GENERAL MEDICAL STAFF
Rules and Regulations
Approved by:
Medical Executive Committee: 2/11/98, 6/12/01, 4/8/03, 3/05, 05/13, 01/14
Medical Staff: 3/12/98, 7/12/01, 5/15/03, 5/05, 04/13, 01/14
Board of Directors: 3/25/98, 8/15/01, 5/28/03, 5/05, 1/07, 05/13, 01/14
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I.
II.
Admission Of Patients
A.
The Hospital shall admit all patients whose identified care, treatment, and service
needs it can meet.
B.
All patients shall be admitted to the Hospital by a physician member of the active
or affiliate Staff who has admitting privileges. Dentists, podiatrists and allied
health professionals may not admit patients to inpatient or observation care.
C.
A physician member of the Medical Staff shall be responsible for the medical care
and treatment of each patient in the Hospital, for the prompt completion and
accuracy of the medical record, for necessary special instructions, and for
transmitting reports on the condition of the patient to the referring practitioner.
Whenever these responsibilities are transferred to another Staff member, a note
covering the transfer of responsibility shall be entered on the order sheet of the
medical record.
D.
Patients will be admitted to the appropriate level of care based on the condition of
the patient, as defined in Hospital Policy 1.1.1.
E.
No patient will be transferred from one level of care to another without such
transfer being approved by the responsible Practitioner.
F.
If any questions as to the validity of admission to or discharge from the Intensive
Care Unit should arise, that decision is to be made through consultation with the
Medical Director of the Intensive Care Unit.
Discharge Of Patients
A.
The attending Practitioner is required to document the need for continued
hospitalization on an on-going basis, including plans for post-op care.
B.
When required under the Hospital’s approved utilization review plan, the
attending Practitioner shall provide written justification of the necessity for
continued hospitalization of any patient. This justification shall be documented
within the time frames stated in the utilization review plan.
C.
Patients shall be discharged only on order of the attending Practitioner. Should a
patient leave the Hospital against the advice of the attending Practitioner, or
without proper discharge, a notation of the incident shall be made in the patient’s
medical record.
D.
It shall be the duty of all Staff members to secure meaningful autopsies, in
accordance with applicable Hospital policies, whenever possible in all deaths that
meet the autopsy criteria adopted by the Medical Staff.
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III.
Medical Records – General Requirements
A.
The Hospital is a “paper light” organization. As such, physicians need to adhere
to record keeping practices that support the electronic environment. As much
data as possible will be created electronically, and paper-based documentation
will be scanned. Records will be accessed by physicians and others online, and
the records will not be printed for internal use.
B.
All medical record documents created after the patient is admitted will be created
using Hospital-approved forms or Hospital electronic systems to allow for patient
information to be exchanged and shared electronically among healthcare
providers. This includes operative/invasive procedure reports, consultations,
discharge summaries, and progress notes.
C.
Access to patient information on the EMR will be made available to Medical Staff
members and their staff and Allied Health Professionals. All access to electronic
records is tracked, and unauthorized access to a patient’s record is not permitted.
All Practitioners and Allied Health Professionals must maintain the
confidentiality of passwords and may not disclose such passwords to anyone.
D.
Medical Staff members and Allied Health Professionals who are
appointed/granted privileges pending electronic medical record training and who
have not completed this training within six (6) months of appointment will be
considered to have voluntarily relinquished clinical privileges and/or to have
voluntarily resigned from the Medical Staff. Practitioners and Allied Health
Professional will be advised of the training requirement at or prior to
appointment/granting of clinical privileges and reminded of the requirement at
least twice after the date of appointment. Exceptions may be made on a case-bycase basis as determined by the Hospital President.
E.
All clinical entries in the patient’s medical record shall be accurately dated, timed
and authenticated by the responsible Practitioner or by other providers within the
authority of their clinical privileges. Electronic signature authentication of
medical records is standard practice at the Hospital. Each individual who makes
entries in the medical record shall submit to Administration a signed statement to
the effect that he/she is the only one who will use his/her electronic signature.
There shall be no delegation of the use of such electronic signature to another
individual.
F.
The following medical record entries must be co-signed by a physician member of
the Medical Staff:
1.
Physical exam documenting, history taking, and writing of orders by
audiologists;
2.
Physical exam documenting, history taking, and writing of orders by
psychologists;
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3.
Physical exam documenting, history taking, and writing of orders by nurse
practitioners, unless otherwise permitted by applicable law and the
Collaboration Agreement between the nurse practitioner and collaborating
physician;
4.
Documentation of histories and physical exams and orders written for
inpatients by physician assistants in the Hospital (co-signing physician
must be physician assistant’s supervising physician). Unless otherwise
precluded by any third party payer’s rules for payment, physician
assistants (except those employed by temporary staffing agencies) may
write orders without co-signature for laboratory services, diagnostic
radiological services, audiology services, and physical, occupational, and
speech therapy to be furnished for outpatients and Emergency Department
patients at the Hospital, provided that the writing of each such order is
within the scope of the physician assistant’s license and Specified Services
and written under the supervision of a physician member of the active
Medical Staff; and
5.
Physical exam documenting, history taking, and writing of orders by
certified nurse-midwives, unless otherwise permitted by applicable law
and the Collaboration Agreement between the nurse-midwife and the
collaborating physician.
G.
Symbols and abbreviations may be used in medical records only when they have
been approved by the Medical Staff. An official record of approved abbreviations
should be reviewed at least yearly by the Medical Staff and kept on file in the
Medical Record Department.
H.
Information contained in all medical records may only be released upon proper
authorization from the patient or his/her legal representative or as required or
allowed by applicable law, in accordance with Hospital policies and procedures.
Medical records may be removed from the Hospital’s jurisdiction and safekeeping
only in accordance with applicable law. All medical records are the property of
the Hospital. Unauthorized removal of or access to medical records is grounds for
suspension of the Practitioner for a period to be determined by the Medical
Executive Committee.
IV. Medical Records – Contents
A.
The attending Practitioner shall be responsible for the preparation of a complete
and legible medical record for each patient. Its contents shall be pertinent and
current. This record shall include:
1.
Patient’s name, address, date of birth, and the name of any legally
authorized representative;
2.
Legal status of patients receiving mental health services;
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3.
Emergency care provided to patient prior to arrival, if any;
4.
The record and findings of the patient’s assessment (including allergies);
5.
A statement of the conclusions or impressions drawn from the medical
history and physical examination;
6.
The diagnosis or diagnostic impression;
7.
The reasons for admission or treatment;
8.
The goals of treatment and the treatment plan;
9.
Evidence of known advance directives;
10.
Evidence of informed consent for procedures and treatments for which
informed consent is required;
11.
Diagnostic and therapeutic orders, if any;
12.
All diagnostic and therapeutic procedures and tests performed and the
results;
13.
Reports of all operative and other invasive procedures performed, using
acceptable disease and operative terminology that includes etiology, as
appropriate, and tissue reports for any removed tissue;
14.
Progress notes made by the Medical Staff and other authorized
individuals;
15.
All reassessments and any revisions of the treatment plan;
16.
Clinical observations (including vital signs);
17.
The patient’s response to the care provided (including complications,
hospital acquired infections, and unfavorable reactions to drugs and
anesthesia);
18.
Consultation reports;
19.
Every medication ordered or prescribed for an inpatient;
20.
Every dose of medication administered and any adverse drug reaction;
21.
Each medication dispensed to or prescribed for an ambulatory patient or
an inpatient on discharge;
22.
All relevant diagnoses established during the course of care, including the
final diagnosis;
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B.
23.
Any referrals/communications made to external or internal care providers
and to community agencies;
24.
Clinical resumes and discharge summaries, or a final progress note or
transfer summary;
25.
Documentation of discharge instructions to the patient and family;
26.
Autopsy findings when an autopsy is performed;
27.
Anatomical gift information, if any; and
28.
Records of communication with the patient and any patient-generated
information.
The medical record must be sufficiently detailed and organized to enable:
1.
The responsible Practitioner to provide continuing care, determine later
what the patient’s condition was at a specified time, and review
diagnostic/therapeutic procedures performed and the patient’s response to
treatment.
2.
A consultant to render an opinion after an examination of the patient and
review of the health record.
3.
Another Practitioner to assume care of the patient at any time.
4.
Retrieval of pertinent information required for utilization review and/or
quality assurance activities.
5.
Accurate diagnosis for coding purposes.
C.
Transfer of primary responsibility of the patient is not effective until either (1) the
transferring physician and accepting physician have agreed to and discussed the
transfer in a phone conversation, or (2) the transfer has been documented in the
EMR by the transferring physician and accepted by the accepting physician in the
EMR. Transfer of responsibility from the Emergency Medicine Physician to an
On-Call Physician or Personal Physician (as those physician descriptions are
provided under Section B of the Emergency Service Rules and Regulations) shall
be documented in the patient’s medical record.
D.
History and Physical Examinations.
1.
A completed history and physical examination shall be recorded by a
physician member of the Medical Staff or Allied Health Professional who
is authorized by the Medical Staff to perform history and physical
examinations, and shall be dated and timed no later than twenty-four (24)
hours after admission or registration, or prior to surgery or a procedure
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requiring anesthesia services (except in emergencies), whichever is
sooner, except as otherwise provided herein. An oral surgeon with
appropriate privileges who admits or registers a patient without medical
conditions may perform the history and physical examination and assess
the medical risks of the procedure to the patient. Dentists and podiatrists
with appropriate privileges are responsible for the part of their patients’
history and physical examination that relates to dentistry or podiatry, in
addition to the medical history and physical.
2.
The completed full history and physical report should include:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
3.
Medical history
Chief complaint
History of the current illness
Relevant past medical, family and/or social history appropriate to
the patient’s age
Review of body systems
A list of current medications and dosages
Any known allergies, including past medication reactions and
biological allergies
Existing co-morbid conditions
Physical examination: current physical assessment
Provisional diagnosis: statement of the conclusions or impressions
drawn from the medical history and physical examination
Initial plan: statement of the course of action planned for the
patient while in the Hospital.
For outpatients undergoing surgical procedures requiring general or
regional anesthesia or monitored anesthesia care, a full history and
physical report, as described above in Section IV(D)(2) must be completed
within 24 hours after registration or prior to surgery or anesthesia,
whichever is sooner (except in emergencies). For outpatients undergoing
surgical or invasive procedures that do not require general or regional
anesthesia or monitored anesthesia care, a short form history and physical
report may be used. A short form history and physical report must
include:
a.
b.
c.
d.
e.
f.
Indications/symptoms for the procedure
A list of current medications and dosages
Any known allergies including past medication reactions
Existing co-morbid conditions
Assessment of mental status
Exam specific to the procedure performed
For patients receiving IV moderate sedation, the completed short form
history and physical report must include all of the above elements plus the
following:
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a. Examination of the heart and lungs by auscultation
b. American Society of Anesthesia (ASA) status
c. Documentation that patient is an appropriate candidate for IV moderate
sedation.
4.
If an appropriate history has been recorded and a physical examination
performed within thirty (30) days prior to the patient’s admission to the
Hospital, surgical procedure, or other procedure requiring completion of a
history and physical, a reasonably durable, legible copy of this report may
be used in the patient’s Hospital medical record in lieu of completing a
history and physical report upon admission or registration as required
above in Sections IV(D)(2) and (3). In all such cases, an update
documenting any changes in the patient’s condition must be completed
within twenty-four (24) hours after admission or registration, or prior to
surgery or a procedure requiring anesthesia services, whichever is sooner
(except in emergencies).
5.
A history and physical examination performed by a non-privileged
physician may be utilized provided that a Medical Staff member or other
authorized/privileged individual: reviews the history and physical
examination document, conducts a second assessment to confirm the
information and findings, updates any information and findings as
necessary (including a summary of the patient’s condition and of the
course of care during the interim period) and the current
physical/psychosocial status, and signs and dates the information as an
attestation to it being current.
6.
If a patient is readmitted within thirty (30) days for the same or related
problem, an interval history and physical that includes all additions to the
history and any subsequent changes in the physical findings may be used
in the medical record provided the original information is readily
available.
7.
When the history and physical examination are not recorded before an
operation or any potentially hazardous diagnostic procedure, the procedure
shall be canceled, unless the attending Practitioner states in writing that
such delay would be detrimental to the patient.
E.
A concise admitting note which indicates reason(s) for hospitalization, working
diagnosis, and general plan of care shall be made on the day of admission.
F.
Pertinent progress notes shall be recorded, dated and timed at the time of
observation, sufficient to permit continuity of care and transferability. Wherever
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.
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G.
Consultations shall show evidence of a review of the patient’s record by the
consultant, pertinent findings on examination of the patient, the consultant’s
opinion and recommendations. Consultation reports shall be written or dictated
within twenty-four (24) hours of seeing the patient. This report shall be dated,
timed, authenticated and made a part of the patient’s medical record. A limited
statement such as “I concur” does not constitute an acceptable report of
consultation. When operative procedures are involved, the consultation note
shall, except in emergency situations so verified on the record, be recorded prior
to the operation.
H.
The current obstetrical record shall include a complete prenatal record. The
prenatal record may be supplied through the electronic medical record system or
may be a legible hard copy of the attending Practitioner’s office record transferred
to the Hospital before admission and updated as necessary.
I.
The following elements must be recorded for all patients receiving emergency
care:
1.
Adequate patient identification. When not obtainable, the reason shall be
entered in the medical record;
2.
Time of arrival, by what means and by whom transported;
3.
Appropriate physical examination to include recording of vital signs. Date
of last tetanus injection should be recorded in all cases where the skin is
broken;
4.
The pertinent history of the illness or injury including details relative to
first aid or emergency care given prior to arrival;
5.
Diagnostic and therapeutic orders;
6.
Clinical observations, including results of treatment, if appropriate;
7.
Reports of procedures, tests and results;
8.
Diagnostic impression;
9.
Condition of patient on discharge or transfer;
10.
Final disposition, including instructions given to the patient and/or family
for follow-up care;
11.
A patient's leaving against medical advice, if applicable; and
12.
Signature of responsible physician.
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The Emergency Department record template contains all of the essential elements
as outlined above.
J.
The responsible Practitioner should record and authenticate a pre-operative
diagnosis prior to surgery. An operative report must be dictated or documented in
the electronic medical record and dated and timed immediately following surgery
for inpatients and outpatients, and the report must be promptly signed by the
surgeon and made a part of the patient’s current medical record. Operative
reports shall include:
1.
Name and hospital identification number of the patient;
2.
Date and times of the surgery;
3.
Name of the surgeon(s) and assistants or other providers who performed
surgical tasks (even when performing those tasks under supervision) and a
description of the specific surgical tasks that were conducted by providers
other than primary surgeon/practitioner;
4.
Pre-operative and post-operative diagnosis;
5.
Name of the specific surgical procedure(s) performed;
6.
Type of anesthesia administered;
7.
Complications, if any;
8.
A description of techniques, findings, and tissues removed or altered;
9.
Prosthetic devices, grafts, tissues, transplants, or devices implanted, if any;
and
10.
Estimated blood loss.
When there is a transcription or filing delay of the dictated operative report, an
operative progress note must be entered in the medical record immediately after
surgery to provide pertinent information to those attending the patient. The
operative progress note must include the name(s) of the primary surgeon(s) and
his/her assistant(s), the procedure performed, a description of each procedure
finding, estimated blood loss, specimens removed, and post-operative diagnosis.
K.
The anesthesia record shall include:
1.
Name and Hospital identification number of the patient;
2.
Name of the anesthesiologist;
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L.
3.
Name, dosage, route and time of administration of all drugs and agents
used;
4.
The monitoring of the patient;
5.
The type and amount of all fluids administered, including blood and blood
products;
6.
Technique(s) used;
7.
Oxygen flow rates;
8.
Continuous recordings of patient status noting blood pressure, heart and
respiration rate;
9.
Any complications or problems occurring during the anesthesia period,
including time and description of symptoms, vital signs, treatments
rendered and patient’s response to treatment; and
10.
The status of the patient at the conclusion of anesthesia.
A pre-anesthetic note will be made on the patient's Hospital chart by the physician
responsible for the anesthesia, and this will include pertinent information such as:
1.
The results of the pre-operative evaluation,
2.
Pre-op medication (amount and time given),
3.
Physical status of patient,
4.
Latest pre-op vital signs, and
5.
Initial pulse and blood pressure readings taken in the O.R. suite.
The patient's medical record shall contain appropriate documentation of pertinent
information relative to the choice of anesthesia and the surgical or obstetrical
procedure anticipated.
M.
The post-anesthesia records should include:
1.
Vital signs and level of consciousness;
2.
Intravenous fluids administered, including blood and blood products;
3.
All drugs administered;
4.
Post-anesthesia visits; and
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5.
Any unusual events or postoperative complications and the management
of those events.
The post-anesthesia visits will be recorded, including at least one note describing
the presence or absence of anesthesia-related complications. Post-anesthesia
entries may be written in the doctor's progress notes, not necessarily on the
anesthesia record sheet. A note made in the surgical or obstetrical suite, or in the
post-anesthesia care unit, does not ordinarily constitute a visit. Complete
recovery and readiness for discharge from the post-anesthesia care unit is
determined by the clinical judgment of an anesthesiologist or another qualified
physician. Each post-anesthesia note shall specify the date and time, cardiac
status, level of consciousness (LOC), any complications and observations. While
the number of visits by an anesthesiologist will be determined by the status of the
patient in relation to the procedure performed and anesthesia administered, a visit
should be made early in the post-operative period and also after complete
recovery from anesthesia.
N.
Final diagnosis, as well as complications and operative procedures performed
shall be recorded in full, without the use of symbols or abbreviations, and dated,
timed and signed by the responsible Practitioner at the time of discharge of all
patients. This will be deemed equally as important as the actual discharge order.
O.
A discharge summary shall be dictated or entered in the EMR and dated and
timed for all inpatients. The discharge summary should recapitulate concisely the
reason for hospitalization, significant findings, procedures performed, treatment
rendered, condition of patient on discharge, and any specific instructions given to
the patient and/or family. All discharge summaries shall be authenticated by the
responsible Practitioner. For short stay observation patients, the responsible
Practitioner must record a final note that includes the outcome of the hospital stay,
disposition of the patient, and provisions for follow-up care.
In the event of death, a summation statement should be added to the record as a
final progress note. This final note should indicate the reasons for admission,
findings and course in the Hospital and events leading to death.
P.
V.
A Practitioner’s routine orders, when applicable to a given patient, shall be
reproduced in detail in the electronic medical record and be dated, timed and
signed by the Practitioner.
Medical Records – Timely Completion
A.
All medical records shall be completed within the time frames defined below:
Documentation
Requirement
Timeframe
Emergency Department
Documented within 24 hours
of discharge/disposition from
Exclusions/Exceptions
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Record
the ED
History and Physical
Examination (full or short
form as required)
Documented within 24 hours
of admission or registration or
prior to any surgery or
procedure requiring anesthesia
services, whichever is earlier
Admitting Progress Note
Documented within 24 hours
of admission
Progress Note
Documented within 24 hours
of observation
Operative or Other High-Risk
Procedure Report
Immediately after procedure
Pre-anesthetic Note
Documented within 24 hours
of the pre-operative evaluation
Post-anesthesia Visit Report
Documented within 48 hours
after surgery
Consultation Report
Documented within 24 hours
of consultation
Discharge/Death Summary or
Final Note for Short Stay
Observation Patients
Documented at the time of
discharge/death but no later
than 7 days post
discharge/death
Verbal Orders
Authenticated within 24 hours
of order
Signatures/Authentication
Transcribed or scanned reports
and progress notes within 15
days from the date of
discharge
B.
If completion of H&P prior to
surgery or procedure requiring
anesthesia services would be
detrimental to patient as
documented in the EMR by
the attending Practitioner
If there is a transcription or
filing delay of the dictated
operative report, an operative
progress note must be entered
in the medical record
immediately after surgery to
provide pertinent information
to those attending the patient.
Current records shall be complete in so far as possible at the discharge of a patient
or within twenty-four (24) to forty-eight (48) hours after discharge. A chart not
complete within fifteen (15) days following discharge shall be considered
delinquent. A patient’s medical record that lacks one or more Practitioner
signatures will be considered incomplete and therefore delinquent.
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C.
The Health Information Management Department shall advise Practitioners by
mail or e-mail of incomplete and delinquent medical records. A Notice of
Incomplete Records will be sent after a qualifying deficiency has reached 7 days
from the date the deficiency is assigned (allocation date). The notice will include
a due date and a list of all incomplete medical records. No additional notification
of incomplete records is given. If at 14 days after discharge the records remain
incomplete, a Notice of Delinquent Records will be sent. If at 21 days after
discharge the records remain incomplete, a Suspension Warning will be sent. The
Suspension Warning will indicate that, if records are not completed within
twenty-four (24) hours, temporary suspension will be imposed in accordance with
paragraph E below.
D.
If a vacation prevents the Practitioner from completing his /her medical records,
the Practitioner must notify the Health Information Management Department in
advance of the vacation; otherwise, the suspension/sanction will remain in effect
until the documentation is completed. If there are extenuating circumstances
(e.g., illness, extended absences) that prevent the Practitioner from completing
his/her medical records, the Practitioner or the Practitioner’s office must notify
the Health Information Management Department. When an individual
Practitioner has notified the Health Information Management Department
regarding being out of town or ill prior to being placed on suspension, the
suspension process will be waived. The Practitioner will be given one week after
his/her return to complete any delinquent records.
E.
A medical record is considered eligible for suspension/sanction beginning 22 days
from the date the deficiency is assigned (allocation date).
1.
22 days from the date the deficiency is assigned, temporary suspension
will apply as further described in this section. Upon temporary
suspension, the delinquent Practitioner shall have no admitting, treating,
surgical and/or consultative privileges, other than patients needing
emergent care, until delinquent records have been completed. A member
whose privileges have been suspended under this Section shall be allowed
to continue to treat his/her patients who were in the Hospital under their
care prior to imposition of the temporary suspension of privileges.
Suspension of privileges does not apply to emergency cases nor does it
preclude a Practitioner from taking assigned or voluntary call rotations.
Specifically, a suspended Practitioner shall NOT: admit new patients (the
Practitioner may continue to treat a patient previously admitted by such
Practitioner), schedule new admissions, treat patients under an
associate’s/covering physician’s name, perform consultations on new
patients, schedule inpatient or outpatient surgeries or perform other nonemergent/elective procedures, assist in elective surgery or administer
anesthesia.
2.
If the Practitioner accumulates 23 consecutive or intermittent days of
suspension in a revolving 12-month period, the Chief of Service or
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designee will attempt to contact the Practitioner informing him/her of their
medical record responsibilities and further consequences. Documentation
of this communication will be placed in the Practitioner’s file.
F.
3.
If the Practitioner accumulates 25 consecutive or intermittent days of
suspension in a revolving 12-month period, he/she will be contacted by a
member of the Medical Staff leadership and/or Chief Medical Officer who
will explain the documentation requirements and the consequences of
accumulating 60 days of suspension. Documentation of the
communication will be placed in the Practitioner’s file.
4.
If the Practitioner accumulates 60 consecutive or intermittent days of
suspension in a cumulative/revolving 12-month period, such suspension
will be taken into consideration at the time of reappointment to the
Medical Staff.
5.
Restoration of suspended privileges can be accomplished only by
completion of all delinquent records assigned to the suspended physician.
It shall be the responsibility of the Health Information Management
Department to immediately notify appropriate parties upon completion of
delinquent records so that the name of the Practitioner may be removed
from the suspension list.
Allied Health Professionals are subject to the provisions above regarding
incomplete medical records. The privileges of Allied Health Professionals shall
be suspended in accordance with the policy above for incomplete records.
VI. General Conduct Of Care
A.
A general consent form, signed by or on behalf of every patient admitted to the
Hospital, must be obtained at the time of admission. The admitting officer shall
notify the attending Practitioner if such consent has not been obtained. Except in
emergency situations, a specific consent must also be obtained by the Practitioner
from the patient or his or her legal representative prior to any “surgery,” invasive”
non-surgical procedure, (unless an explicit exception applies), or other treatment,
as set forth in the Informed Consent Policy and/or as the treating physician
determines is appropriate.
B.
All orders for treatment shall be in writing. Verbal and telephone orders of
authorized Practitioners shall be accepted by credentialed professional medical
personnel, authorized to accept and implement orders, in the area of their
expertise. The individual accepting the verbal or telephone order shall write it
down or enter it into a computer and read back the written order to the individual
giving the order to confirm that it has been received and recorded correctly.
Verbal and telephone orders shall be used sparingly. All verbal and telephone
orders shall be authenticated within 24 hours and dated and timed by the
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individual responsible for ordering, providing or evaluating the item or service, or
by the covering Medical Staff member, as appropriate.
C.
Diagnostic and rehabilitative services may be ordered for nonhospitalized patients
by licensed practitioners, within the legal scope of their license, who are not
members of the Medical Staff. The Medical Staff shall determine, with Board
approval, which services non-Medical Staff members may order and the criteria
governing which licensed practitioners may order such services. An Emergency
Department physician or hospitalist may order diagnostic tests for nonhospitalized
patients, provided that the ordering of such tests is discussed with the patient’s
primary care physician or specialist and the primary care physician or specialist
agrees to follow up with the patient regarding the test results.
D.
Each member of the Staff who does not reside in the vicinity of the Hospital shall
have a previously designated member of the Medical Staff who is resident in the
area to see his/her Hospital patients, or any new or acute outpatient, when he may
not be available for any reason at all.
E.
Any qualified Practitioner with clinical privileges in this Hospital may be called
for consultation within his area of expertise.
F.
The patient’s attending physician is primarily responsible for requesting
consultation when indicated and for calling in a qualified consultant. The
attending physician will provide written authorization to permit another
Practitioner to attend or examine his patient, except in an emergency
G.
Except in an emergency, consultation is recommended in the following situations:
a)
If the proposed operation or treatment presents high risk for the patient.
b)
If the diagnosis is obscure after ordinary diagnostic procedures have been
completed.
c)
If there is doubt as to the choice of therapeutic measures to be utilized.
d)
In unusually complicated situations in which specific skills of other
Practitioners may be needed.
e)
In instances in which the patient exhibits severe psychiatric symptoms.
f)
If requested by the patient or his family.
If a nurse has any reason to doubt or question the care provided to any patient or
believes that appropriate consultation is needed, and has not been obtained, the
nurse shall call this to the attention of her superior who in turn may refer the
matter to the Vice President of Patient Care Services who shall contact the
attending physician. If warranted, the Vice President of Patient Care Services may
bring the matter to the attention of the chief of service wherein the Practitioner
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has clinical privileges. If circumstances justify such action, the chief of service
may on his own initiative, request a consultation.
H.
If in a nurse’s assessment, placement of a patient in restraints is necessary, the
attending physician shall be notified as soon as possible. Physician orders and
procedures shall be done according to the Hospital’s Patient Restraint Policy.
I.
All protocols for research and clinical investigation involving Hospital patients
and/or medical records must be reviewed and approved by Hospital
administration and an institutional review board prior to initiation of the study.
All research subjects must give informed consent in accordance with applicable
law prior to being involved in research.
VII. Organized Health Care Arrangement (OHCA) under HIPAA
A.
Subject to the limitations in the Hospital’s OHCA policy, the Hospital and its
Medical (and Allied Health) Staff members (referred to for purposes of this
section as “members”) operate as an Organized Health Care Arrangement
“OHCA” in that they provide direct patient care services through clinically
integrated settings (e.g., inpatient or outpatient hospital settings and/or other
hospital-based clinic settings). Under HIPAA, if two or more providers (including
a hospital and its medical staff) are part of the same OHCA, they may issue a joint
notice of their privacy practices and obtain a joint acknowledgement from an
individual patient. Accordingly, for patients treated through the Hospital’s
OHCA, only one notice and one acknowledgement are required for the Hospital
and all members in the OHCA. In accordance with members’ obligations under
the Medical Staff Bylaws, members shall comply with the terms and conditions of
the Hospital’s OHCA policy.
B.
Notwithstanding the foregoing OHCA relationship described in this policy:
a)
The Hospital shall not be liable to any third parties, whether under theories
of apparent agency or any other theory of liability, for the acts and
omissions of its Medical Staff members; and
b)
The members of the Medical Staff shall not be liable to any third parties,
whether under theories of apparent agency or any other theory of liability,
for the acts and omissions of the Hospital.
VIII. AHP Qualifications, Responsibilities And Clinical Duties
A.
Audiologist
The audiology staff shall consist of individuals who are legally licensed to
practice as audiologists in the State of Wisconsin. They shall exercise Specified
Services as may be determined in conformity with the Medical Staff Bylaws.
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Within the limits specified in Article V of the Bylaws, the audiologist shall
perform specified patient care services and will record the interpretation of reports
and progress notes pertinent to the auditory condition of the patient.
All patients attended by the audiology staff shall be admitted and discharged by a
physician Medical Staff member who has the primary responsibility for the care
of the patient. Physical exam documenting, history taking and writing of orders
are the dual responsibility of the Medical Staff member and the audiologist and
must be signed by the physician Medical Staff members.
Audiology staff members shall not be eligible to admit patients to the Hospital, to
vote on matters related to the Medical Staff, nor to hold office in the Medical
Staff organization. They may vote on matters related to committees or services to
which they are assigned.
B.
Psychologist
The psychology staff shall consist of individuals with a doctorate in psychology
or its equivalent from an accredited college or university and legally licensed to
practice psychology in the State of Wisconsin. They shall exercise Specified
Services as may be determined in conformity with the Medical Staff Bylaws.
Within the limits specified in Article V of the Bylaws, psychologists shall limit
their practices to their demonstrated areas of professional competency including,
as appropriate:
a)
Evaluation, diagnosis, and assessment of the functioning of individuals.
b)
Interventions to facilitate the functioning of individuals. Such
interventions may include psychological counseling, psychotherapy, and
process consultation.
c)
Consultations relating to (a) and (b) above.
All patients attended by the psychology staff shall be admitted and discharged by
a physician member of the Medical Staff who has the primary responsibility for
the care of the patient.
Psychologists shall not be eligible to admit patients to the Hospital, to vote on
matters related to the Medical Staff, nor to hold office in the Medical Staff
organization. They may vote on matters related to committees or services to
which they are assigned.
The psychologist will record reports and progress notes pertinent to the
psychological condition of the patient. Physical exam documenting, history taking
and writing of orders are the dual responsibility of the Medical Staff member and
the psychologist and must be signed by a physician Medical Staff member.
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C.
Nurse Practitioner
The nurse practitioner staff shall consist of individuals who are appropriately
certified and legally licensed to practice as advance practice nurse prescribers in
the State of Wisconsin. Each nurse practitioner caring for Emergency Department
patients must maintain evidence of current ACLS certification and evidence of
CPR competency. Nurse practitioners shall exercise Specified Services as may be
determined in conformity with the Medical Staff Bylaws.
The nurse practitioner shall be sponsored by, and work in collaboration with, a
physician on the active Staff at the Hospital.
Within the limits specified in Article V of the Bylaws, the nurse practitioner shall
perform specified patient care services and will record reports and progress notes
as to the condition of the patient.
All patients attended by the nurse practitioner will be admitted and discharged by
a physician Medical Staff member who has the primary responsibility for the care
of the patient. Physical exam documenting, history taking, and writing of orders
must be co-signed by the physician Medical Staff member, unless otherwise
permitted by applicable law and the Collaboration Agreement between the nurse
practitioner and the collaborating physician. Unless otherwise precluded by any
third party payer’s rules for payment, nurse practitioners may write orders without
co-signature by a physician for laboratory services, diagnostic radiological
services, audiology services, and physical, occupational, and speech therapy to be
furnished to outpatients at the Hospital, provided that the writing of each such
order is within the scope of the nurse practitioner’s license and Specified Services
granted by the Hospital’s Medical Staff.
Nurse practitioners shall not be eligible to admit patients to the Hospital, to vote
on matters related to the Medical Staff, nor to hold office in the Medical Staff
organization. They may vote on matters related to committees or services to
which they are assigned.
D.
Physician Assistant
The physician assistant staff shall consist of individuals who are appropriately
certified and legally licensed to practice as physician assistants in the State of
Wisconsin. Each physician assistant caring for Emergency Department patients
must maintain evidence of current ACLS certification and evidence of CPR
competency. Physician assistants shall exercise Specified Services as may be
determined in conformity with the Medical Staff Bylaws.
The entire practice of a physician assistant shall be sponsored and supervised by a
physician on the active staff at the Hospital. The physician assistant's practice
may not exceed his or her educational training or experience and may not exceed
the scope of practice of the supervising physician. A medical care task assigned
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by the supervising physician to a physician assistant may not be delegated by the
physician assistant to another person.
Within the limits specified in Article V of the Bylaws, the physician assistant
shall perform specified patient care services and will record reports and progress
notes as to the condition of the patient.
All patients attended by the physician assistant will be admitted and discharged by
a physician Medical Staff member who has the primary responsibility for the care
of the patient. Documentation of histories and physical exams and orders written
for inpatients by physician assistants in the Hospital must be co-signed by the
physician Medical Staff member supervising the physician assistant. Unless
otherwise precluded by any third party payer’s rules for payment, physician
assistants (except those employed by a temporary staffing agency) may write
orders without co-signature by a physician for laboratory services, diagnostic
radiological services, audiology services, and physical, occupational, and speech
therapy to be furnished for outpatients and Emergency Department patients at the
Hospital, provided that the writing of each such order is within the scope of the
physician assistant’s license and Specified Services granted by the Hospital’s
Medical Staff and that the order is written under the supervision of a duly licensed
physician who is on the active Medical Staff of the Hospital.
Physician assistants shall not be eligible to admit patients to the Hospital, to vote
on matters related to the Medical Staff, nor to hold office in the Medical Staff
organization. They may vote on matters related to committees or services to
which they are assigned.
As required by Wisconsin law, a physician must supervise the prescribing practice
of a physician assistant and must conduct a periodic review of the prescription
orders prepared by the physician assistant to ensure quality of care. In conducting
the periodic review of the prescriptive practice of a physician assistant, the
supervising physician must:
1. Review a selection of the prescription orders prepared by the physician
assistant; and/or
2. Review a selection of the patient records prepared by the physician
assistant practicing in the office of the supervising physician or at a
facility or a hospital in which the supervising physician has staff
privileges.
The supervising physician must determine the method and frequency of the
periodic review based upon the nature of the prescriptive practice, the experience
of the physician assistant, and the welfare of the patients. The supervising
physician must document the process and schedule for review in writing and must
indicate the minimum frequency of review and identify the selection of
prescriptive orders or patient records to be reviewed.
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E.
Surgical Assistant
The surgical assistant shall consist of professional support personnel employed by
members of the Staff or by the Hospital. They may be approved to provide
services upon the receipt of a completed Surgical Assistant Scope of Practice
Request Form, including required documents.
Within the limits specified in Article V of the Bylaws, the surgical assistant may
assist in operative procedures in the Operating Room Suite under the direct
supervision of the supervising surgeon.
Surgical assistants shall not be eligible to admit patients to the Hospital, to vote
on matters related to the Medical Staff, nor to hold office in the Medical Staff
organization. They may vote on matters related to committees or services to
which they are assigned.
MW01/ 9017469.7
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