so with health insurance companies.

You can learn all about Prudent Lay Person standard here on PrudentLay.


How do you become a Prudent Layperson?

To be a prudent person, you must possess an average knowledge and understanding of health and medicine. If you are in the medical profession, chances are you have an above average understanding and knowledge of health and medicine which makes you overqualified for a position such as this.

If you wish to apply for a Prudent Layperson position at a local health care company, you can look at websites like or inquire on their hiring or contact page. For other positions, click here.

What happens when a Prudent Layperson exceeds average knowledge of health and medicine?
As soon as a person employed in the review of Emergency Room chart notes has exceeded the average understanding of health and medicine, it is time for them to change positions.

The purpose of the role is that the PLP exercise the same type of judgement (or at least close enough) to an average ER utilizer. When this individual no longer fits the definition, their decision making may become more lenient toward the symptoms, diagnoses, and hospital work-up as noted in the ER chart notes.

However, the PLP profession calls for an evaluation based not on diagnoses or the medical opinion of the physician, but on the initial presenting symptoms of the Emergency Room patient.


Does the Prudent Person Standard save the state money?

Think of this scenario:

Hospitals and clinics bill emergency room codes, called CPT codes 99281 through 99285. These codes are based on the severity of the visit, the 1 being the least urgent and the 5 being the most critical, near fatal event.

When a nurse, nurse practitioner, physician or even a medical assistant writes up the chart notes, they may inadvertently over emphasize the degree of symptoms. Perhaps intentionally they will do so at times.

The medical coding professional will then evaluate the chart notes and determine the severity CPT code. They may assign a level 5 urgency for an event that was actually a mere 2 event.

When the proprietary adjudication system (software that processes ER claims based on a variety of codes and the CPT code) runs a thousand claims through its decision making algorithms, it will not always make the best of decisions.

It may take that 99285 code with more valence than the note within the charts that state the patient was in no acute distress, laughing and enjoying themselves in the ER.

This is where the Prudent Layperson profession comes into play: it would eliminate a good deal of claims that are up-coded unnecessarily and that pay out far more money on a hospital visit than they should.


You may be interested in the following references:

Feature Image Attribution: Mendolus Shank (CC)

Reasons to Go to the ER: Part 1

Why do we go to the ER? For a cold? A cough?

No: The ER is where true medical emergencies are presented by a patient and treated by a skillful emergency medical “pit crew”. Their job is not to be your primary care doctor, it is to save a limb, to treat people who have been in an accident, to save the life of a friend, brother, sister, father and mother. When we misuse the ER for coughs, to get a general health check up, we are using up the resources in our local area that could be used to treat a truly sick person faster. Even with the current process of triaging patients (prioritizing the severity of symptoms in patients and ordering who will get treated in which order), having nurses and other medical personnel tied up with registering non-emergencies makes little sense.

What if, while the ER fills up with non-emergencies, the nurses have to turn someone away who has a deadly and sudden condition? It’s time to pause and call the primary care physician, or locate another option like Urgent Care if it is available; most emergency room visits in the United States are NOT emergencies and a waste of this emergency resource.

The below conditions are considered true emergencies and if you exhibit these conditions, you SHOULD go to the ER.

Severe Headache. On a pain scale, it’s 10/10 – Headaches like this may come with vomiting, hematemesis and other conditions. If you feel it is the worst headache in your life, then you SHOULD go to the ER.
Exacerbation of a Chronic Condition: when a previously diagnosed condition becomes worse, or new symptoms arise. A person with chronic fibromyalgia who develops severe spasms and excruciating pain should go to the ER. A person with increasing numbness in their extremities while undergoing chemotherapy should go the ER. A person who had a mild allergic reaction to a food they ingested now develops increased swelling of the face and arms SHOULD go to the ER.
Severe Medication Side Effects such as shortness of breath, chest pain, loss of vision, hearing and any other side effect that results in bodily dysfunction or damage. A person takes a medication prescribed by their doctor and as their doctor indicated, they experienced one of the side effects which is very severe: chest pain. They SHOULD go to the ER for a side effect that suddenly develops and is severe.
Asthma Attack, Difficulty of Breathing, Shortness of breath. A person unable to breath is in grave danger of losing consciousness – if they are on the road, this can be doubly dangerous. This person SHOULD go to the ER.
Chest pain, pain in left arm or jaw, sudden weakness or dizziness lasting longer than two minutes. May indicate a heart attack or loss of consciousness.

Go to Part 2 of the Series: Reasons to Go to the ER

Photo by Tony Webber (CC)