OU Medical Center Medical Staff Rules and Regulations
October 19, 2006
MEDICAL STAFF RULES AND REGULATIONS
OU MEDICAL CENTER
Revised
October 19, 2006
OU Medical Center Medical Staff Rules and Regulations
October 19, 2006
TABLE OF CONTENTS
Page
A.
GENERAL ...........................................................................................................................1
B.
PERFORMANCE IMPROVEMENT ..................................................................................2
C.
ADMISSION AND DISCHARGE ......................................................................................2
D.
EMERGENCY SERVICES .................................................................................................3
E.
MEDICAL RECORDS AND ORDERS .............................................................................6
F.
GENERAL CONDUCT OF CARE ...................................................................................10
G.
SURGICAL CARE ............................................................................................................11
H.
OBSTETRICAL AND NEWBORN CARE ......................................................................14
I.
NON-PHYSICIANS ..........................................................................................................15
J.
AUTOPSIES ......................................................................................................................16
K.
CONTINUING MEDICAL EDUCATION .......................................................................16
L.
MEDICAL DIRECTORS ..................................................................................................17
M.
PEER REVIEW AND CONFIDENTIALITY...................................................................17
N.
IMPAIRED PRACTITIONERS ........................................................................................18
O.
ADVANCE DIRECTIVES................................................................................................19
P.
DNR ORDERS ..................................................................................................................19
Q.
SENTINEL EVENTS ........................................................................................................19
R.
COMMITTEES..................................................................................................................20
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OU Medical Center Medical Staff Rules and Regulations
October 19, 2006
OU MEDICAL CENTER
MEDICAL STAFF RULES AND REGULATIONS
A.
GENERAL
1.
This document sets forth the Rules and Regulations of the Medical Staff and is
subject to the provisions of the Medical Staff Bylaws. The terms defined in the Medical Staff
Bylaws shall have the same meanings herein.
2.
These Rules and Regulations may be adopted, amended, revised, modified, restated
and repealed in the manner set forth in the Medical Staff Bylaws.
3.
Various Hospital policies address a number of matters affecting procedures,
practice restrictions or limitations, protocols, quality of care, admission and discharge,
performance improvement, emergency services, medical records, medical orders, operating room
and surgical matters, allied health professionals, pediatric patients and their care, disaster plans
and procedures, medical research, advance directives and a number of other issues and matters
affecting Medical Staff members, care of patients and Hospital personnel. These policies
supplement the Rules and Regulations. Information about such policies will be made available
to the Medical Staff upon request.
4.
A Clinical Service may develop rules and policies applicable to the Clinical
Service. Such rules and policies must be consistent with these Rules and Regulations. In the
event of a conflict between the Clinical Service rules and policies and these Rules and
Regulations, these Rules and Regulations will control. The rules and policies of Clinical
Services will be applicable on a Hospital-wide basis and are subject to the approval of the
Medical Executive Committee.
5.
These Rules and Regulations address many of the functions and responsibilities of
“attending physicians.” A member of the House Staff may perform such functions or
responsibilities on behalf of the attending physician to a degree determined to be appropriate by
a member of the Medical Staff who regularly supervises and monitors the care provided by the
member of the House Staff and in accordance with Hospital policy, Medical Staff policy, the
Medical Staff Bylaws, legal requirements and accreditation standards.
6.
It is the intent that these Rules and Regulations will comply with all requirements of
law, including hospital licensure laws, laws governing the practice and scope of practice of
physicians and other licensed professionals, conditions of participation in Medicare, Medicaid
and other federal and state benefits programs, and the Social Security Act, as well as applicable
accreditation standards.
7.
Each member of the Medical Staff is part of the organized health care arrangement
with the Hospital as defined in 45 C.F.R. Parts 160 and 164 (HIPAA Privacy Regulations) as a
clinically-integrated care setting in which individuals typically receive healthcare from more
than one healthcare provider. This arrangement allows the Hospital to share information with
the practitioner and the practitioner’s practice for purposes of treatment, payment and health care
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October 19, 2006
operations. The patient will receive a Notice of Privacy Practices in Admissions, which will
include information about the organized health care arrangement with the Medical Staff.
B.
PERFORMANCE IMPROVEMENT/PATIENT SAFETY
1.
The Medical Staff, through the Medical Executive Committee and Medical Staff
officers shall set expectations, develop plans, and implement procedures to assess and improve
the quality of the Hospital’s governance, management, clinical, and support processes. The
Medical Staff, through the Clinical Services, shall (a) undertake education concerning the
approach and methods of performance improvement and patient safety activities; (b) set
priorities for organization-wide performance improvement activities that are designed to improve
patient safety and outcomes; (c) in conjunction with Administration, allocate adequate resources
for assessment and improvement of the Hospital’s governance, managerial, clinical, and support
processes through the assignment of personnel, as needed, to participate in performance
improvement activities; the provision of adequate time for personnel to participate in
performance improvement activities; and information systems and appropriate data management
processes to facilitate the collection, management, and analysis of data needed for performance
improvement; (d) assure that personnel are trained in assessing and improving the processes that
contribute to improved patient outcomes; (e) individually and jointly develop and participate in
mechanisms to foster communication among individuals and among components of the
organization, and to coordinate internal activities; and (f) analyze and evaluate the effectiveness
of their contributions to improving organizational performance.
2.
The Medical Staff shall participate in performance improvement and patient safety
activities as provided in the Hospital’s performance improvement plan.
C.
ADMISSION AND DISCHARGE
1.
Patients may be admitted and discharged only on order of the attending practitioner.
The Hospital will not be obligated to accept patients for which facilities for proper care are not
available. Patients should not be admitted as a matter of convenience while only undergoing
tests or therapy that could be obtained on an outpatient basis.
2.
The Hospital will permit the admission of patients in the following order of priority
when there is a shortage of available beds: (a) emergency and (b) elective.
3.
With the exception of emergency admissions, the Hospital will not admit patients
until the practitioner has provided a provisional diagnosis or valid reason for admission. In
emergency cases, the emergency physician must record the diagnosis or reasons as soon as
possible. A copy of the Emergency Department record shall accompany the patient to the
nursing unit.
4.
Practitioners must be able to justify emergency admissions based on criteria
developed by the Medical Staff. The history and physical must provide a clear justification of
the patient’s admission on an emergency basis, and the attending practitioner must record all
findings on the patient’s medical record as soon as possible after admission.
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5.
Practitioners may not admit a patient under another practitioner’s name in an effort
to avoid responsibility for care of the patient or to circumvent policies regarding suspension of
privileges due to failure to complete medical records.
6.
The Hospital will give a patient admitted on an emergency basis the opportunity to
select a member of the Active or Provisional Staff as attending physician for the patient while in
the Hospital. Where the patient does not make a selection or where the selected physician does
not assume responsibility for care of the patient for some reason, the on call physician shall serve
as the patient’s attending physician.
7.
Practitioners shall make admissions and discharges to special care units in
accordance with established criteria. The unit medical director must approve any exceptions.
8.
Patients may leave the Hospital on pass privileges only on order of the attending
practitioner. The practitioner should specify in the order the period of time the patient may be
out of the Hospital. Generally, the time period should not be more than six hours.
9.
The attending practitioner may discharge a patient from the Hospital by entering a
discharge order. If a patient leaves the Hospital against the advice of the attending practitioner
or without proper discharge, Hospital staff shall take appropriate steps to have the patient sign
out AMA and shall make a notation in the patient’s medical record.
10. When a patient dies in the Hospital, the attending physician or his or her physician
designee must pronounce the death within a reasonable time. The attending physician must
complete and sign the death certificate. The attending physician may delegate the responsibility
for completing and signing a death certificate to a member of the House Staff. The Hospital will
not release the body until a physician has made and signed an entry of the death in the orders of
the medical record. Policies with respect to the release of dead bodies shall conform to local law
and Medical Examiner requirements.
11. Practitioners must comply with the Hospital’s utilization management plan,
including the appropriateness and medical necessity of admissions, continued stay, support
services, and discharge planning.
12. Practitioners and staff shall take proper safety precautions with respect to patients
who are known to be suffering from drug abuse, alcoholism and mental health problems.
D.
EMERGENCY SERVICES
1.
The Clinical Service Chief of Emergency Services shall have the overall
responsibility for emergency care. At least one emergency physician shall be in the Hospital and
immediately available to provide emergency patient care 24 hours per day, seven days per week.
2.
Members of the Medical Staff must accept responsibility for emergency care in
accordance with Medical Staff and Emergency Department policies and procedures, including
call schedules. All Active Staff members and others, as determined by an individual Clinical
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Service and approved by the Medical Executive Committee, are required to be on at least one
call schedule as appropriate to meet patient care needs.
3.
The Hospital will maintain in the Emergency Department a physician call list
designating Medical Staff members on duty or on call for primary care coverage and specialty
care coverage. The Hospital shall maintain the list for a period of five years. If a physician on
call is not available to accept the care of the patient, the Emergency Department physician will
continue down the rotation until he or she reaches the next on call physician. Once a physician
has accepted care of the patient, it becomes the physician’s responsibility to provide such
inpatient and follow-up care as is required, and he or she must make an appropriate disposition
of the case.
4.
Each member of the Medical Staff shall identify and make arrangements with other
members of the Medical Staff to provide coverage for him or her.
5.
The emergency physician shall arrange for an interpretation of X-rays by a
radiologist, EKG’s by a physician with clinical privileges to interpret EKG’s, and a comparison
of initial and final interpretations. In cases where an X-ray interpretation of the radiologist is
different from that initially made by the emergency physician, the radiologist shall notify the
emergency physician and/or the patient’s private physician as soon as possible and shall arrange
to make copies of his or her report available to the emergency physician and the patient’s private
physician. In cases where the EKG interpretation is different from that initially made by the
ordering physician and suggests an acute life-threatening situation, the EKG physician shall
notify the ordering physician as soon as possible.
6.
With the exception of medication approved by the Medical Executive Committee,
practitioners shall not administer general anesthesia in the emergency treatment area.
7.
If, in the judgment of the emergency physician, a patient needs to be admitted to the
Hospital as an inpatient, either for observation or for further treatment, the patient’s practitioner
or the on call practitioner shall admit the patient. Patients recommended for inpatient admission
will be promptly admitted to an inpatient bed on the appropriate service unless the attending
physician from that service personally evaluates the patient and arranges for an alternate
disposition which is agreed upon by both the emergency physician and attending physician. If in
the judgment of the emergency physician the patient’s condition requires immediate attention,
the emergency physician shall continue to accept responsibility for the patient until the assigned
practitioner assumes responsibility for the patient by coming to the Hospital and caring for the
patient. The assigned practitioner shall come to the Hospital as promptly as possible if requested
by the emergency physician.
8.
In an emergency case in which it appears that the patient will have to be admitted to
the Hospital, the practitioner shall, when possible, first contact the Emergency Department and
the admitting office or, if the admitting office is closed, the nursing service supervisor to
ascertain the availability of beds.
9.
The admitting physician is responsible for seeing the patient in a timely manner and
providing care for the patient in the Hospital. This responsibility includes writing admission
orders for the patient. If the admitting physician chooses to delegate the task of writing
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admission orders to a House Staff physician or the emergency physician, the admitting physician
nonetheless remains responsible for the content of those orders and the care of the patient.
10. The Clinical Service Chief of Emergency Services shall arrange for calls to the
patient’s private practitioner in accordance with Emergency Department policies and procedures.
11. The Hospital shall keep and maintain in the Emergency Department a record or log
listing every person who presents himself or is brought to the Emergency Department for
treatment or care. The record shall include a notation concerning treatment or transfer. The
Hospital shall keep and maintain in the Emergency Department an appropriate medical record
for every patient receiving emergency service. The Hospital shall include such record in the
patient’s previous inpatient medical record, if one exists. The Emergency Department medical
record shall include: adequate patient identification; information concerning the time of the
patient’s arrival and method of transportation; pertinent history of the injury or illness, including
details relative to first aid or emergency care given to the patient prior to arrival at the Hospital;
history of allergies; description of significant clinical, laboratory, X-ray and EKG findings;
diagnosis, including condition of patient; treatment given and plans for management; condition
of the patient on discharge or transfer; and final disposition, including instructions given to the
patient and the patient’s family relative to necessary follow-up care.
12. The emergency physician or private physician in attendance shall sign the patient’s
emergency medical record and will responsible for its clinical accuracy.
13. A copy of the Emergency Department medical record shall accompany patients that
are admitted as inpatients or who are transferred to another facility in accordance with
Emergency Department policies.
14. The Clinical Service Chief of Emergency Services shall provide for monthly patient
care evaluation concerning the quality and appropriateness patient care.
15. The Hospital will provide an appropriate medical screening examination for
individuals who present themselves to the Emergency Department requesting an examination or
treatment to determine whether an emergency medical condition exists or to ascertain if the
patient is in active labor. A physician, will perform the emergency medical screening
examination. A registered nurse in an OB Urgent Care/Labor and Delivery setting can assess the
patient and report the findings to the physician. A physician will be responsible for making a
final determination about whether an emergency medical condition exists. If the physician
determines that the patient does not have an emergency medical condition or is not in active
labor, then the patient will be treated until stabilized, or the patient may be transferred to another
hospital. The Hospital may not transfer any patient who is not stabilized or who is in active
labor, except: (a) where the patient requests a transfer, and (b) where a physician signs a
certification which states that the physician has weighed the reasonable risks and benefits to the
patient, and the medical benefits reasonably expected at the receiving hospital would be greater
than the risks to the patient from transfer. The transfer must in any event be appropriate. The
Emergency Department may not postpone a medical screening, further treatment, or medical
examination in order to determine or ask about the individual’s method of payment or insurance
status. The Clinical Service Chief of Emergency Services shall establish, maintain and enforce
policies relating to appropriate medical screening examinations, patient transfers, physician
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certifications, and other matters to comply with the emergency transfer provisions of the
Emergency Medical Treatment and Active Labor Act.
16. Emergency physicians shall not refuse to accept patient transfers from other
hospital emergency departments if the transfer is medically appropriate and Hospital staff and
facilities are available to provide care for the patient.
17. The Clinical Service Chief of Emergency Services shall coordinate emergency
procedures with the Hospital’s disaster plan, especially as they pertain to the care of mass
casualties.
E.
MEDICAL RECORDS AND ORDERS
1.
The attending practitioner will be responsible for the preparation of a complete and
legible medical record for each patient. Its contents shall be pertinent and current for the patient
and include sufficient information to justify the diagnosis and warrant the treatment. A medical
record is considered delinquent if it has not been completed within 30 days of discharge or date
of service rendered. Corrective action will be taken against practitioners with delinquent medical
records, as provided in the Medical Staff Bylaws and as outlined in the Medical Executive
Committee policy.
2.
A complete admission history and physical examination on each patient must be
written, electronically entered or dictated and in the medical record within 24 hours of
admission. The report should include all of the pertinent findings resulting from an assessment
of all systems of the body. A complete history and physical includes: reasons for
admission/chief complaint, history of present illness including pain, pertinent past medical
history, social history, family history, review of systems, pertinent physical examination
findings, pertinent laboratory and x-ray findings, provisional diagnosis, current medications, and
allergies. Negative findings for a system may be indicated in the record of the physical
examination by the lack of an entry for that system. The omission of an entry signifies the
system was examined and no significant findings were noted or that no examination of the
system was performed. Specific abnormal or pertinent negative findings of the examination of
the affected or symptomatic body area(s) must be denounced. If a complete history has been
recorded and a physical examination performed within 30 days prior to the patient’s admission to
the Hospital, a reasonably durable, legible copy of such reports may be used in the patient’s
Hospital medical record in lieu of the admission history and report of the physical examination,
provided the reports were recorded by a member of the Medical Staff. In such incidences, this
requires an updated medical record entry documenting an examination for any changes in
patient’s condition when the medical history and physical examination are completed within 30
days before admission. If, upon examination, the licensed practitioner finds no change in the
patient’s condition since the history and physical was completed, he/she may indicate in the
patient’s medical record that the history and physical was reviewed, the patient was examined,
and “no change” has occurred in the patient’s condition since the history and physical was
completed. A readmission note will be sufficient if the patient is readmitted within 30 days of
discharge for the same condition
3.
If at the time of admission a complete history and physical examination has been
dictated but not written, a practitioner’s admission note must be written or electronically entered
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that includes, but is not limited to, the following: reasons for admission, pertinent medical
history, pertinent physical examination findings, pertinent laboratory and x-ray findings, current
medications, allergies, a statement that the history and physical examination was dictated (or, if
not dictated, the reasons and time for completion) and all other requirements as defined by the
Oklahoma State Hospital licensure laws.
4.
Pertinent progress notes sufficient to permit continuity of care and transferability
shall be recorded at the time of observation. Whenever possible, each of the patient’s clinical
problems should be clearly identified in the progress notes and correlated with specific orders, as
well as results of tests and treatment.
5.
All clinical entries and summaries in the patient’s medical record shall be
accurately dated, timed, signed/electronically signed, and authenticated.
6.
The practitioner responsible for prescribing, ordering, providing or evaluating the
service furnished shall accurately and promptly date, time and authenticate all clinical entries and
summaries in the patient’s medical records, except under limited circumstances when the
practitioner is not available. In such cases, the person covering for the practitioner or a member
of the practitioner’s group may authenticate the entry, and such an authentication indicates that
the covering physician or practitioner assumes responsibility for his colleague’s order and
verifies that the order is complete, accurate, appropriate and final.
7.
Certain Symbols, abbreviations and dose designations are not to be used as
identified and approved for non-use by the Medical Executive Committee.
8.
The following persons may make entries in medical records of Hospital patients:
members of the Medical Staff, Allied Health Professionals, medical residents and fellows,
nursing personnel, physician’s assistants, pharmacists, radiology technicians, dietitians, physical
therapists, respiratory therapists, occupational therapists, speech therapists, social workers, case
managers, and pastoral care staff. Medical students under the supervision of an attending
physician or member of the House Staff may make entries in medical records; provided, any
entries, including orders entered by a medical student, will not be valid until appropriately
countersigned by the attending physician or a member of the House Staff. The Medical
Executive Committee may authorize other persons or classes of persons to make such entries.
9.
Orders for treatment and medications must be in writing or electronically entered,
and signed by the practitioner or Allied Health Professional, privileged to write orders, attending
the patient. A member of the Medical Staff, an advance practice nurse with prescriptive
authority or a physician’s assistant may write or enter orders electronically and give verbal
orders to authorized nursing personnel, pharmacist (for medication), respiratory therapist
technicians (for respiratory therapy), radiology technicians (for orders specific to radiology),
dietitians (for dietary orders only), registered physical therapists, registered speech therapists or
registered occupational therapists (for physical, speech and occupational therapy orders only),
social workers (for discharge planning activities) or medical technologists (for orders specific to
lab work). The history and physicals, operative notes and discharge summaries of a physician
assistant and advance registered nurse practitioner must be co-signed by the attending
practitioner. The orders of a physician assistant must be co-signed by the physician within 24
hours. Advanced registered nurse practitioners progress notes and orders are not required to be
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co-signed. For patient safety, verbal orders should be given only in emergent situations to meet
the care needs of the patient when it is impossible or impractical for the ordering physician sto
write the order or enter it into a computer without delaying treatment. Verbal orders are not to
be used for the convenience of the ordering practitioner. Verbal orders must be counter-signed,
timed and dated by the ordering Medical Staff member or member of the House Staff or
Physician Assistant or Nurse Practitioner authorized to write such orders as soon as possible to
assure verification by the ordering Medical Staff member. “As soon as possible” means the
earlier of the following:



The next time the prescribing practitioner provides care to the patient, assesses
the patient, or documents information in the patient’s medical record,
The prescribing practitioner signs or initials the verbal order within time
frames consistent with Federal and State law or regulation and hospital policy,
or
Within 48 hours of when the order was given
In some instances, the ordering physician may be unable to authenticate his or her verbal order
(e.g., the ordering physician gives a verbal order which is written or transcribed, and then is “offduty” for the weekend or an extended period of time). In such cases, it is acceptable for a
covering physician to co-sign the verbal order of the ordering physician. The signature indicates
that the covering physician assumes responsibility for his/her colleague’s order as being
complete, accurate and final. However, an Allied Health Professional, such as a physician
assistant or nurse practitioner, may not “co-sign” a physician’s verbal order or otherwise
authenticate a medical record entry for the physician who gave the verbal order.
10. Standing orders can be used in highly emergent situations. Highly emergent
situations are those situations when it is important to implement the orders as soon as possible
due to sudden changes that place the patient in a life and death situation, without being able to
first consult the physician. Standing orders must be approved for use in the hospital by the
medical staff and board of trustees. Periodically, the physician or appropriate committee shall
review and revise, as necessary, standing orders.
11. Electronic Hospital Order Sets will be developed from approved pre-printed orders
and/or may submit orders sets to the ePOM coordinator. These order sets will be available for all
Providers to use and should be service specific. They will require review and approval from the
submitting services or physician, Pharmacy and in some cases the ePOM Physician Steering
Group or the Pre-Printed Order Committee. Clinical Services are to review their order sets
periodically and submit any changes as necessary. Attendings and residents will be able to
electronically save order sets as a “favorite” in ePOM.
12. Automatic stop orders shall be in force for those categories of drugs or specific drugs that
have been approved by the Medical Executive Committee. The following shall apply to
medication automatic stop orders: (a) open-ended orders (those not stating a specific period of
time or a specific number of doses) for medications will be automatically stopped after 30 days,
unless re-ordered by the practitioner; (b) notification of the stop order will be placed
conspicuously on the record at least two days prior to expiration; (c) all orders will reviewed by
the medical staff when a patient undergoes surgery (exception – local anesthesia) or transfers
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into or out of the critical care areas (e.g. ICU, CCU, NICU) or Labor and Delivery. Orders
written to “resume previous orders” cannot be honored.
13. Verbal restraint orders and DNR orders must be signed by the physician within 24
hours after giving the verbal order.
14. When the history and physical examination are not recorded on the patient medical
record before surgical/high risk procedures or any potentially hazardous diagnostic procedure,
the procedure shall be canceled, unless the attending physician states in writing that such delay
would be detrimental to the patient.
15. Written consent of the patient, or parent/legal guardian in the case of a minor, is
required for release of medical information to persons not otherwise authorized to receive such
information in accordance with HIPAA Privacy Regulations and state law. No one other than
authorized persons shall have access to or information from the medical records without the
written permission of the patient, in which case the written permission shall be attached to the
record.
16. Records may be removed from the Hospital’s jurisdiction and safekeeping only in
accordance with a court order, subpoena or statute. All records, including x-rays, are the
property of the Hospital and shall not otherwise be taken or removed from the Hospital without
the permission of the CEO, the Chief Medical Officer or a Medical Director.
17. A patient may be discharged only on order of the attending practitioner or a member
of the Medical Staff acting on the practitioner’s behalf. The attending practitioner shall be
responsible for completing the medical record, which shall include the practitioner’s final
diagnoses and signature.
18. The attending practitioner shall complete the medical record at the time of the patient’s
discharge, including progress notes, final diagnosis and discharge summary. Where this is not
possible because final laboratory or other essential reports have not been received at the time of
discharge, the medical record will be available in the Medical Records Department. If the
practitioner cannot dictate the discharge summary at the time of discharge, he or she shall write a
final progress note in the medical record, including a final diagnosis.
19. The attending practitioner shall write, enter electronically or dictate a discharge
summary for any patient hospitalized over 48 hours. The medical record should provide a
justification for the diagnosis or the treatment and the end results. The summary should include
the condition of the patient on discharge and follow-up plans. The attending practitioner should
sign the summary.
20. The attending practitioner shall write, enter electronically or dictate a discharge note for
any patient hospitalized for less than 48 hours. The note should include the condition of the
patient on discharge, medications, diet, activity, instructions given to the patient, and follow-up
plans.
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21. In any case of readmission of a patient, all previous records shall be available for the
use of the attending practitioner. This will apply whether the patient is attended by the same
practitioner or by another practitioner.
22. The Hospital shall not permanently file a medical record until the responsible
practitioner completes it or the Chief Medical Officer or Medical Executive Committee orders
that it be filed.
23. All practitioners and Allied Health Professionals who access protected health
information (as defined in the HIPAA Privacy Regulations) maintained by the Hospital, in either
paper or electronic format, shall treat information as confidential. The Medical Executive
Committee shall recommend disciplinary action against any practitioner or Allied Health
Professional who breaches this confidentiality requirement in accordance with standards
established by the appropriate Hospital committees. Such disciplinary action may include
termination of Medical Staff membership and clinical privileges.
F.
GENERAL CONDUCT OF CARE
1.
Every patient admitted to the Hospital or the patient’s duly authorized
representative shall sign a general consent form at the time of admission. The admitting office
shall notify the attending practitioner if for any reason the patient has not furnished a signed
consent form.
2.
The practitioner performing the procedure or providing treatment will be
responsible for obtaining the patient’s informed consent. In accordance with Hospital policy, an
Allied Health Professional may obtain a patient’s informed consent for procedures or care that
they provide within their scope of practice. When consent is not obtainable, the reason shall be
entered in the patient’s medical record. The medical record shall contain the signed informed
consent form of the patient.
3.
A physician member of the Medical Staff will be responsible for coordination and
management of a patient’s general medical condition. The attending practitioner will be
responsible for the treatment and the prompt completion and accuracy of the medical record, for
necessary special instructions, and for transmitting reports of the condition of the patient, if
appropriate, to any referring practitioner. Whenever these responsibilities are transferred to
another practitioner, a note covering the transfer of responsibility shall be entered on the order
sheet of the medical record. A progress note summarizing the patient’s condition and treatment
shall be made, and the practitioner transferring responsibility shall personally notify the other
practitioner to ensure the acceptance of that responsibility is clearly understood.
4.
A history and physical examination may be performed in whole or in part by a
physician, a non-physician practitioner who is granted the appropriate clinical privileges, a
member of the House Staff under the direction and supervision of a member of the Medical
Staff, and an Allied Health Professional who is authorized by the Hospital to do so. Allied
Health Professionals who are granted specified services to perform history and physical
examinations include individuals who may practice independently under state law and
individuals who are required by state law to practice under the supervision of a physician or
other practitioner.
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5.
The attending physician shall see patients in an intensive care unit every 24 hours.
The attending physician shall make an entry in the progress notes of the patient’s medical record.
6.
Each member of the Medical Staff shall name another member of the Medical Staff
as an alternate to be called to attend his or her patients in an emergency when the Medical Staff
member is not available or until the Medical Staff member can be present. In the case of an
emergency when the appointee cannot be reached or is unavailable, the designated alternate
physician shall be called. In case the alternate is not available, the Emergency Department
physician, the CEO, the Chief Medical Officer, or the Chief of Staff will have the authority to
call the on call practitioner or any other member of the Medical Staff to attend the patient.
7.
The Medical Staff, through the Medical Executive Committee, shall determine the
circumstances under which a consultation is required.
8.
Patients who are emotionally ill, who become emotionally ill while in the Hospital,
or who suffer the results of alcoholism or drug abuse shall be referred to the appropriate mental
health professional or program.
9.
There shall be no smoking in the Hospital in accordance with policies established
by the Hospital.
10. Practitioners shall utilize and follow procedures developed by the Centers for
Disease Control relating to “standard precautions” in patient care.
11. The Pharmacy and Therapeutics Committee is responsible for preventing,
monitoring and reporting medication errors.
12. Medical Staff members shall report to Hospital Administration any and all noted
accidents or injuries resulting from the use of medical devices or equipment. Any noted
equipment defects, malfunctions or failures shall be reported to Hospital Administration for
maintenance, repair or other action.
13. Medical Staff members shall report to Medical Staff officers, the CEO, the Chief
Medical Officer or the Medical Directors questionable medical practices of other practitioners,
Allied Health Professionals, nursing personnel, or other personnel in the Hospital.
14. The Hospital will not transfer a patient within the Hospital without the approval of
the attending practitioner.
15. The acquisition of investigational devices used as implants in clinical research shall
be coordinated through the Hospital’s Materials Management Department in order for the
devices to be identified at the point of entry into the Hospital. No investigational devices may be
implanted without the appropriate acquisition through the Hospital’s Materials Management
Department.
G.
SURGICAL CARE
1.
This section of the rules shall apply to the care of patients in the operating room.
Medical Staff members shall comply with the rules and policies relating to surgical care and use
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of operating rooms that are established by the Operating Room Committee, and shall comply
with Hospital policy when caring for patients undergoing diagnostic or therapeutic procedures.
2.
Except in emergencies, a history and physical examination, the pre-operative
diagnosis, appropriate consents, required laboratory and radiology reports, and consultations,
when requested, must be recorded on the patient’s medical record prior to any surgical
procedure. In the case of an emergency, where any or all of the above entries have not been
made in the medical record, the operating surgeon shall state in writing that a delay would be
detrimental to the patient (and shall make a comprehensive note in the medical record indicating
the patient’s condition prior to induction of anesthesia and the start of surgery) and that the
patient’s condition is deemed to be satisfactory for the planned surgery. In all other cases the
responsible nurse shall notify the operating surgeon, preferably no later than the night before
surgery is scheduled, that entries are not complete and preparation for surgery including
premedication shall not be performed until proper entries are recorded in the patient’s medical
record. If this delay causes a change to be made in the surgery schedule, the surgery shall be
rescheduled to the next available time.
3.
All patients admitted to surgery for operative or other procedures must be assessed
by a qualified registered nurse with surgical experience to ensure that a plan of care is developed
appropriate to the patient’s specific needs and the severity level of the patient’s disease,
condition, impairment or disability. The plan of care developed by the surgical nursing staff
must be consistent with the physician’s plan of care documented in the patient’s medical record.
The patient must be reassessed for modifications or changes in the intraoperative and
postoperative plan of care.
4.
An appropriate selection of medications shall be readily available in the operating
room.
5.
The patient shall be transported to and from the operating room by gurney or bed,
with both side rails of the gurney or bed in the up position.
6.
The patient shall be informed as to the potential risks and benefits of the proposed
procedure and type of sedation or anesthesia to be administered, including possibility of
blood/blood components transfusion, as appropriate to the planned procedure. Written, signed,
informed procedural consent for the surgery shall be obtained by the physician prior to the
procedure, except in those situations in which the patient’s life is in jeopardy and the patient’s
signature cannot be obtained due to the condition of the patient. In emergencies involving a
minor or unconscious patient in which consent for surgery cannot be immediately obtained from
parents, guardian or next of kin, the circumstances should be fully explained on the patient’s
medical record. A consultation in such instances may be desirable before the operative
procedure is undertaken, if time permits.
7.
Patients who are admitted to the Hospital for surgery shall have a documented
physical examination by a doctor of medicine or osteopathy no more than 30 days prior to
admission or 24 hours after admission. The history and physical must be completed and
documented before the surgery or procedure takes place, even if that surgery or procedure occurs
less than 24 hours after admission. Proper notes shall be made in the progress notes as to the
findings. The operating surgeon shall be responsible for such physical examinations having been
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completed prior to surgery. Patients admitted only for oral maxillofacial surgery by an oral
surgeon who has been granted privileges by the Medical Staff shall have a physical examination
and medical history done no more than 30 days before or 24 hours after admission. An updated
medical record entry is required for documenting an examination of any changes in patient’s
condition when the medical history and physical examination are completed within 30 days or
less before surgery.
8.
It shall be the responsibility of nursing service to check the patient’s records for
completeness before surgery. A patient’s medical record shall be deemed complete when the
history and physical, any indicated diagnostic tests, and a preoperative diagnosis are recorded in
the medical record. If these are not present, the surgery shall be canceled unless the operating
surgeon states in writing that such delay would constitute a hazard to the patient.
9.
Only qualified and appropriately credentialed personnel may provide moderate or
deep sedation and anesthesia.
10. The anesthesiologist or a person authorized to administer anesthesia or
sedation/analgesia to the patient is responsible for performing a pre-sedation or pre-anesthesia
assessment no more than 48 hours prior to beginning moderate or deep sedation or anesthesia
induction. This assessment is to determine that the patient is an appropriate candidate to undergo
the planned sedation or anesthesia and for writing a pre-sedation or pre-anesthetic note in the
medical record prior to the patient’s transfer to the operating area and before pre-operative
medication has been administered. This note shall indicate a choice of sedation or anesthesia,
the surgical or obstetrical procedure anticipated, and the patient’s prior anesthetic history. The
anesthesiologist or anesthesia provider is responsible for writing a post-anesthetic note within 48
hours after the patient has completed post-anesthesia recovery care which includes at least a
description of the presence or absence of anesthesia-related complications. Each sedation or
anesthesia entry shall be dated, timed, signed and authenticated by the responsible practitioner.
11. The anesthesiologist or a person authorized to administer anesthesia to the patient
shall monitor the patient’s physiological status during sedation or anesthesia to ensure
appropriate physiological support. The type of monitoring will depend upon the patient’s preprocedure status, sedation or anesthesia choice, and complexity of the procedure.
12. The anesthesiologist or a person authorized to administer anesthesia to the patient
shall maintain a complete anesthesia record which includes evidence of pre-anesthetic evaluation
and post-anesthetic follow-up of the patient’s condition within 48 hours after surgery.
13. A qualified registered nurse shall assess the patient’s post-procedure status on
admission to and discharge from the post-sedation and post-anesthesia recovery area, and shall
discharge a patient from the post-sedation and post-anesthesia recovery area only upon an order
of the attending practitioner.
14. The operating surgeon shall ensure that all tissues removed during surgery, except
those specifically exempted by the Medical Executive Committee, shall be sent to the Hospital
pathologist, who shall make such examination, as necessary to arrive at a pathological diagnosis.
The pathologist’s report shall be made a part of the patient’s medical record. Each specimen
shall be accompanied by necessary information including the preoperative diagnosis, description
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of tissue and brief pertinent clinical data which the surgeon will complete or cause to be
completed.
15. Operative reports shall include a detailed account of the findings at surgery, as well
as the details of the surgical technique. Operative reports shall be written, electronically entered
or dictated immediately following surgery when possible, and in any event within 24 hours postsurgery for all surgical patients, and the report shall be promptly signed by the surgeon and made
a part of the patient’s current medical record. If an operative report is not entered in the medical
record immediately after surgery, a handwritten progress note shall be entered immediately,
which will include the procedure performed and description of the procedure; the name(s) of the
practitioners and assistants; findings; estimated blood loss; specimens removed; and post
operative diagnosis.
16. Review of outside pathology cases is required for patients for whom additional
definitive or major treatment, such as radical surgical resections or staging procedures, radiation
therapy, chemotherapy, or other combined multimodality therapy is planned based on outside
pathologic diagnosis. The attending practitioner will be responsible for notifying the Hospital
pathologist about such material and to indicate the laboratory from which it may be obtained.
H.
OBSTETRICAL AND NEWBORN CARE
1.
The Hospital obstetrical record shall include a prenatal record, if available. A
complete admission history and physical examination on obstetrical patients shall be written or
dictated with 24 hours of admission or within 30 days prior to admission. An obstetrical medical
record shall also have a prenatal history and discharge summary. The prenatal record may be a
legible copy of the attending physician’s office record transferred to the Hospital, shall be up-todate, and shall include findings since the time of the last visit.
2.
Informed consent for the delivery shall be obtained on the patient’s arrival to labor
area.
3.
Patients having Caesarean sections shall have an updated history and physical
examination. A progress note on important or new physical findings since the patient’s last
physical examination shall suffice.
4.
The OB and newborn attending practitioner should dictate or complete an
appropriate delivery note immediately following the delivery.
5.
A practitioner may interrupt a pregnancy as permitted by law following the
guidelines of the most current issue of the “Standards for Obstetric-Gynecologic Services”
published by the American College of Obstetricians and Gynecologists.
6.
Before performing a procedure for termination of a pregnancy, the request will be
approved by three (3) staff OB-GYN Physicians.
7.
The Obstetrics and Gynecology Service shall review all mid-trimester termination
cases on a regular basis, and at least quarterly.
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8.
A physical examination shall be recorded in the medical record of all newborns
within 24 hours of delivery.
I.
NON-PHYSICIANS
1.
Oral and Maxillofacial Surgery. A patient admitted for oral-maxillofacial surgery
shall be the responsibility of the oral surgeon. An oral surgeon may admit patients for oralmaxillofacial surgery, if granted clinical privileges to do so.
(a) The responsibilities of the oral surgeon shall include: (i) the medical history
and physical examination to assess the medical, surgical and anesthetic risks of the proposed
operative or other procedure(s); (ii) a pre-operative diagnosis; (iii) a complete operative report,
describing the findings and techniques; in cases of extraction of teeth and fragments removed, all
tissue including teeth and fragments shall be sent to the hospital pathologist for examination; (iv)
progress notes; and (v) discharge summary.
(b) In the event that the patient requires management of a medical condition, a
physician member of the Medical Staff shall be responsible for the care and treatment related to
the medical condition.
2.
Dental Care. A patient admitted for dental care is a dual responsibility of the
dentist and a physician member of the Medical Staff.
(a) The responsibilities of the dentist shall include: (i) a detailed dental history
justifying hospital admission; (ii) a detailed description of the examination of the oral cavity and
a pre-operative diagnosis; (iii) a complete operative report, describing the findings and
techniques; in cases of extraction of teeth and fragments removed, all tissue including teeth and
fragments shall be sent to the hospital pathologist for examination; (iv) the dentist or oral
surgeon is totally responsible for the oral or dental care; (v) progress notes as are pertinent to the
oral condition; and (vi) discharge summary.
(b) The responsibilities of the physician shall include: (i) admission and
discharge of the patient; (ii) medical history pertinent to the patient’s general health; (iii) a
physical examination to determine the patient’s condition prior to anesthesia and surgery; (iv)
supervision of the patient’s general health status while hospitalized; and (v) availability during
the performance of a surgical procedure. The physician is not responsible for any dental care.
3.
Podiatric Care. A patient admitted for podiatric care is a dual responsibility of the
podiatrist and a physician member of the Medical Staff.
(a) The responsibilities of the podiatrist shall include: (i) co-admission of the
patient; (ii) a detailed history justifying hospital admission; (iii) a detailed description of the
examination of the feet and pre-operative diagnosis; (iv) a complete operative report, describing
the findings and technique; all tissue removed shall be sent to the hospital pathologist for
examination; (v) progress notes; (vi) the podiatrist is solely responsible for the care of the feet;
and (vii) discharge summary or summary statement.
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(b) The responsibilities of the physician shall include: (i) co-admission and
discharge of the patient; (ii) medical history pertinent to the patient’s general health; (iii) a
physical examination to determine the patient’s condition prior to anesthesia and surgery; (iv)
supervision of the patient’s general health status while hospitalized; and (v) availability during
the performance of a surgical procedure. The physician is not responsible for the podiatric care.
4.
A health service psychologist with clinical privileges at the Hospital shall be subject
to supervision by a physician. The physician shall be responsible for the medical evaluation and
medical management of the patient.
J.
AUTOPSIES
1.
The Medical Executive Committee, with the Hospital pathologists, shall develop
and use criteria to identify deaths in which an autopsy should be performed. Members of the
Medical Staff shall attempt to secure autopsies in all cases of unusual deaths, of medical-legal
and educational interest, and consistent with state law.
2.
An autopsy shall not be performed without the written consent of the responsible
party and in compliance with state law. Autopsies shall be performed by the Hospital pathologist
or by a physician to whom the Hospital pathologist delegates the duty.
3.
The attending physician and member of the Medical Staff who had been involved in
the care of a patient shall be notified by the Hospital pathologist when an autopsy is being
performed.
4.
Findings from autopsies shall be used as a source of clinical information in
performance improvement activities.
K.
CONTINUING MEDICAL EDUCATION
1.
All members of the Medical Staff are encouraged to participate in pertinent selfassessment programs and in basic cardiopulmonary resuscitation training.
2.
Each practitioner or other person with clinical privileges shall be encouraged to
participate in the Hospital’s continuing education programs and in other continuing education
activities that relate to the privileges granted.
3.
Continuing medical education programs will be based at least in part on the findings
in the performance improvement program.
4.
Emergency physicians shall maintain current certification in advanced cardiac life
support or board certification by AOBEM or ABEM.
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L.
MEDICAL DIRECTORS
1.
Hospital Administration in collaboration with the Medical Staff will designate a
Medical Director for Adult Patient Services and a Medical Director for Pediatric Patient
Services. In addition, Hospital Administration may identify Hospital services that provide direct
patient care which have need for a medical director.
2.
The medical direction of the service shall be provided by a physician who is a
member of the Active Staff with special interest and knowledge in the diagnosis, treatment, and
assessment of patients who require the services. Whenever possible, the physician shall be
qualified by special training or experience in the management of acute and chronic problems
related to the care provided by the service.
3.
The physician serving as a Medical Director shall have the authority and
responsibility for assuring that:
(a)
established policies are carried out;
(b) overall direction in the provision of care in the inpatient and outpatient
settings is provided; and
(c) the quality, safety and appropriateness of patient care, treatment and services,
are monitored and evaluated, and that appropriate actions based on findings are taken.
4.
Medical Directors will report to Hospital Administration and the Medical Executive
Committee with respect to policies, procedures and performance improvement activities.
5.
A Medical Director must designate a qualified physician who is a member of the
Active Staff to act in his or her absence.
6.
M.
Medical Directors shall be available to provide required consultations.
PEER REVIEW AND CONFIDENTIALITY
1.
Medical Staff records and the records relating to credentialing, peer review,
utilization review, and performance improvement activities shall be considered confidential and
subject to requirements of law. Confidentiality extends to records and minutes of Medical Staff
committees.
2.
Medical Staff records, including all records related to credentialing, peer review,
and utilization management shall be maintained under the direction of the Chief Medical Officer,
the Chief of Staff and the Medical Directors. The Hospital designates these individuals as the
persons who have the authority and responsibility for evaluating all requests for access to peer
review information. These individuals are referred to as the “Designated Medical Officials.”
3.
All requests to obtain or inspect peer review information shall be presented to the
Designated Medical Officials. The request must be in writing and specify a proper purpose. The
Designated Medical Officials shall carefully consider each request. The person requesting
access to peer review information shall have the burden of proving that a proper purpose exists,
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recognizing the importance and primary goal of preserving confidentiality of all peer review
information. In reviewing the request, the Designated Medical Officials will consider: (a) the
purpose of the request, (b) the position of person or persons who will be granted access to the
information, (c) whether there are other ways to obtain the same or similar information, and (d)
the safeguards in place to ensure that if the information is released, it will be kept confidential to
the greatest extent possible. The Designated Medical Officials shall permit access only when
absolutely necessary or required by law. Peer review documents shall not be removed from the
Hospital without the express prior approval of a Designated Medical Official.
4.
The Designated Medical Officials may release information contained in Medical
Staff files in response to a proper request from another hospital or health care facility or
institution. The request must include information that the practitioner is a member of the
requesting facility’s medical staff, has been granted privileges at the requesting facility, or is an
applicant for medical staff membership or clinical privileges at that facility, and must include an
authorization for the release for such records signed by the practitioner involved. The
information shall not be released until the Hospital receives a copy of a signed authorization and
release from liability. The Hospital shall limit disclosure to the specific information requested.
5.
The Designated Medical Officials shall review any subpoena for peer review
information which is directed to the Hospital, a member of the Hospital’s medical staff or a
Hospital employee. If a subpoena relates to a civil action involving a member of the Medical
Staff, a Designated Medical Official shall notify the Medical Staff member of the subpoena,
unless special circumstances indicate that notification may not be appropriate.
N.
IMPAIRED PRACTITIONERS
1.
The Hospital shall provide mechanisms for the identification, intervention, and
referral for treatment of a member of the Medical Staff, a licensed practitioner with clinical
privileges or an Allied Health Practitioner who is permitted to provide specified services at the
Hospital who may be impaired that is separate from the corrective action process set forth in
these Bylaws. Practitioner impairment includes any physical, psychological, emotional or
behavioral disorder that interferes with the practitioner’s ability to safely engage in professional
activities, including inability to work cooperatively with others and disruptive behavior.
2.
The Hospital shall develop appropriate policies for identification, referrals for
diagnosis and treatment, investigations, consultations, confidentiality, coordination with
licensing boards and agencies, rehabilitation, reinstatement, education about practitioner health,
and reporting concerning impaired practitioners.
3.
The Medical Staff shall develop policies relating to reinstatement of any impaired
practitioner who has taken a leave of absence or whose clinical privileges have been suspended,
voluntarily or involuntarily. Such policy shall include requirements relating to treatment,
prognosis, continued impairment, monitoring, whether professional performance has been
affected and other pertinent information or requirements.
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O.
ADVANCE DIRECTIVES
1.
Members of the Staff shall comply with the requirements of state and federal law
and Hospital policies concerning advance directives, health care proxies and withholding or
withdrawal of life-sustaining treatment.
2.
The Medical Staff shall establish an Ethics Committee for the purpose of providing
consultation for Medical Staff members, Hospital personnel involved in patient care, patients and
families of patients in difficult situations when further assistance may be needed to make,
develop, review or update decisions on ethical issues in patient care.
3.
The Medical Staff shall undertake efforts to educate Hospital personnel, members
of the Medical Staff, patients, families of patients and the community about advance directives,
health care proxies, and ethical issues affecting patient care.
P.
DNR ORDERS
1.
Hospital patients will receive full resuscitative procedures in the event of
unexpected cessation of cardiac or respiratory function to the extent provided in Hospital
policies.
2.
Only a physician may enter a Do Not Resuscitate (DNR) order. A DNR order may
be entered only in compliance with state law and Hospital policy.
3.
DNR orders must be in writing or electronic, and signed/electronically signed and
dated by the attending physician. A DNR order entered by a resident must be co-signed by the
attending physician (a second DNR order entered by the attending will act as a co-signature for
electronic orders). The orders, along with documentation of the basis for the orders, shall be
entered in the patient’s medical record. The order shall be updated at regular intervals based on
the physician’s periodic reevaluation of the patient’s condition to determine whether
continuation of the order remains medically justified.
Q.
SENTINEL EVENTS
1.
A sentinel event is an event that has resulted in an unanticipated death or major
permanent loss of function, not related to the patient’s illness or underlying condition. Sentinel
events also include suicide of a patient, abduction of any patient, discharge of an infant to the
wrong family, unanticipated death of a full-term infant, rape, hemolytic transfusion reaction
involving administration of blood or blood products having major blood group incapabilities,
surgery on the wrong patient or wrong body part, unintended retention of a foreign object in an
individual after surgery or other procedure, severe hyperbilirubinemia, or excessive radiation
overdose.
2.
The Medical Staff, in conjunction with the Administration, will collect data to
monitor and improve the performance of processes that may result in sentinel events. Such
processes include: (a) medication use; (b) operative and other procedures that place patients at
risk; (c) use of blood and blood components; (d) restraint use; (e) seclusion when part of care or
services provided; and (f) care or services provided to high-risk populations.
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3.
When a sentinel event occurs, a report shall be given to the CEO, the Chief Medical
Officer, and the Chief of Staff, who will direct an investigation of the root cause of the sentinel
event and implement a risk reduction plan. The physician will notify the patient and/or family
when a significant adverse event occurs in patient care.
4.
The CEO may report a sentinel event to the Joint Commission on Accreditation of
Healthcare Organizations (“JCAHO”).
5.
Any investigation and report regarding a sentinel event shall be conducted as part of
a peer review process.
R.
COMMITTEES
1.
The Medical Executive Committee shall designate the Medical Staff functions to be
performed by each committee.
2.
The operating committees of the Hospital are: (a) Peer Review Committee, (b)
Medical Records Committee, (c) Infection Control Committee, (d) Ethics Committee, (e)
Operating Room Committee, (f) Pharmacy and Therapeutics Committee, (g) Transfusion
Committee, (h) Patient Care Committee, (i) Children’s Health Committee, (j) Special Care
Committee, (k) Solid Organ Transplant Committee (l) Cancer Care Committee, (m) Joint
Quality Review and (o) Credentialing Committee
3.
In addition, the Chief of Staff shall appoint a Nominating Committee consisting of
not less than five and no more than 15 members of the Active Staff, subject to the approval of the
Medical Executive Committee. The Nominating Committee shall evaluate potential candidates
for position as officers of the Medical Staff and shall make recommendations of nominees to the
Medical Executive Committee.