Generic Outline For Medical Staff Rules and Regulations

TABLE OF CONTENTS

DEFINITIONS

GENERAL INTRODUCTION

PART ONE: ADMISSION OF PATIENTS

1.1 TYPES OF PATIENTS

1.2 GENERAL ADMISSION RULES

1.3 ADMITTING PREROGATIVES

1.3-1 GENERALLY
1.3-2 STAFF PRIORITIES WHEN RESOURCES STRAINED

1.3-3 LIMITATIONS FOR DENTISTS AND PODIATRISTS

1.4 ADMISSION PRIORITIES BASED ON PATIENT CONDITION

1.4-1 EMERGENT CONDITION - FIRST PRIORITY
1.4-2 GUARANTEED ADMISSIONS - SECOND PRIORITY

1.4-3 POSTOPERATIVE ADMISSIONS - THIRD PRIORITY

1.4-4 URGENT CONDITION - FOURTH PRIORITY

1.4-5 SCHEDULED ELECTIVE ADMISSIONS - FIFTH PRIORITY

1.4-6 CURRENT DAY REQUESTS FOR ELECTIVE ADMISSIONS- SIXTH PRIORITY

1.5 ADMISSIONS DURING PEAK CENSUS

1.6 ADMISSIONS OF NEWBORNS BORN IN AND OUT OF THE MEDICAL CENTER

1.7 ADMISSIONS TO PSYCHIATRY

1.8 TIME OF ADMISSION

1.9 RESTRICTED BED USE AREAS

1.10 ADMISSION INFORMATION

1.11 TIMELY VISITATION AFTER PATIENT ADMITTED

PART TWO: ASSIGNMENT AND ATTENDANCE OF PATIENTS

2.1 ASSIGNMENT TO SERVICE

2.2 ATTENDANCE OF PATIENTS

2.2-1 PRIVATE PATIENTS
2.2-2 IMMEDIATE VICINITY REQUIREMENT

2.3 PARTICIPATION IN THE ON-CALL ROSTER

2.3-1 GENERAL REQUIREMENTS

2.4 EMERGENCY DEPARTMENT ON-CALL COVERAGE

2.4-1 PHYSICIAN SPECIALIST COVERAGE OF THE EMERGENCY DEPARTMENT

PART THREE: GENERAL RESPONSIBILITY FOR AND CONDUCT OF CARE

3.1 GENERALLY

3.2 TRANSFER OF RESPONSIBILITY

3.3 ALTERNATE COVERAGE

3.4 DENTISTS, PODIATRISTS AND MEDICAL ANCILLARY AFFILIATES

3.5 POLICY CONCERNING IMMEDIATE QUESTIONS OF CARE

3.6 CONSULTATIONS

3.6-1 RESPONSIBILITY
3.6-2 GUIDELINES FOR CALLING CONSULTATIONS

3.6-3 QUALIFICATIONS OF CONSULTANT

3.6-4 RULES REGARDING CONSULTATIONS

3.6-5 PEDIATRIC CONSULTATIONS/CASE MANAGEMENT BY A PEDIATRICIAN

3.6-6 PSYCHIATRIC PATIENTS- MEDICAL CONSULTATIONS

3.6-7 DOCUMENTATION

PART FOUR: TRANSFER OF PATIENTS

4.1 INTERNAL TRANSFER

4.2 TRANSFER TO ANOTHER FACILITY

4.2-1 GENERAL REQUIREMENTS
4.2-2 SPECIFIC REQUIREMENTS

4.2-3 DEMANDED BY EMERGENCY OR CRITICALLY ILL PATIENT

4.3 SOCIAL TRANSFERS

4.4 INTER-FACILITY TRANSFERS FOR SPECIALIZED TREATMENT

4.5 TRANSFERS FROM ANOTHER FACILITY

PART FIVE: DISCHARGE OF PATIENTS

5.1 REQUIRED ORDER

5.2 TIME OF DISCHARGE

5.3 LEAVING AGAINST MEDICAL ADVICE

5.4 DISCHARGE OF MINOR PATIENTS

5.5 DISCHARGE PLANNING

PART SIX: ORDERS

6.1 GENERAL REQUIREMENTS

6.2 STANDING ORDERS

6.3 UNACCEPTABLE ORDERS

6.4 VERBAL/TELEPHONE ORDERS

6.4-1 BY WHOM AND CIRCUMSTANCES
6.4-2 DOCUMENTATION

6.5 ORDERS BY MEDICAL ANCILLARY AFFILIATE

6.6 AUTOMATIC CANCELLATION OF ORDERS

6.7 STOP ORDERS

6.7-1 DRUGS/TREATMENT COVERED AND MAXIMUM DURATION
6.7-2 SCHEDULE FOR THE REWRITING OF MEDICATION ORDERS

6.7-3 EXCEPTIONS

6.7-4 NOTIFICATION OF STOP

6.8 BLOOD/BLOOD PRODUCTS TRANSFUSIONS AND INTRAVENOUS INFUSIONS

6.8-1 STARTING
6.8-2 NEED FOR INFORMED CONSENT

6.8-3 AUTOLOGOUS BLOOD

6.9 SPECIAL ORDERS

6.9-1 NO CODE ORDERS
6.9-2 WITHDRAWAL OF LIFE SUSTAINING TREATMENT IN AN OTHERWISE MEDICALLY STABLE PATIENT

6.9-3 DETERMINATION OF BRAIN DEATH

6.9-4 ADVANCE DIRECTIVES

6.9-5 RESTRAINT AND SECLUSION

6.9-6 CONSCIOUS SEDATION

6.9-7 MULTIDISCIPLINARY CARE PLAN

6.9-8 OBSERVATION FOR SUICIDAL PRECAUTIONS- INPATIENTS

6.9-9 SPECIAL TREATMENT PROCEDURES

6.9-10 CLOSE OBSERVATION STATUS

6.9-11 PATIENT'S OWN DRUGS AND SELF-ADMINISTRATION

6.10 FORMULARY AND INVESTIGATIONAL DRUGS

6.10-1 GENERAL REQUIREMENTS
6.10-2 FORMULARY

6.10-3 INVESTIGATIONAL DRUGS

6.11 PAIN MANAGEMENT

6.11-1 POLICY
6.11-2 PURPOSE

6.11-3 PROCEDURE

PART SEVEN: INPATIENT MEDIAL RECORDS

7.1 UNIT RECORD SYSTEM

7.1-1 SCOPE OF MEDICAL RECORD DOCUMENTATION
7.1-2 UNIT RECORD

7.1-3 AUTHORIZED ENTRIES

7.1-4 REQUIRED CONTENT

7.1-5 USE OF ENGLISH LANGUAGE

7.1-6 DELINQUENT MEDICAL RECORDS

7.2 HISTORY AND PHYSICAL EXAMINATION

7.2-1 GENERALLY
7.2-2 MEDICAL EVALUATIONS OF PATIENTS RECEIVING CONTINUING AMBULATORY CARE

7.2-3 USE OF REPORTS PREPARED PRIOR TO CURRENT ADMISSION

7.3 PREOPERATIVE DOCUMENTATION

7.3-1 HISTORY AND PHYSICAL EXAMINATION
7.3-2 LABORATORY TESTS

7.3-3 PREOPERATIVE ANESTHESIA EVALUATION

7.4 PROGRESS NOTES

7.4-1 GENERALLY

7.5 OPERATIVE SPECIAL PROCEDURE AND TISSUE REPORTS

7.5-1 OPERATIVE AND SPECIAL PROCEDURE REPORTS
7.5-2 TISSUE EXAMINATION AND REPORTS

7.5-3 POSSIBLE EXEMPTED CATEGORIES

7.5-4 PRE-PROCEDURE REVIEW OF EXTERNAL HISTO-PATHOLOGIC DIAGNOSIS

7.6 ENTRIES AT CONCLUSION OF HOSPITALIZATION

7.6-1 FACE SHEET
7.6-2 DISCHARGE SUMMARY

7.6-3 INSTRUCTIONS TO PATIENT

7.7 AUTHENTICATION

7.7-1 GENERALLY
7.7-2 SPECIFICALLY

7.8 LATE ENTRIES

7.9 USE OF SYMBOLS AND ABBREVIATIONS

7.10 FILING

7.11 OWNERSHIP AND REMOVAL OF RECORDS

7.12 ACCESS TO RECORDS

7.12-1 BY PATIENT OR THEIR LEGALLY DELEGATED REPRESENTATIVE
7.12-2 FOR WORKER'S COMPENSATION CASES

7.12-3 FOR STATISTICAL PURPOSES AND REQUIRED ACTIVITIES

7.12-4 TO FORMER MEDICAL STAFF MEMBERS

7.12-5 PATIENT CONSENT REQUIRED UNDER OTHER CIRCUMSTANCES

7.12-6 USE OF MEDICAL RECORD ON READMISSION

PART EIGHT: CONSENTS

8.1 GENERAL

8.2 INFORMED CONSENT

8.2-1 WHEN REQUIRED
8.2-2 WHEN NOT REQUIRED

8.2-3 DOCUMENTATION REQUIRED

8.2-4 SIGNATURES

8.2-5EMERGENCIES

8.2-6 CONSENT RELATING TO PHYSICAL ASSAULT AND VENEREAL DISEASES AND CARE OF THE SEXUALLY ASSAULTED PERSON

8.2-7 INFORMED CONSENT FOR PSYCHIATRIC CARE

PART NINE: SPECIAL SERVICES UNITS AND PROGRAMS

9.1 DESIGNATION

9.2 POLICIES

9.3 ANCILLARY SERVICE ISSUES

PART TEN: MEDICAL CENTER DEATHS AND AUTOPSIES

10.1 MEDICAL CENTER DEATHS

10.1-1 PRONOUNCEMENT
10.1-2 DETERMINATION OF BRAIN DEATH

10.1-3 REPORTABLE DEATHS

10.1-4 DEATH CERTIFICATE

10.1-5 RELEASE OF BODY

10.2 AUTOPSIES

1O.2-1 UNCLAIMED REMAINS

PART ELEVEN: INFECTION CONTROL

11.1 CULTURES

11.2 PATIENTS WITH INFECTIOUS/COMMUNICABLE DISEASES

11.3 REPORTING OF INFECTIOUS/COMMUNICABLE DISEASES

11.4 PULMONARY TUBERCULOSIS

11.5 TUBERCULOSIS TESTING OF MEDICAL STAFF

11.6 HIV TESTING

11.7 GENERAL AUTHORITY

11.8 NOSOCOMIAL INFECTIONS

PART TWELVE: MEDICAL/DENTAL/PODIATRY STAFF HOME PHONE NUMBERS AND TELEPHONE COVERAGE

12.1 MEDICAL/DENTAL/PODIATRY STAFF HOME PHONE NUMBERS

12.2 TELEPHONE COVERAGE

PART THIRTEEN: RECORDING OF MEETINGS

13.1 RECORDING OF MEETINGS

PART FOURTEEN: MEDICALLY INDIGENT

14.1 MEDICALLY INDIGENT

PART FIFTEEN: DISRUPTIVE BEHAVIOR - INDEPENDENT PRACTITIONERS/MEMBERS OF MEDICAL STAFF

15.1 DISRUPTIVE BEHAVIOR

PART SIXTEEN: ORGAN DONATIONS

16.1 POLICY

16.2 OBJECTIVE/PURPOSE

16.3 PROCEDURE

16.4 HARVESTING OF ORGANS

PART SEVENTEEN: DISASTER EMERGENCY ASSIGNMENTS

17.1 DISASTER EMERGENCY ASSIGNMENTS

PART EIGHTEEN: PHYSICIAN PERFORMANCE FILES

18.1 PHYSICIAN PERFORMANCE FILES

PART NINETEEN: MEDIA INQUIRIES AND DISSEMINATION OF INFORMATION

19.1 MEDIA INQUIRIES

19.2 DISSEMINATION OF INFORMATION

19.2-1 PURPOSE OF POLICY
19.2-2 POLICY

19.3 PROCEDURES FOR THE RELEASE OF PATIENT INFORMATION

19.3-1 CASES OF PUBLIC RECORD
19.3-2 CORONERS CASES

19.3-3 CASES NOT OF PUBLIC RECORD

19.3-4 NEWSWORTHY EVENTS

PART TWENTY: AMENDMENT

20.1 AMENDMENT

PART TWENTY-ONE: ADOPTION

21.1 MEDICAL STAFF

21.2 BOARD OF TRUSTEES

APPENDIX 1: GENERAL RULES FOR EMERGENCY DEPARTMENT

A-1.1 GENERAL RULES
A-1.2 ON-CALL SPECIALISTS' RESPONSE TO EMERGENCY DEPARTMENT

A-1.3 DUTY SCHEDULE

APPENDIX 2: GENERAL RULES FOR SURGICAL SERVICES AND THE OPERATING AND RECOVERY ROOMS

A-2.1 TIME OF ADMISSION FOR SURGICAL PATIENTS
A-2.2 SCHEDULING EMERGENCY SURGERY

A-2.2-1 POLICY
A-2.2-2 PROCEDURE

A-2.3 REQUIREMENTS PRIOR TO INDUCTION OF ANESTHESIA & OPERATION

A-2.3-1 PREOPERATIVE EVALUATION AND DOCUMENTATION
A-2.3-2 CONSENT

A-2.3-3 IDENTIFICATION

A-2.4 SURGICAL PROCEDURES NOT REQUIRING ASSISTANTS

A-2.5 SURGICAL PROCEDURES REQUIRING ASSISTANTS

A-2.5-1 MAJOR SURGERY: QUALIFIED FIRST ASSISTANTS

A-2.6 TRANSPORT OF PATIENTS

A-2.7 ENFORCEMENT AND INTERPRETATION

A-2.8 OPERATING ROOM

A-2.8-13 SCHEDULE
A-2.8-14 RESERVATIONS AND PRIORITY

A-2.8-15 INFORMATION PROVIDED UPON SCHEDULING

A-2.8-16 STARTING TIME FOR OPERATIONS AND CANCELLATIONS

A-2.8-17 MONITORING

A-2.8-18 ATTIRE

A-2.8-19 TRAFFIC PATTERNS

A-2.8-20 UNUSUAL EVENT REPORTING

A-2.9 ANESTHESIA ON-CALL RULES

A-2.10 POST ANESTHESIA RECOVERY ROOM

A-2.11 NEW PROCEDURES

A-2.12 SURGICAL DAY STAY UNIT DISCHARGE CRITERIA

APPENDIX 3: GENERAL RULES FOR SPECIAL CARE UNITS GUIDELINES

A-3.1 ADMISSION
A-3.2 NORTH ADMISSION/DISCHARGE CRITERIA

A-3.2-1 POLICY
A-3.2-2   ADMISSION/DISCHARGE CRITERIA

A-3.2-3   DRUGS WHICH MAY BE INITIATED WHILE ON UNIT- PATIENT HEMODYNAMICALLY STABLE

A-3.2-4   PRIORITY PATIENT PLACEMENT

A-3.3 SRICU ADMISSION/DISCHARGE CRITERIA

A-3.3-1   POLICY
A-3.3-2   ADMISSION/DISCHARGE CRITERIA

A-3.4 CCU ADMISSION/DISCHARGE CRITERIA

A-3.4-1   POLICY
A-3.4-2 ADMISSION/DISCHARGE CRITERIA

A-3.5 MICU ADMISSION/DISCHARGE CRITERIA

A-3.5-1 POLICY
A-3.5-2 ADMISSION/DISCHARGE CRITERIA

A-3.6 PEDIATRIC ADMISSION TO ADULT ICU

A-3.6-1 POLICY
A-3.6-2 PROCEDURE

A-3.7 CONSULTATIONS IN CCU

A-3.8 STANDING ORDERS

A-3.8-1 POLICY
A-3.8-2 PROCEDURE

APPENDIX 4: STEP DOWN UNIT ADMISSION/DISCHARGE CRITERIA

A-4.1 WEST STEPDOWN AREA ADMISSION/DISCHARGE CRITERIA
A-4.1-1 POLICY
A-4.1-2 ADMISSION/DISCHARGE CRITERIA

A-4.2 RESPONSIBILITY FOR PATIENT CARE IN THE CRITICAL CARE/ WEST STEPDOWN UNITS

A-4.2-1 POLICY
A-4.2-2 PROCEDURE

APPENDIX 5: ADMISSION CRITERIA FOR USE OF THE LABOR AND DELIVERY UNIT

A-5.1 POLICY
A-5.2 ADMISSION CRITERIA

A-5.3 LIMITATIONS OF THE LABOR AND DELIVERY UNIT

A-5.4 SPECIAL CIRCUMSTANCES

APPENDIX 6: LABOR AND DELIVERY POST ANESTHESIA CARE UNIT

A-6.1 PURPOSE
A-6.2 ADMISSION CRITERIA

A-6.3 DISCHARGE CRITERIA

APPENDIX 7: OUTPATIENT DEPARTMENT AND SPECIALITY CLINICS

A-7.1 MEDICAL DIRECTION FOR THE OUTPATIENT DEPARTMENT
A-7.1-1 POLICY
A-7.1-2 PROCEDURE

A-7.2 OUTPATIENT DEPARTMENT DISCHARGE CRITERIA

A-7.2-1 POLICY
A-7.2-2 DISCHARGE CRITERIA

APPENDIX 8: NEWBORN NURSERY

A-8.1 STANDING ORDERS FOR THE NEWBORN NURSERY
A-8.1-1 POLICY
A-8.1-2 PROCEDURE

APPENDIX 9: ALCOHOL WITHDRAWAL UNIT

A-9.1 CRITERIA FOR ADMISSION TO THE ALCOHOL WITHDRAWAL UNIT
A-9.1-1 POLICY
A-9.1-2 ADMISSION CRITERIA AND RULES

A-9.2 DISCHARGE FROM THE ALCOHOL WITHDRAWAL UNIT

A-9.2-1 POLICY

A-9.2-2 PROCEDURE

A-9.3 VISITORS IN THE ALCOHOL WITHDRAWAL UNIT

A-9.3-1 POLICY

A-9.3-2 PROCEDURE