Manual:
Policy #:
Approval Date:
Effective Date:
Revision Date:
Medical Staff
MS 1.27
August 2013
August 2013
August 2016
OBSERVERS IN PATIENT CARE/PROCEDURE AREAS
See related policy: IC 1.18 Control of Communicable Diseases in Health Care Workers
I.
PURPOSE
To establish guidelines for authorizing observation in patient care/procedure areas of
the Hospital(s) and to ensure that proper supervision and confidentiality issues are
addressed.
II.
SCOPE
This policy applies to all individuals who are invited to observe patient care
connected with performance of medical staff activities in the Hospital(s).
III.
EXCEPTIONS
None
IV.
DEFINITIONS
Observer: Observers are visiting physicians, dentists, researchers, students from
other institutions, including high schools, technicians, and health care professionals
engaged in unpaid activities of an educational or training nature that benefits the
observer. The observer is different from a visitor or volunteer which are governed by
hospital policy. This policy does not apply to visiting medical students who have
been approved by and are the responsibility of the Indiana University School of
Medicine.
V.
POLICY STATEMENTS
A. It is the policy of Indiana University Health (IU Health) to permit authorized
individuals to observe patient care activities as a means of promoting an
environment of teaching and discovery. All such observations must be done
under the sponsorship and supervision of an Active Member of the Medical Staff
at IU Health where the observation will be done. Observers should not participate
or perform any cases normally performed by a health care worker. The
observation must be done in such a way that it does not compromise or interfere
with patient care and that appropriate confidentiality is maintained.
Observers in Patient Care/Procedure Areas
MS 1.27
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B. Observers are prohibited from observing mental health, sexual assault or
communicable disease cases without prior authorization from the Clinical
Director/Co-chief of the service.
C. Observers who have evidence of respiratory infections or communicable disease
will not be allowed to observe.
D. Under no circumstances should children under the age of eighteen be allowed in
patient care areas without prior written consent from parents/guardians and prior
approval from the Clinical Director/Co-Chief of the service.
E. Community media requests for observing must be cleared through and approved
by Media Relations in Marketing.
F. The Observation Agreement and Confidentiality Statement must be completed
and signed prior to any observation experience.
G. The Medical Staff President or his /her designees sign off on observations
requests for more that two (2) days. The Medical Staff President or his/her
designee has the right to decline requests for observers.
H. The Department Director/Manager sign off on observation requests within their
patient care area for less than two days. The Department Director/Manager has
the right to decline requests for observers.
I.
VI.
Observation period may not exceed thirty (30) days.
PROCEDURES
A. Procedure For Observers In Patient Care Areas For More Than Two Days
1. Observers in patient care areas for more than two days must complete and
sign the “Observation Confidentiality Agreement and Release of Liability Form”
(Addendum A) and return to the Medical Staff Office at least seven (7) working
days prior to the guest’s presence in the hospital(s)
2. Observers must wear identification badges obtained from the Medical Staff
Office.
3. A copy of the Observation Confidentiality Agreement and Release of Liability
form will be maintained in the Medical Staff Office.
4. The sponsoring/supervising physician shall notify the appropriate patient care
and/or procedure area that an observer will be accompanying him/her.
B. Procedure For Observers in Patient Care Areas For Less Than Two Days
1. Observers in patient care areas for two days or less must complete and sign
the “Observation Confidentiality Agreement and Release of Liability Form” and
present to the Department Director/ Manager prior to the beginning of the
observation period.
Observers in Patient Care/Procedure Areas
MS 1.27
Page 2 of 4
2. Observers must wear an identification badge obtained from the Department.
3. A copy of the Observation Confidentiality Agreement and Release of Liability
Form will be maintained in the Department. A copy is also to be sent vial fax
or email to the IU Health Medical Staff Office.
C. Sponsoring/Supervising Physician Responsibilities
1. The sponsoring/supervising physician arranging the observation shall agree
to:
a. Remind the observer of his or her obligation under the confidentiality
statement and HIPAA regulations.
b. Minimize the amount of protected health information provided or exposed
to the observer.
2. A short orientation session prior to the observation experience to review
expectations of the sponsoring/supervision physician and observer and to
allow the observer to ask any questions regarding his/her responsibilities
3. Be personally responsible for their observer for the time they are here. An
alternate person should be declared in advance to sponsor/supervise the
observer if the sponsor/supervisor is called away.
4. Notify patients that observations are taking place and ask for the patient’s
consent to having the observer present during their examination.
D. Observer Responsibilities
1. Observers are not permitted to discuss confidential patient information with
anyone other than the person(s) or his/her designee they are observing.
2. Observers are not permitted to use or disclose patient health information.
3. The Observer must read and sign the Confidentiality Statement.
4. The Observer can not make entries into the medical record.
5. During the experience, the Observer can not have direct contact with patients
or participate in any clinical action.
6. The Observer must wear a name tag/badge at all times that indicates he/she
is an observer or visitor.
7. Observer’s failure to comply with hospital and medical staff policies and
procedures will result in termination of the observation agreement.
VII.
CROSS REFERENCES
IC 1.18 Control of Communicable Diseases in Health Care Workers
VIII.
REFERENCES/CITATIONS
None
IX.
FORMS/APPENDICES
Appendix A: Observation Confidentiality Agreement and Release of Liability Form
Observers in Patient Care/Procedure Areas
MS 1.27
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X.
RESPONSIBILITY
Medical Staff
Medical Staff Office
XI.
APPROVAL BODY
Medical Staff Executive Committee
Board of Directors
XII.
APPROVAL SIGNATURES
XIII.
________________________________________________
Anne Gilbert, MD
Chair, Medical Staff Executive Committee
President, IU Health Medical Staff
_______________
Date
________________________________________________
V. William Hunt
Chairman, Board of Directors
Indiana University Health
_______________
Date
DATES
Approval Date:
Effective Date:
Review/Revision Dates:
November 2007
December 2007
November 2009, January 2010, January 2013,
August 2013
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MS 1.27
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