ST. JOSEPH HOSPITAL
MEDICAL STAFF DEPARTMENT
POLICY AND PROCEDURE
TITLE: Shadowing: Observing Physicians in a Clinical Setting
Key Words:
FUNCTIONAL AREAS
Policy #
MEDICAL STAFF
Page 1
of 1
Date Implemented:
Date Reviewed:
Date Revised:
4/06
2/10
May 13, 2009 with
HR approval; 2/10
with MEC approval
PURPOSE:
1. To provide guidance to individuals requesting to observe physicians delivering
patient care in the hospital setting. This type of observation will be referred to as
“shadowing”.
2. To ensure that the confidentiality of health information is maintained.
3. To ensure that patients are not exposed to communicable disease.
4. To ensure that the observer does not provide any patient care.
RELEVANT FORMS:
Observer Application Form (attached below)
Confidentiality Agreement (attached below)
Medical Staff Safety Orientation Manual (attached below)
Observer Agreement (attached below)
Expectations of Observer (attached below)
PROCEDURE:
1. Observer shall request permission in advance from the physician they wish to
shadow.
2. Observer shall notify Medical Staff Services of the intent to shadow.
3. Prior to receiving permission to observe the participant shall:
a. Complete application to observe
b. Designate the scope, date and duration of experience
c. Provide proof of immunization
d. Sign a confidentiality agreement
e. Secure a signed observer agreement
f. Agree to not provide any patient care
g. Assure patients consent to the presence of the observer
PEROGATIVES:
1. Medical Staff Services shall retain the right to refuse permission to an Observer
who has requested a shadowing experience.
2. Observers are not permitted to discuss protected health information with anyone
other than the person they are shadowing. Observers are not permitted to use
or disclose protected health information
3. Staff being observed is asked to minimize the amount of protected health
information they disclose to the observer.
4. Observer is to not perform any direct patient care
5. When an observer is in attendance in a clinical situation involving examinations,
procedures or treatments they must secure the patients consent to be present.
Consent is sought without the observer present so that patient is given every
opportunity to refuse.
6. Terms of this agreement are limited to three months
DEFINITIONS:
Staff being observed means a physician (MD, DO, DMD/DDS or Podiatrist) who is
currently credentialed as a courtesy, associate or active medical staff member of St.
Joseph Hospital who had agreed to accept an observer in their workplace.
Observer means an individual who is an adult (18 or older) who is
- currently enrolled in an either a Physician Assistant, Physician, ARNP training
programs, or
- considering making application to a Physician Assistant, Physician, ARNP training
program who meets criteria, or
- licensed providers who request to observe medical staff for specific clinical care, or
- currently enrolled in an educational program and desires to shadow physicians, or
- an employee who wishes to observe medical staff for specific clinical care and has
completed all the documentation requirements associated with this policy*, AND
- Has an agreement with a medical staff member to observe under this policy.
*Any employee who shadows a physician under this policy is on unpaid time off.
(Approved by SJH Human Resources on May 13, 2009)
Site means St. Joseph Hospital and Medical Group where the observer will watch the
physician work. Medical Staff Services has the responsibility for administration of the
shadowing experience in accordance with this policy.
REFERENCES:
Medical Staff Bylaws, Credentials Policy, Medical Staff Organizational Manual
and Policy on Allied Health Professionals, Approved by St. Joseph Governing
Board August 2009
http://crossroads/SC_MedStaff_Whatcom/contents.htm
Medical Staff Rules and Regulations, Approved by St. Joseph Medical
Executive Committee April 17, 2006
http://crossroads/SC_MedStaff_Whatcom/Documents/Medical%20Staff%20
Bylaws%20Documents/Rules%20and%20Regulations.doc
Expectations of Observers
Physician Shadowing Program
Listed below is what is expected of you when you participate in this program:

To respect patient’s confidentiality. You are not to discuss any patient,
his/her medical history, or his/her reason for visiting a physician, with
anyone other than the person you are observing
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To conduct yourself in a professional courteous and responsible manner
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To dress appropriately when shadowing by adhering to St. Joseph Hospital
dress policy.

To realize that the physician is volunteering his/her time and has a
demanding schedule.
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To contact physician one week before the shadowing to confirm dates,
times and objectives.
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To call physician in advance if an emergency arises and you are unable to
be there.
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To secure patient’s permission prior to entering a clinical situation
involving treatment, procedure or examination.
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To not participate in observation if ill, have fever or cough.
To understand that clinical practice involves situations that will require a
degree of sensitivity to the need of the patient and the obligation of the
physician
To not provide any direct patient care. Observers may not touch
the patient or manipulate any equipment used in patient care.
Observer Agreement
I, _____________________will be observing the clinical practice of
Observer Name
_______________________at St. Joseph Hospital on ___________.
Physician Name
Date(s)
I am aware of the risks involved with an observational experience at St. Joseph
Hospital. I have read and understand the expectations of an observer. I have
read and understand the Medical Staff Safety Orientation Manual.
I confirm that I have current immunizations for:
 Rubella
 Measles
 PPD within the last year or negative chest x-ray
Any costs I incur as a result of this experience will be my responsibility
I agree to be guided by the physician being shadowed regarding policies and
procedures of SJH and the appropriateness of my observation of aspects of their
role. My signature indicates that I have the required immunizations and that I
release St. Joseph Hospital from liability claims for loss or injury arises from the
negligent or wrongful acts or omissions of the employees or agents of
PeaceHealth. I understand that I cannot provide any direct patient care.
____________________________________
Observer Signature
__________
Date
Physician Responsibility:
 I will guide this individual through an observation experience related to the
work I do.
 I will respect my patient’s/family’s wishes regarding privacy and exclusions
from being observed.
 I will inform the observer of all customary precautions, including applicable
policies and procedures, which apply to this experience.
 I will assure that the observer does not provide any direct patient
care and observers may not touch the patient or manipulate any
equipment used in patient care.
_____________________________________
Physician Signature
___________
Date
OBSERVER APPLICATION
All questions must be answered; if not applicable, indicate with "NA"
NAME _____________________________________________ SEX _____
Last
First
M.I.
DATE OF BIRTH ____/____/____
ADDRESS: _____________________________________________________
PHONE NUMBER:_______________________________________________
NAME OF PHYSICIAN OBSERVING: _______________________________
Describe areas or types of activities you will be observing and duration: (limit to three months)
___________________________________________________________________________________
_____________________________________________________________________________________
OBSERVER EDUCATION/TRAINING/BACKGROUND:
(please include: degree and dates)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________
Date
________________________________________________
Applicant’s Signature
MEDICAL STAFF OFFICE USE ONLY
APPROVALS:
____________________________
Date: ______________
Director, Medical Staff Services
___________________________
Medical Staff Services/Designee
Date: _______________
Statement and Agreement Regarding PeaceHealth
Information
During the course of your work with PeaceHealth, you may develop, use, maintain, or have incidental
contact with or access to patient information or business information that is confidential
(“PeaceHealth Information”). PeaceHealth Information from any source in any form (including paper
records, oral communication, audio recordings, and electronic displays) should be kept strictly
confidential. You may access PeaceHealth Information only if you need to know the specific
PeaceHealth Information to perform your job responsibilities.
You agree to comply with the notice of privacy practices adopted by PeaceHealth (“Joint Notice of
Privacy Practices”) as well as PeaceHealth’s policies and procedures to respect and preserve the
privacy, security, and confidentiality of PeaceHealth Information. You agree and recognize that you
are solely responsible for your own actions relating to protecting the privacy, security, and
confidentiality of PeaceHealth Information.
Violations of PeaceHealth’s policies and procedures may include, but are not limited to:
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Accessing PeaceHealth Information that is not within the scope of your job or responsibilities
to PeaceHealth or otherwise permitted by written policy.
Leaving patient medical records or charts in an unsecured place or leaving a secured
application unattended while signed on to the computer system.
Misusing, disclosing without proper authorization, or improperly altering PeaceHealth
Information.
Disclosing your sign-on code and/or password or using another person’s sign-on code and/or
password for accessing electronic or computerized records.
Discussing PeaceHealth Information in a public place (e.g., elevator or cafeteria) or with
persons not authorized to receive such information.
Violation of PeaceHealth policies and procedures by any user of PeaceHealth Information may
constitute grounds for corrective action, up to and including termination of employment or loss of
medical staff privileges, in accordance with applicable Medical Staff Bylaws, Rules, and Regulations.
Violation of PeaceHealth policies and procedures by students may constitute grounds for corrective
action in accordance with applicable PeaceHealth or educational institution procedures. Violation of
PeaceHealth policies and procedures by third parties, such as vendors, may constitute grounds for
termination of the contract or other terms of affiliation. Violation of PeaceHealth policies and
procedures also may result in civil and/or criminal liabilities and penalties.
If you use or disclose a “limited data set,” which is PeaceHealth Information that has had some but
not all identifiers removed, then you specifically agree to only use or disclose the limited data set for
research, public health, or health care operations and to comply with PeaceHealth’s policy on Deidentification of Protected Health Information and Limited Data Sets. Certain federal and state laws
provide you with the right to request access to your personal health information, under specific
circumstances. Some users have been provided the right to access their personal health information
electronically because of their job responsibilities. If you are one of these users, your right to access
your personal health information is subject to the following conditions:
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You will review only the level of information for which you have electronic information
systems access. PeaceHealth will not grant you higher levels of authorization for your review
of your personal health information. You may access your remaining health information
through your regional health information or medical records department, according to
PeaceHealth policy.
You will only review your own personal health information. You understand that you are not
authorized to review the personal health information of your spouse, children, friends, or any
other person.
Your review will take place under your sign-on password. You will not share or access
another person’s password to gain greater access.
It is your responsibility to talk with your medical provider who may have ordered any
diagnostic testing for results interpretation.
The information that you review is to be read only, and you cannot and will not alter or delete
the information.
If you find what you believe to be an error in the electronic medical record, you will submit
your request for an amendment to the Health Information Management/Medical Records
Department, for review, following PeaceHealth procedures for requesting an amendment to
your personal health information.
If you have access authorization to any financial data as part of your job responsibilities and
you have concerns regarding your financial information, you will not alter or delete any
financial data. You will direct all of your inquiries to Patient Financial Services.
If you elect to print one or more pages/screens from your personal health information, you will
then be responsible for handling your information in a confidential manner.
The opportunity to access your personal health information in any electronic information
system is subject to state and federal laws and PeaceHealth policies and procedures.
PeaceHealth retains the right to modify and change this access at any time.
I agree to comply with the terms of the above statement and agreement and also have read and agree to
comply with PeaceHealth Privacy and Security Policies and the Joint Notice of Privacy Practices adopted
by PeaceHealth. I understand that the obligations set forth in this statement and agreement continue
beyond the end of my relationship with PeaceHealth.
______________________________________________
First Name
MI
_______________________
Last Name (please print)
SSN or employee ID #
(PeaceHealth employees only)
Affiliation with PeaceHealth:
 Employee
 Medical Staff Member
 Intern or Student
 Vendor or Contractor
 Physician Office Staff
 Volunteer
 Other/Clinic name: _____________________________
______________________________________________
________________________
Signature
Date