Medical Staff Policies

If you are in need of any of these medical staff rules, please send E-mail. Be sure to include the name and # of the rules/policies that you desire. The first 5 are free. Additional policies will be made available for a fee. A CD of all of the policies will be available in the near future on our website. If you are interested in the CD, please contact us by E-mail so that we have an idea of the approximate number of CD's needed for possible purchase.

GENERIC TABLE OF CONTENTS FOR MEDICAL STAFF RULES

DEFINITIONS

GENERAL INTRODUCTION

PATIENT RIGHTS

PART ONE: ADMISSION OF PATIENTS

TYPE OF PATIENTS

1.2 GENERAL ADMISSION RULES

1.3 ADMITTING PREROGATIVES

1.3‑1 GENERAL REQUIREMENTS

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 ADMISSION ‑ FIFTH PRIORITY

1.4‑6 CURRENT DAY REQUESTS FOR ELECTIVE ADMISSION

SIXTH PRIORITY

1.5 ADMISSIONS DURING PEAK CENSUS

1.5-1 PURPOSE

1.5-2 POLICY

1.6 ADMISSIONS OF NEWBORNS BORN IN AND OUT OF THE

HOSPITAL

1.6-1 BABIES BORN IN THE HOSPITAL

1.6-2 BABIES BORN OUTSIDE THE HOSPITAL OR IN A SEPTIC

ENVIRONMENT

1.6-3 OTHER APPLICABLE POLICIES

1.7 ADMISSIONS TO PSYCHIATRY

1.7-1 ADMITTING POLICY

1.7-2 CRITERIA FOR ADMISSION

1.7-3 PSYCHIATRIC EVALUATION

1.8 OBSERVATION STATUS POLICY

1.8-1 PURPOSE

1.8-2 GENERAL REQUIREMENTS

1.8-3 TYPES OF PATIENTS APPROPRIATE FOR OBSERVATION

1.8-4 STATUS

1.8-4 PHYSICIAN COVERAGE

1.8-5 OTHER SPECIFIC REQUIREMENTS/PROCEDURES

1.9 RESTRICTED BED USE AREAS

1.10 ADMISSION INFORMATION

1.11 ADMISSION OF PERSONS INCAPACITATED BY ALCOHOL/DRUGS

1.12 ADMISSION OF PATIENTS TO NURSING UNIT FROM COUNTY JAIL

1.13 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

2.3-2 EXEMPTIONS

2.3-3 ON-CALL SCHEDULING

2.3-4 WEEKEND COVERAGE-PSYCHIATRY

2.4 EMERGENCY DEPARTMENT ON-CALL COVERAGE

2.4-1 PHYSICIAN SPECIALIST COVERAGE OF THE EMERGENCY

2.4-2 DEPARTMENT

PART THREE: GENERAL RESPONSIBILITY FOR AND CONDUCT

OF CARE

3.1 GENERAL REQUIREMENTS

3.2 TRANSFER OF RESPONSIBILITY

3.3 ALTERNATE COVERAGE

3.4 DENTISTS, PODIATRISTS AND ALLIED HEALTH PROFESSIONALS

(MEDICAL ANCILLARY STAFF

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 PSYCHIATRIC CONSULTATIONS

- EMERGENCY DEPARTMENT

- SERVICE CONSULTATIONS

- MEDICAL/SURGICAL FLOORS

3.6-8 PSYCHIATRIC CONSULTATIONS FOR POTENTIALLY

SUICIDAL PATIENTS

3.6‑9 DOCUMENTATION

PART FOUR: TRANSFER OF PATIENTS

4.1 INTERNAL TRANSFER

4.1-1 TRANSFER PRIORITIES

4.1-2 GENERAL REQUIREMENTS

4.1-3 SPECIFIC REQUIREMENTS

4.1-4 OF CRITICAL CARE PATIENTS

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

4.2-4 TRANSFER OF HIGH RISK OBSTETRICAL PATIENTS

4.3 INTER‑FACILITY TRANSFERS FOR SPECIALIZED TREATMENT

4.4 TRANSFERS FROM ANOTHER FACILITY

PART FIVE: DISCHARGE OF PATIENTS

5.1 REQUIRED ORDER

5.1-1 GENERAL REQUIREMENTS

5.2 TIME OF DISCHARGE

5.3 LEAVING AGAINST MEDICAL ADVICE

5.4 DISCHARGE OF MINOR PATIENTS

5.5 DISCHARGE PLANNING

5.5-1 GENERAL REQUIREMENTS

5.5-2 FOR BHS PATIENTS

5.6 DISCHARGE OF THE AMBULATORY SURGICAL PATIENT

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 ALLIED HEALTH PROFESSIONALS/ADVANCED PRACTICE

NURSES

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 TRANSFUSIONS AND INTRAVENOUS INFUSIONS

6.8-1 STARTING

6.8-2 NEED FOR INFORMED CONSENT

6.8-3 AUTOLOGOUS BLOOD

6.8-4 PITOCIN DRIP

6.8-5 IV STREPTOKINASE

6.8-6 TPA

6.8-7 CENTRAL LINE THERAPY

6.8-8 INTRAVENOUS THERAPY POLICIES

6.9 SPECIAL ORDERS

6.9‑1 DO NOT RESUSCITATE ORDERS

6.9-2 COMFORT MEASURES ONLY

6.9-3 WITHHOLDING/WITHDRAWAL OF LIFE SUSTAINING

TREATMENT

6.9-4 DETERMINATION OF BRAIN DEATH

6.9-5 ADVANCE DIRECTIVES

6.9‑6 RESTRAINT AND SECLUSION

6.9-7 CONSCIOUS SEDATION

6.9‑8 MULTIDISCIPLINARY CARE PLAN

6.9-9 1:1 OBSERVATION FOR SUICIDAL PRECAUTIONS-

INPATIENTS

6.9-10 SPECIAL TREATMENT PROCEDURES

6.9-11 CLOSE OBSERVATION

6.9-12 SUICIDAL PRECAUTIONS

6.9-13 PATIENT'S OWN DRUGS AND SELF‑ADMINISTRATION

6.9-14 POLICE INTERROGATION OF HOSPITAL PATIENTS

6.10 FORMULARY AND INVESTIGATIONAL DRUGS

6.10-1 GENERAL REQUIREMENTS

6.10‑2 FORMULARY

6.10‑3 INVESTIGATIONAL DRUGS

6.10-4 SPECIFIC DRUGS & ASSOCIATED REQUIREMENTS

- RITODRINE

- PITOCIN DRIP (SEE 6.8-4)

- IV STREPTOKINASE (SEE 6.8-5)

- TPA (SEE 6.8-6)

- AMNIOINFUSION VIA INTRAUTERINE CATHETER

- PREPIDIL GEL

6.11 PAIN MANAGEMENT

6.11-1 POLICY

6.11-2 PURPOSE

6.11-3 PROCEDURE

6.11-4 DEFINITIONS

6.11-5 MANAGEMENT OF EPIDURAL/INTRATHICAL

ANALGESIA

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

- FOR INPATIENT MEDICAL RECORDS

- FOR BHS PROGRAM

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 USE OF REPORTS PREPARED PRIOR TO CURRENT

ADMISSION

7.2-3 EVALUATION OF PSYCHIATRIC PATIENTS

7.3 PREOPERATIVE DOCUMENTATION

7.3‑1 HISTORY AND PHYSICAL EXAMINATION

7.3-2 SHORT FORM

7.3‑3 LABORATORY TESTS

7.3‑4 PREOPERATIVE ANESTHESIA EVALUATION

7.4 PROGRESS NOTES

7.4‑1 GENERAL REQUIREMENTS

7.4‑2 BY ATTENDING PRACTITIONER WHEN HOUSE STAFF

ARE INVOLVED

7.4-3 BY OTHER DISCIPLINES/REQUIRED FORMAT

7.4-4 FOR PSYCHIATRIC PATIENTS

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 GENERAL CONDITIONS

7.12-2 BY PATIENT OR THEIR LEGALLY DELEGATED

REPRESENTATIVE

7.12‑3 FOR STATISTICAL PURPOSES AND REQUIRED

ACTIVITIES

7.12-4 FOR RESEARCH PROJECTS

7.12‑5 BY FORMER MEDICAL STAFF MEMBERS

7.12‑6 PATIENT CONSENT REQUIRED UNDER OTHER

CIRCUMSTANCES

7.12‑7 USE OF MEDICAL RECORD 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

8.2‑5 EMERGENCIES

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

8.2-8 DETERMINATION OF PATIENT’S ABILITY TO MAKE

INFORMED DECISIONS

PART NINE: SPECIAL SERVICES UNITS AND PROGRAMS

9.1 DESIGNATION

9.2 POLICIES

9.3 ANCILLARY SERVICE ISSUES

PART TEN: HOSPITAL DEATHS AND AUTOPSIES

10.1 HOSPITAL 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 STAFF HOME PHONE

NUMBERS AND TELEPHONE COVERAGE

12.1 MEDICAL/DENTAL STAFF HOME PHONE NUMBERS

12.2 TELEPHONE COVERAGE

PART THIRTEEN: MEDICAL STAFF RECORDS

13.1 MEDICAL STAFF RECORDS

13.1-1 SCOPE

13.1-2 GENERAL POLICY

13.1-3 LOCATION AND SECURITY PRECAUTIONS

13.1-4 ACCESS BY PERSONS WITHIN THE HOSPITAL

OR MEDICAL STAFF

13.1-5 ACCESS BY PERSONS OR ORGANIZATIONS OUTSIDE OF

THIS HOSPITAL OR MEDICAL STAFF

13.5-6 RESPONSIBILITIES OF MEMBERS OF THE MEDICAL

STAFF

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

19.3 PROCEDURES FOR THE RELEASE OF PATIENT INFORMATION

19.3-1 CASES OF PUBLIC RECORD

19.3-2 CORONER’S CASES

19.3-3 CASES NOT OF PUBLIC RECORD

19.3-4 NATURE OF ACCIDENT OR INJURY

19-3-5 ATTENDING PHYSICIAN

19.3-6 BIRTHS

19.3-7 RELEASE OF INFORMATION AND ADMITTING CODES

19.3-8 RESPONSIBILITIES

19.3-9 ADVANCED NOTIFICATION

19.3-10.1 STAFF AND EMPLOYEE RESPONSIBILITY TO NOTIFY

COMMUNITY RELATIONS

19.3-11 NEWSWORTHY EVENTS

PART TWENTY: AMENDMENT & ANNUAL REVIEW

20.1 AMENDMENT & ANNUAL REVIEW

PART TWENTY-ONE: ADOPTION

21.1 MEDICAL STAFF

21.2 BOARD OF TRUSTEES