Fayette County Memorial Hospital Medical Staff Rules and Regulations 2015

Transcription

1 Fayette County Memorial Hospital Medical Staff Rules and Regulations 2015

2 Section One: GENERAL Rule 1.01 Rule 1.02 These Rules & Regulations adopt and incorporate by reference the definitions contained in the Medical Staff Bylaws or AHP Policy, as applicable, unless a different definition is set forth herein. These Rules & Regulations are applicable to all Practitioners and Allied Health Professionals granted Privileges at the Hospital. Section Two: ADMISSION AND DISCHARGE Rule 2.01 Admissions Patients can only be admitted to the Hospital by Medical Staff Appointees who have been granted admitting Privileges. Rule 2.02 Admission Policy The Hospital shall admit patients suffering from all types of acute and chronic diseases subject to the Hospital s capacity and capability. Rule 2.03 Admission through Emergency Department. 1. Every patient in the Emergency Department will be cared for by an Emergency Department provider with or without the involvement of the patient s personal attending Practitioner. If inpatient admission is indicated, the patient will be admitted under the care of the patient s personal attending Practitioner provided such Practitioner is a Medical Staff Appointee with admitting Privileges at the Hospital. 2. Patients who have no personal attending Practitioner, or whose personal Practitioner is not a Medical Staff Appointee with admitting Privileges at the Hospital, will be admitted to a Physician who is part of the Hospitalist service. 3. If there is a disagreement concerning the need for a patient to be admitted, the patient s personal attending Practitioner, the appropriate on-call Practitioner, or the on-duty Hospitalist will be asked to present to the Emergency Department for evaluation of the patient and to write disposition or admitting orders. 4. If the patient s personal Practitioner cannot be reached, after multiple attempts, within thirty (30) minutes, the Emergency Department Physician may contact the following individuals, in the order noted, for further assistance. a. The patient s choice of Practitioner provided the Practitioner is a Medical Staff Appointee with appropriate Privileges. b. Hospitalist c. The Service Chief relative to the patient s complaint.

3 d. The Chief of Staff. 5. Any admitting orders written by an Emergency Department Physician shall conform to the appropriate protocols established by the Medical Director for the Emergency Department. 6. In the event of a disaster or influx of patients beyond the capability of the Emergency Department providers, other Practitioners and Allied Health Professionals with Privileges at the Hospital will respond as outlined in the Emergency Disaster Plan. Volunteer Practitioners and Allied Health Professionals may be granted disaster Privileges in accordance with the procedure set forth in the Medical Staff Bylaws or Allied Health Policy, as applicable, to assist the Hospital during a disaster. Rule 2.04 Admission to Swing Bed 1. Patients who require skilled nursing or rehabilitative care will only be admitted under the care of the patient s personal attending Practitioner if the personal attending Practitioner is appointed to the Medical Staff with admitting Privileges. 2. Patients who have no personal attending Practitioner, or whose personal attending Practitioner is unavailable to provide care or has not been granted Medical Staff appointment with admitting Privileges, will be admitted to a Physician who is part of the Hospitalist service. 3. Swing bed admissions shall be in accordance with the procedures set forth in the Hospital s Admission Process Swing Bed policy as such policy may be amended from time to time. Rule 2.05 Advance Directives All adult patients admitted to the Hospital shall be questioned regarding the existence of any advance directives; and, such documents shall be respected when completed and provided in accordance with Ohio law. Additional requirements with respect to advance directives are set forth in the Hospital s Advance Directives policy as such policy may be amended from time to time. Rule 2.06 General Consent 1. Except in an emergency, a proper general Hospital consent for care/treatment, signed by or on behalf of every patient, must be obtained before the patient is treated in the Hospital. 2. Admitting office personnel shall notify the admitting Practitioner whenever such consent has not been obtained. This consent does not obviate the Practitioner s responsibility for informing the patient of, and obtaining informed consent to, medical treatment or procedures to be performed by the Practitioner as outlined in the Hospital s Informed Consent policy as such policy may be amended from time to time.

4 Rule 2.07 Dentists, Oral Surgeons, Podiatrists, and Psychologists Dentists, Oral Surgeons, and Podiatrists may admit patients to the Hospital if granted the Privilege to do so. Psychologists may not admit or co-admit patients to the Hospital. Psychologists may treat only those patients who have been admitted by a Physician- Appointee with admitting Privileges and must maintain a consultative relationship with the attending Physician during the patient s course of treatment. Additional requirements regarding care of patients by a Dentist, Oral Surgeon, Podiatrist, or Psychologist are set forth in the Medical Staff Bylaws. Rule 2.08 Outpatient Observation Status Attending Practitioners must comply with the outpatient observation status criteria in accordance with applicable law and the requirements of payer groups contracted with the Hospital. Any patient who does not meet the inpatient admission criteria will be placed in outpatient observation for the purpose of identifying the patient s diagnosis and disposition (i.e. discharge or inpatient admission). Attending Practitioners will work closely with all Hospital departments concerned regarding the continuity of care for such patients. Rule 2.09 Outpatient Surgery Elective outpatient surgery should be scheduled to allow for adequate recovery time and discharge the same day. Rule 2.10 Patient Discharge 1. Patients shall be discharged only upon order of the attending Practitioner, unless the patient requests discharge against medical advice. 2. If the patient requests discharge against medical advice, the patient shall be requested to sign a form provided by the Hospital indicating that the patient s discharge is at the patient s request and against medical advice. The attending Practitioner shall be contacted to discuss the risks and alternatives to leaving against medical advice with the patient. This conversation may be face to face or by telephone. This discussion shall be documented in the patient s medical record. If the patient refuses to talk to the Practitioner or leaves before the Practitioner is contacted, the Practitioner is still to be contacted. The event will be documented in the patient s medical record. Rule 2.11 Discharge Planning It shall be the responsibility of the attending Practitioner to discharge his or her patients in a timely fashion and in a manner consistent with the continuing care, treatment, and services that the patient may need. Page 4 of 16

5 Section Three: MEDICAL RECORDS Rule 3.01 Authentication 1. All entries in the medical record must be dated, timed, and authenticated by the person responsible for providing or evaluating the care, treatment, and/or service(s) provided. 2. Authentication means to establish authorship by written signature, identifiable initials, computer key, or other code. Rule 3.02 Confidentiality of Patient Medical Records/Protected Health Information 1. A Practitioner s and AHP s access to patient medical records is limited to necessary access for purposes of treatment, payment, or healthcare operations in accordance with federal and state law. In case of readmission of a patient to the Hospital, all of the patient s previous medical records shall be available for the use of the attending Practitioner, responsible AHP, if any, and any consulting Practitioner(s). This shall apply whether the patient is attended by the same Practitioner/AHP as in the first admission or by a different Practitioner(s)/AHP(s). 2. All Practitioners and AHPs are required to maintain the confidentiality of patients medical records/protected health information and to comply (i) with all federal and state laws regarding confidentiality of medical records/protected health information and (ii) with all Hospital policies and rules regarding confidentiality of medical records/protected health information including, but not limited to, the Hospital s HIPAA Notice of Privacy Practices. Improper use or disclosure of a patient s protected health information/medical record may be grounds for corrective action. Written consent of the patient or his/her legal representative is required for release of medical record copies/protected health information to persons not otherwise authorized to receive such information. Rule 3.03 Contents of Medical Record The contents of the medical record are defined in the Hospital medical record policy Components of a Medical Record as such policy may be amended from time to time. Rule 3.04 H&P, Operative Report/Note, and Discharge Summary The Hospital policy Medical Record Documentation and Completion, as such policy may be amended from time to time, defines the requirements for completion and documentation of the history and physical, operative/high risk procedure report and operative/procedure note, and discharge summary. Rule 3.05 Abbreviations/Acronyms and Symbols Approved and prohibited abbreviations as defined in the Hospital Abbreviation Policy, as such policy may be amended from time to time, apply to all orders, pre-printed forms, medication related documents, and all other medical record entries. Page 5 of 16

6 Rule 3.06 Delinquent Medical Records The procedure for addressing delinquent medical records is set forth in the Medical Staff Bylaws and applicable Medical Staff/Hospital policy as such policy may be amended from time to time. Section Four: PATIENT CARE ORDERS Rule 4.01 Automatic Cancellation of Orders All previous orders, including standing orders, are automatically canceled for patients at the time of surgery and upon transfer from one nursing unit to another. Rule 4.02 Orders in Writing 1. All orders shall be in writing, dated, timed, and authenticated. 2. Practitioners shall have the authority to issue orders as permitted by their Privileges. 3. The ability of an AHP to issue orders, if any, shall be as defined in the applicable AHP Privilege set. All AHP orders must be (i) within the AHP s defined scope of authority; (ii) within the AHP s delineated Privileges; (iii) consistent with the AHP s certificate to prescribe and standard care arrangement or supervision agreement; and (iv) in accordance with all applicable laws and Hospital and Medical Staff polices. Rule 4.03 Verbal and Telephone Orders 1. Verbal and telephone orders shall be issued in accordance with the Pharmacy policy and procedure Verbal/Telephone Orders as such policy may be amended from time to time. The use of verbal/telephone orders should be infrequent. 2. The ordering Practitioner or AHP must date and time the order at the time he or she signs the order and must sign a verbal/telephone order as soon as possible which would be the earlier of the following: (i) the next time the prescribing Practitioner or AHP provides care to the patient, assesses the patient, or documents information in the patient s medical record; or, (ii) within forty-eight (48) hours after giving the verbal or telephone order. In the event the ordering Practitioner or AHP is not able to authenticate his/her verbal/telephone order, it is acceptable for a covering Practitioner to co-sign the verbal/telephone order of the ordering Practitioner or AHP. The signature indicates that the covering Practitioner assumes responsibility for his/her colleague s order as being complete, accurate and final. An AHP may not co-sign a Practitioner s verbal/telephone order or otherwise authenticate a medical record entry for the Practitioner who gave the verbal /telephone order. 3. A repetitive behavior of failure by a Practitioner or AHP to sign his/her verbal or telephone orders within a timely fashion shall be brought to the attention of the Medical Executive Committee for appropriate action. Page 6 of 16

7 Rule 4.04 Medical Necessity for Ordering Tests Patient care orders must include the medical necessity reason. The ordering Practitioner s or Allied Health Professional s name is to be on the order. Section Five: PATIENT CARE Rule 5.01 Abortion No abortion shall be performed without the written concurrence of three (3) Appointees of the Medical Staff which documentation shall be on file with the patient s medical record. Rule 5.02 Alternate Practitioner Coverage 1. Each Practitioner with Privileges shall be responsible for providing or arranging for the provision of continuous care for his/her patients. Each Practitioner shall have made arrangements with an alternate Practitioner with comparable Privileges at the Hospital to be called to attend his/her patients when the attending Practitioner is not available. 2. The Practitioner s Service Chief, the Chief of Staff, or the Chief Executive Officer shall have authority to call any Practitioner with appropriate Privileges at the Hospital should the attending Practitioner and the alternate be unavailable or arrange for an appropriate transfer of the patient to another facility. Rule 5.03 Assistants in Surgery 1. For the welfare of the patient, it shall be the obligation of the operating Practitioner to secure appropriate assistance for him/herself on surgical cases as needed at the discretion of the operating Practitioner. The assistance of another Practitioner with Privileges, or of a qualified AHP, shall be deemed acceptable. 2. Registered nurses or scrub technicians trained in sterile surgical techniques who demonstrate documented evidence of experience and capability may also be assigned to assist in surgery. 3. Such surgical assistants will be credentialed and may be granted permission to provide services pursuant to an approved position description in accordance with the procedure set forth in the AHP Policy as such Medical Staff Policy may be amended from time to time. Rule 5.04 Autopsies 1. It shall be the duty of all Practitioners to secure autopsies whenever clinically reasonable or legally appropriate. 2. Unless otherwise provided or required by law (i.e. a coroner s case), an autopsy may be performed only with a written consent from one of the following persons who, as applicable, can be located with reasonable effort, who is of sound mind, and who is eighteen years of age or older in the order shown: Page 7 of 16

8 a. The deceased person during his or her lifetime or the individual who has the right of disposition pursuant to a written declaration executed by the deceased during his/her lifetime that remains in force at the time of the deceased s death. b. The decedent s spouse. c. The decedent s children. d. The decedent s parents. e. The decedent s siblings. f. The decedent s grandparents. g. The decedent s grandchildren. h. The lineal descendants of the decedent s grandparents. i. The person who was the deceased person s guardian at the time of the decedent s death if a guardian had been appointed. j. Any other person willing to assume the right of disposition (e.g. who assumes custody of the body for burial) after attesting in writing that a good faith effort has been made to locate the individuals above. k. A public officer or employee responsible for arranging the final disposition of the remains of the deceased person if the deceased person was an indigent person or other person whose body is the financial and statutory responsibility of the state or a political subdivision of the state. 3. The autopsy report shall be made a part of the medical record once completed. Rule 5.05 Death in the Hospital 1. In the event of a patient death occurring in the Hospital, the deceased shall be pronounced dead by a Physician as soon as possible following the death. The body shall not be released until an entry has been made and signed in the medical record of the deceased by a Physician-Appointee to the Medical Staff, except in those instances of incontrovertible and irreversible terminal diseases wherein the patient s course has been adequately documented to within a few hours of death. 2. Policies with respect to pronouncement of death and release of dead bodies shall conform to applicable law. 3. An adequate death summary shall be dictated or hand written by the attending Physician detailing relevant findings of the patient s death in accordance with applicable Hospital/Medical Staff policy as such policy may be amended from time to time. Page 8 of 16

9 Rule 5.06 Informed Consent 1. In addition to the general Hospital consent (described in Rule 2.06), a written, signed, dated, and timed informed consent shall be obtained by the responsible Practitioner prior to any operative or invasive procedure, or as may be otherwise needed, except in those situations when the patient s life is in jeopardy and signature cannot be obtained due to the condition of the patient. 2. For emergencies involving a minor or unconscious patient in which informed consent cannot be immediately obtained from the patient s parents, guardian, or other authorized/legal representative, the circumstances should be fully explained in the patient s medical record. 3. Should a second procedure be required during the patient s stay in the Hospital, a second informed consent shall be obtained. 4. It is the Practitioner s responsibility to ensure that an appropriate informed consent is obtained and made a part of the patient s medical record in accordance with the requirements set forth in the Hospital s informed consent policy as such policy may be amended from time to time. Rule 5.07 Patient Care Responsibility 1. The attending Practitioner shall be responsible for the care and treatment of each of his or her patients in the Hospital, for the prompt completion and accuracy of the patient s medical record, for necessary special instructions, and for transmitting reports of the condition of the patient to the referring Practitioner and the patient or to the patient s legal guardian or other authorized representative(s), as appropriate. 2. The admitting Practitioner is responsible for completion and documentation of the history and physical. 3. The attending Practitioner will be responsible for the discharge summary. 4. Whenever these responsibilities are transferred to another Practitioner a note shall be entered on the order sheet of the medical record to reflect this transfer of responsibility. Such arrangements for the transfer of patient care responsibility shall be made to a Practitioner with appropriate Privileges. Such transfers shall be made by direct contact with the Practitioner who shall be assuming such care; and, such Practitioner must agree to accept this responsibility. 5. Should there be disagreement regarding patient care responsibility; the applicable Service Chief will be contacted to make needed decisions and/or assume the responsibility for the patient s care. Page 9 of 16

10 Rule 5.08 Patient Transfer Whenever an attending Practitioner believes that a patient should be transferred to another Hospital, the attending Practitioner must contact the receiving Practitioner, make arrangements for the transfer, determine the mode of transportation of the patient, and complete the transfer form in accordance with applicable Hospital policy as such policy may be amended from time to time. Rule 5.09 Patient Visits 1. With the exception of swing bed admissions, the attending Practitioner or the attending Practitioner s designee must see the patient daily or more frequently as the patient s condition warrants and document each visit in a progress note. 2. The frequency of patient visits in the Hospital s Swing Bed Unit shall be in accordance with the applicable Hospital policy as such policy may be amended from time to time. Rule 5.10 Care of Specimen Handling of tissues and/or specimens shall be in accordance with the procedure set forth in the Hospital s Care of Specimen policy as such policy may be amended from time to time. Section Six: CONSULTATION Rule 6.01 Consultant Qualifications A consultant must be well qualified to give an opinion in the field in which the consultant s opinion is sought. Any qualified Practitioner may be called as a consultant so long as he or she has Privileges appropriate to the patient s condition. Rule 6.02 Required Consultations 1. Except in an emergency, consultation with another qualified Practitioner is required in the following situations. a. Cases in all Services in which, according to the judgment of the Practitioner responsible for the care of the patient: (i) (ii) the diagnosis is obscure. there is doubt as to the best therapeutic measures to be utilized. b. To address a request by the patient or the patient s family. c. In unusually complicated situations when specific skills of other Practitioners may be needed. d. Any patient with significant history (e.g., diabetes, hypertension, CAD, CVD or other history of cardiac disease, or other similar conditions or non- Page 10 of 16

11 functional metabolic state) will require pre-operative medical/cardiac evaluation by the primary care physician prior to scheduling a surgical procedure. e. When the services needed by the patient are available within the Hospital but fall outside the attending Practitioner s scope of delineated Privileges. 2. Such consultations shall be within twenty-four (24) hours. Rule 6.03 Recommended Consultations 1. Pulmonary consult is recommended for mechanically ventilated patients. 2. Pediatric/PCP consultation is recommended for any patients under 18 years of age for general anesthesia. 3. Pharmacology consultation is recommended for renal dose adjustment. Rule 6.04 Consultation Timeframe and Report 1. The consultant Practitioner may initiate diagnostic and therapeutic services in the interest of prompt and proper patient care. 2. A consultant must see the patient within twenty (24) hours of the request for a consultation unless the requesting Practitioner and the consultant agree upon a different time period as appropriate to the patient s condition. 3. A written, electronic, or dictated opinion shall be prepared and authenticated, dated, and timed by the consultant and made a part of the patient's medical record as soon as reasonably possible after seeing the patient. The consultation report shall reflect assessment of available data and include: a. Date and time of the consultation. b. Indication of a review of the patient's record. c. Indication of examination of the patient and documentation of the pertinent findings. d. The consultant's opinion and recommendation. Section Seven: EMERGENCY DEPARTMENT RULES Rule 7.01 Purpose and Objectives The Emergency Department of the Hospital provides emergency care to patients. No person presenting to the Emergency Department will be refused treatment because of race, religion, color, creed, sex, national origin, age, handicap, ability to pay or as otherwise prohibited by law. Page 11 of 16

12 Rule 7.02 Emergency Department Policies and Procedures 1. Policies, procedures, and protocols shall be developed to establish acceptable standards and practices for treating specific types of emergency patients or for dealing with certain situations which may arise in the Emergency Department. 2. As these policies, procedures, and protocols are developed, they shall be reviewed by the Medical Director of the Emergency Department and the appropriate Medical Staff committees including, but not limited to the Medical Executive Committee, prior to implementation/action. Approved policies, procedures, and protocols shall be kept in the Emergency Department and maintained electronically for review and reference. Rule 7.03 Responsibilities of Emergency Department On-Call Practitioners 1. Practitioners who are on-call must be readily available by phone and/or beeper and are expected to be able to arrive at the Hospital within sixty (60) minutes after having been contacted or such other longer time as is medically appropriate under the circumstances. The fact that a Practitioner fails to arrive within a designated time will not be viewed as establishing patient harm. Rather, in the event a Practitioner fails to arrive within an appropriate time period, the matter will be referred to the peer review process for a determination as to whether such failure constitutes grounds for corrective action. 2. The responsibility for follow-up care for those Emergency Department patients with no primary care Physician, will default to the Hospital s physician practice or pediatrician as clinically appropriate. 3. Emergency Department on-call Practitioners must: a. Be available for coverage during the week assigned. b. Provide or arrange for any appropriate and designated follow-up care for discharged Emergency Department patients who have no established Practitioner/patient relationship, regardless of payment source. Rule 7.04 Emergency Department Physician Responsibilities 1. In addition to any responsibilities outlined in the Emergency Department rules, the following specific Emergency Department Physician responsibilities apply. 2. Emergency Department Physicians shall: a. Notify the patient s family (as permitted by the patient or applicable law) or private Practitioner concerning any transfers to another facility. Prior notification is preferred, unless the delay in reaching the private Practitioner may be potentially harmful to the patient. Page 12 of 16

13 b. Respond to any patient emergencies within the Hospital, unless the Physician s presence is immediately required in the Emergency Department for critical treatment. c. Pronounce a patient s death if an admitting/attending Physician is not available for such activity. However, the patient s attending or private Physician shall be responsible for completion of the patient s death certificate. d. Provide medical direction or telephone assistance to Emergency Life Squad staff, as needed. e. Complete all Emergency Department medical records in accordance with applicable law and accreditation standards. f. Record preliminary interpretations on the appropriate form for all radiology examinations ordered by such Emergency Department Physician. g. Dress and groom in a professional and appropriate manner, including a Hospital name/identification badge. h. Remain on the Hospital grounds at all times and be immediately available, when required, to the Emergency Department. i. Arrive on time for work shifts or contact the Emergency Department if such Physician will be arriving more than ten (10) minutes late for a scheduled shift. Make appropriate arrangements for back-up coverage for any other work absences. Rule 7.05 Emergency Department Protocols 1. Protocols may be developed by the Medical Staff to serve the following purposes. a. As guidelines for treating specific types of emergency patients or for dealing with certain situations which may arise in the Emergency Department. b. As standards for quality review activities. c. For in-service educational activities. 2. Protocols represent testing or treatment orders which may be initiated, in appropriate situations, by the nursing staff prior to a patient being assessed by a Physician or Allied Health Professional. The development and use of protocols will be consistent with applicable law and accreditation standards. 3. A Medical Screening Examination may be performed by a Physician or AHP with appropriate Privileges who is qualified to conduct such examination in compliance with applicable law. Page 13 of 16

14 Section Eight: INTENSIVE CARE UNIT POLICIES Rule 8.01 Purpose and Objectives The Intensive Care Unit exists to provide an appropriate level of quality care to those patients who are or show the potential to become critically ill or for post-operative patients following major procedures. Rule 8.02 Admission Guidelines 1. Patients who are unstable or critically ill and in need of intensive treatment. 2. Patients requiring mechanical ventilation, arterial lines, or other invasive pressure monitoring devices. 3. Patients requiring insulin drips, high risk medications (e.g., pressors) and/or as otherwise identified in the Pharmacy Management of High Risk Medication policy, as such Hospital policy may be amended from time to time. 4. Patients who require monitoring of treatment modalities. 5. Patients who require increased nursing patient care ratio, suicide precautions, etc. Rule 8.03 Discharge Guidelines Patients may be transferred, as appropriate, for more definitive or specialized treatment in accordance with applicable Hospital policy as such policy may be amended from time to time. Patients may be discharged to home or transferred to a step-down or medical/surgical unit when ICU criteria are no longer met. Rule 8.04 Physician Requirements Physicians providing care to ICU patients shall be granted Privileges to do so and should be certified in ACLS or have completed a comparable advanced life support critical care course. Section Nine: OUTPATIENT SPECIALTY CLINICS POLICIES Rule 9.01 Purpose and Objectives The Hospital s provider-based Outpatient Specialty Clinics are established to provide specialty services for residents of Fayette County and the surrounding areas. Rule 9.02 Requirements for Providers 1. Assessment of each patient by the Practitioner is mandatory. 2. All Practitioners who provide services in the Outpatient Specialty Clinics shall be appropriately credentialed and granted Privileges to do so. Page 14 of 16

15 3. Practitioners may only provide services in the Outpatient Specialty Clinics consistent with their approved Privileges. Section Ten: OPERATING ROOM, PACU, AND AMBULATORY CARE SURGERY UNITS Rule Purpose and Objectives The Operating Room, PACU, and Ambulatory Care Surgery Unit are established to provide quality inpatient and outpatient surgery, including pre-operative assessment and teaching, and post-operative care in the immediate recovery period. Rule Providers of Care 1. The Practitioners and anesthesia providers providing care, treatment, and/or services are appropriately credentialed and granted Privileges to do so in accordance with the Medical Staff Bylaws or AHP Policy. 2. Practitioners and AHPs will provide care, treatment, and/or services consistent with the requirements set forth in the applicable Privilege sets. 3. Certified Registered Nurse Anesthetists ( CRNAs ) administering anesthesia will be supervised by the operating Practitioner who is performing the procedure. The Hospital permits the operating Practitioner to supervise CRNAs administering anesthesia for those procedures for which the operating Practitioner has Privileges. Rule On-Call Coverage 1. Twenty-four (24) hour on-call coverage is provided by Practitioners with designated Privileges on an established rotation schedule. 2. The Practitioner is expected to arrive at the Hospital for an emergent surgery within sixty (60) minutes from the time of contact. Rule Pre-operative and Post-operative Evaluations 1. Any patient with significant history (e.g., diabetes, hypertension, CAD, CVD or other history of cardiac disease, or other similar conditions or non-functional metabolic state) will require a pre-operative medical/cardiac evaluation by the patient s primary care Physician prior to scheduling a surgical procedure. 2. A pre-anesthesia evaluation must be performed prior to inpatient or outpatient surgery by an individual qualified to administer anesthesia and should include notation of anesthesia risk, anesthesia, drug and allergy history, any potential anesthesia problems identified, and the patient s condition prior to induction of anesthesia. 3. A post-anesthesia follow-up report must be written on all inpatients and outpatients prior to discharge from surgery and anesthesia services by an individual qualified to administer anesthesia and must include, at a minimum, cardiopulmonary status, level Page 15 of 16

16 of consciousness, any follow up care and/or observations and any complications occurring during post-anesthesia recovery. Page 16 of 16