PRATTVILLE BAPTIST HOSPITAL MEDICAL STAFF RULES & REGULATIONS October 15, 1997 Revised: April 1999 Revised: November 2002 Revised: June 2005 Revised: December 2005 Revised: December 2006 Revised: November 2007 Revised: June 2008 Revised: July 2009 Revised: November 2009
TABLE OF CONTENTS I. General Medical Staff Rules & Regulations PAGE 4 II. Credentials & Privileges PAGE 5 III. Standing Committees & Functions PAGE 6 III.1 Department of Family Practice/Internal Medicine PAGE 6 III.1-1 Composition III.1-2 Functions III.1-3 Meetings III.2 Department of Surgery PAGE 7 III.2-1 Composition III.2-2 Functions III.2-3 Meetings III.3 Pharmacy & Therapeutics Committee PAGE 7 III.3-1 Composition III.3-2 Functions III.3-3 Meetings III.4 Infection Control Committee PAGE 9 III.1-1 Composition III.1-2 Functions III.1-3 Meetings III.5 Medical Staff Involvement in Safety/Disaster/Radiology Safety Function PAGE 9 III.1-1 Composition III.1-2 Functions III.1-3 Meetings III.6 Ethics Committee PAGE 10 III.1-1 Composition III.1-2 Functions III.1-3 Meetings III.7 Special Committees of the Staff PAGE 11 III.1-1 Composition III.1-2 Functions III.1-3 Meetings IV. Emergency Services Rules & Regulations PAGE 14 IV.1 General Emergency Department Rules IV.2 Emergency Department Call List & Call Schedule Management V. Medical Records Rules & Regulations PAGE 14 VI. General Conduct of Care Rules & Regulations PAGE 18 VII. Department of Surgery Rules & Regulations PAGE 20 2
VIII. Department of Internal Medicine Rules & Regulations PAGE 23 IX. Department of Family Practice Rules & Regulations PAGE 23 X. Department of Hospital-Based Physicians Rules & Regulations PAGE 24 XI. Medical Staff Peer Review Process PAGE 25 XII. The Baptist Medical Center South Residency Program PAGE 25 XIII. Miscellaneous Rules & Regulations PAGE 25 XIV. Adoption of Rules & Regulations PAGE 26 XV. Review of Rules & Regulations PAGE 26 3
PRATTVILLE BAPTIST HOSPITAL I. GENERAL MEDICAL STAFF RULES AND REGULATIONS 1. Only practitioners granted Medical Staff membership and clinical privileges may admit patients to this Hospital and treat them except as provided in the Medical Staff Bylaws and Rules and Regulations. 2. Prattville Baptist Hospital does not provide psychiatric or substance abuse services. In the event of a psychiatric emergency, however, the hospital does provide arrangements for consultative or transfer services to an appropriate psychiatric facility. Should a patient arrive at the hospital with a psychiatric emergency or mental health management issue, the physician may contact a Case Manager for assistance in obtaining a consultation or transfer. In all cases, medical stabilization will take place prior to any transfer to a psychiatric facility. 3. If primary responsibility is transferred to another practitioner, a note covering the transfer of responsibility shall be made and the practitioner transferring his responsibility shall personally notify the other practitioner to ensure that the acceptance of that responsibility is clearly understood. Being on call for another practitioner constitutes temporary transfer of responsibility. 4. Except in the state of an emergency admission, no patient shall be admitted to the Hospital until a provisional diagnosis or valid reason for admission has been stated. In the case of an emergency such statement shall be recorded as soon as possible. A copy of the emergency service record shall accompany the patient to the nursing unit. 5. Physicians shall be able to justify emergency admissions. The history and physical must clearly justify the patient being admitted on an emergency basis and these findings must be recorded on the patient s medical record within twenty-four hours after admission. 6. When a patient is to be admitted on an emergency basis and does not have a member of the Medical Staff to accept responsibility for the patient while in the Hospital, then the on-call physician shall assume responsibility for the patient as appropriate. 7. Each member of the Medical Staff shall name another member of the Medical Staff as an alternate to be called to attend patients in an emergency, when the attending physician is not available or until the attending physician can be present. In case the alternate is not available, The Department Chair, Chief of Staff or the Administrator shall have the authority to call the on-call physician or any other member of the staff to attend the patient. Failure of a member of the staff to meet these requirements may result in disciplinary action. 8. Patients shall be discharged from the Hospital only on the order of a patient s attending practitioner or his designated physician. If a patient leaves the Hospital against the advice of the attending practitioner, or without proper discharge, a notation shall be made in the patient s medical record. 9. Patients shall be admitted to the Hospital on the basis of the following order of priorities when there is a shortage of available beds: (A) Emergency (B) Non emergency The committee responsible for the case management functions shall review admissions that do not meet the established criteria for the above categories if there is a need to do so. 4
10. The patient shall not be routinely transferred within the Hospital without the approval of the attending practitioner or his designee or consultant. The order of priority for patient transfers will be determined by the involved attending physician or, if necessary, the Chief of Staff. 11. Admissions and discharges to special care units shall be in accordance with established criteria. Any disputes regarding admission, discharge, or care of patients in Special Care units shall be referred to the Department Chairs, and ultimately the Chief of Staff, for resolution. 12. Practitioners shall give consideration to the Hospital s case management plan to include: (A) The appropriateness and medical necessity of admissions (B) Continued stay (C) Supportive services (D) Discharge planning 13. In the event of a Hospital death, the deceased shall be pronounced dead by the attending practitioner, his designee, or the physician on the scene, within a reasonable time. The body shall not be released until an entry has been made and signed in the medical record of the deceased by a member of the Medical Staff. Policies with respect to release of dead bodies and completion of death certificate shall conform to local law. 14. The attending physician must be notified within a reasonable time of the death of his patient. 15. Practitioners shall write discharge orders that will allow patients to be discharged from the Hospital as early as possible on the day of discharge. II. CREDENTIALS AND PRIVILEGES 1. Medical Staff applications for privileges will be considered active for a period of six (6) months from the date of receipt. It shall be the responsibility of the applicant to assure that all materials are received in order that the application may receive timely consideration by the Medical Staff. Any application that is not complete within six (6) months of receipt will be considered withdrawn. 2. The application fee for medical staff membership shall be as follows: Initial application to Temporary, Emergency or Provisional Medical Staff will be $ 150; Application or reapplication to any category other than Active Medical Staff - $100; Application or reapplication to Active Medical Staff or Emeritus Staff will be $ 100. 3. Allied Health Professionals Temporary privileges are granted to meet an important patient care, treatment, and service need for the time period defined in the Medical Staff Bylaws. When temporary privileges are granted to meet an important patient care need, the organized Medical Staff verifies current licensure and current competence. Temporary privileges for new applicants may be granted while awaiting review and approval by the organized Medical Staff upon verification of the following: a. Current licensure, if applicable. b. Relevant training or experience. c. Current competence. d. Ability to perform the privileges requested. e. Other criteria required by the organized Medical Staff Bylaws. f. A query and evaluation of the National Practitioner Data Bank, when applicable for licensed allied health professionals. g. No current or previously successful challenge to licensure or registration. h. No subjection to involuntary termination of medical staff membership at another organization. 5
i. No subjection to involuntarily limitation, reduction, denial or loss of clinical privileges. All temporary privileges are granted by the administrator or authorized designee on the recommendation of the Medical Staff president or authorized designee. Temporary privileges for new applicants are granted for no more than 120 days. (06/24/2009) III. STANDING COMMITTEES AND FUNCTIONS III.1 DEPARTMENTS OF FAMILY PRACTICE / INTERNAL MEDICINE / HOSPITAL-BASED PHYSICIANS These three departments will meet jointly. III.1-1 III.1-2 COMPOSITION The Departments of Family Practice/Internal Medicine/Hospital-Based Physicians shall consist of members of the Medical Staff whose scope of practice includes Family Practice, Internal Medicine, Hospitalists, Radiologists or Emergency Medicine. The Administrator, Chief Nursing Officer, appropriate ancillary clinical managers, and the Performance Improvement Manger are ex-officio members. FUNCTIONS The functions of the Departments of Family Practice/Internal Medicine/Hospital- Based Physicians shall include effective mechanisms to monitor, identify, evaluate, improve and resolve problems that impact on the quality and appropriateness of patient care and patient safety, including but not limited, to the following: (a) To assure clinical case management and outcomes assessment of patient care services (b) Review the results of Performance Improvement outcomes of care in each ancillary hospital department under Family Practice/Internal Medicine/Hospital- Based (Emergency, Radiology, Cardiopulmonary, Laboratory, Med/Surgery Unit, ICU and Sleep Disorders Center). (c) Assure the functions of Medical Education for the Department which shall be as follows: Develop and plan, or participate in, programs of continuing medical education that are designed to keep the Medical Staff informed of significant new developments and new skills in medicine and that are responsive to evaluation findings. Evaluate, through the hospital s performance improvement program and specifically the patient care evaluation function, the effectiveness of the educational programs developed and implemented. Analyze and make recommendations on a continuing basis the hospital s and staff s needs for professional library services. Act upon continuing education recommendations from the MEC, the departments or other committees responsible for patient care evaluation and other quality maintenance and monitoring functions. Assure that hospital sponsored educational activities are offered and relate to: (a) The type and nature of the care offered by the hospital; (b) The findings of performance improvement activities; (c) The expressed educational needs of individuals and clinical privileges. III.1-3 MEETINGS This committee shall meet bimonthly and maintain a record that includes the resultant conclusions, recommendations and actions and a copy is forwarded to the Performance Improvement Committee, the MEC and the Advisory Board. 6
III.2 DEPARTMENT OF SURGERY III.2-1 COMPOSITION The Department of Surgery shall consist of all members of the Medical Staff whose scope of practice includes surgery, pathology and anesthesiology. The Administrator, Chief Nursing Officer, Surgery Manager and the Performance Improvement Manager are ex-officio members. III.2-2 III.2-3 FUNCTIONS The functions of the Department of Surgery shall include effective mechanisms to monitor, identify, evaluate, improve and resolve problems that impact on the quality and appropriateness of patient care and patient safety, including but not limited, to the following: (a) Assure the functions of Surgical Case Review are conducted for each case when: (l) A specimen was removed, tissue or non-tissue. (2) Preoperative and postoperative (including pathologic) diagnosis do not agree (3) There is a question about the procedure or its indications. (4) No specimen was removed. (b) Assure the review and resolution of issues relating to the patient care outcomes. These outcomes may be reviewed through the monitoring activities of the Performance Improvement Committee and the Peri-Operative Unit, including Anesthesiology. (c) Assure the functions of Medical Education for the department that shall be: (l) Develop and plan, or participate in, programs of continuing medical education that are designed to keep the Medical Staff informed of significant new developments and new skills in medicine and that are responsive to evaluation findings. (2) Evaluate, through the hospital s performance improvement program and specifically the patient care evaluation function, the effectiveness of the educational programs developed and implemented. (3) Analyze and make recommendations on a continuing basis the hospital s and staff s needs for professional library services. (4) Act upon continuing education recommendations from the MEC, the departments, or other committees responsible for patient care evaluation and other quality maintenance and monitoring functions. (5) Assure that hospital-sponsored educational activities are offered and relate to: (a) The type and nature of the care offered by the hospital; (b) The findings of performance improvement activities; (c) The expressed educational needs of individuals and clinical privileges. MEETINGS This committee shall meet quarterly and maintain a record that includes the resultant conclusions, recommendations and actions and a copy is forwarded to the Performance Improvement Committee, the MEC and the Advisory Board. III.3 PHARMACY & THERAPEUTICS COMMITTEE III.3-1 COMPOSITION The Pharmacy & Therapeutics Committee shall consist of at least five (5) medical staff representatives; two (2) pharmacists; one (1) representative from the Laboratory; the Quality Manager; the hospital Administrator or his/her representative; representative(s) from Nursing; and representative(s) from Nutritional Services. The voting body will consist of one (1) Physician appointed by the Chief of Staff to serve as Pharmacy & Therapeutics Committee Chairperson; one (1) representative from each Medical Department (Surgery, Family Practice, Internal Medicine and Hospital- 7
Based Physicians) who shall be appointed by the corresponding Department Chairman; two (2) Pharmacists, one (1) of which will be the Director of Pharmacy. III.3-2 FUNCTIONS The elements of the Pharmacy and Therapeutics function shall be: (a) To serve in an advisory capacity to the hospital and medical staff, in all matters pertaining to the use of medications, which include at least the following: (1) Selection or choice of drugs which meet the need in relation to the diseases treated in this institution. Selection of drugs for facility use is based on criteria which encompasses the effectiveness of the drugs, the risks associated with the drugs (i.e., medication errors, abuse potential, sentinel events) and the costs or financial impact. (2) Prevention of unnecessary and costly duplication of identical chemical entities or combination of drugs in the formulary. (3) Development of a basic drug list or formulary of accepted medications to be used in the hospital which will be continually reevaluated and revised to ensure the distribution of the most effective, newest, safest and most economical therapeutic agents available. (4) Recommend drugs to be stocked in hospital patient care units or services. (5) Review and approve all emergency medications stocked in the hospital. (b) Monitor implementation of the written policies and procedures and make recommendation for improvement: (1) The Pharmacist in consultation with other appropriate health professionals and administration shall be responsible for the development and implementation of procedures. Policies and procedures shall be revised and/or revised at least annually. (2) Present recommendations of the committee to the medical staff for decisions regarding medical procedures and problems. The medical staff has final authority in these matters. The hospital administration has final authority regarding the administrative responsibilities in carrying out the recommendations of the medical staff. (3) Evaluate the entire service provided and make recommendation to the Medical Executive Committee of the medical staff and the hospital administration. (c) Recommend policies regarding the safe use of drugs in hospitals including a study of such matters as investigational drugs, hazardous drugs and others. (d) Review all reported adverse reactions (both significant and minor) to drugs administered to the patients. (e) Evaluate the drug therapy component of the patient s medical records; review and approve limiting durations of drug therapy. (f) Study problems related to the administration of medications. (1) Plan suitable educational programs for the professional staff or pertinent matters related to drugs and their use. (2) Make recommendations for the solution of problems involved in the appropriate preparing, labeling, distribution and administration of medications for inpatients and outpatients. (g) Approve and review standing orders for drugs used for specified patients and physicians. (h) Review and approve limiting durations of drug therapy. (i) Review and approve the override medications kept in the automated dispensing machines. (j) Standardize nutrition care approaches and processes across the organization. (k) Recommend or assist in the formulation of educational programs designed to meet the needs of the professional staff (physicians, nurses and pharmacists) for complete knowledge on matters related to drugs and drug practice. 8
III.4-3 MEETINGS This committee shall meet at least quarterly and recording of the meeting s minutes shall be the responsibility of the Director of Pharmacy or his/her designee (who serves as secretary) who shall maintain permanent records that includes the conclusions, recommendations, and actions. Recommendations of the Pharmacy & Therapeutics Committee shall be presented to the MEC for adoption or recommendation. III.4 INFECTION CONTROL COMMITTEE III.4-1 COMPOSITION This committee shall consist of at least one representative from the Medical Staff, nursing administration, and the person directly responsible for the management of the infection surveillance, prevention, and control program. Representation from housekeeping, laundry, the dietetic department, the engineering and maintenance department, pharmacy, and the operating suite is recommended on at least a consultative basis. III.4-2 III.4-3 FUNCTIONS The functions of the Infection Control Committee shall be to approve the type and scope of surveillance activities, which include at least the following: (1) Review of designated microbiological reports; (2) Review of patient infections, as appropriate, to determine whether an infection is nosocomial, using definitions and criteria approved by the committee; (3) Review focuses on those infections that present the potential for prevention or intervention to reduce the risk of future occurrence; (4) Review is directed to surveillance data, when available, looking particularly for a. Unusual epidemics; b. Clusters of infections; c. Infections due to unusual pathogens; and d. Any occurrence of nosocomial infection that exceeds the usual baseline levels; e. Prevalence and incidence studies, if appropriate; and f. Routine or special collection of other data, as approved by the committee. (5) Sampling of personnel or the environment for infective agents is done only at the direction of the committee, or its designee, and only in accordance with applicable law or regulations. (6) The committee approved actions to prevent or control infection, based on an evaluation of the surveillance reports of infections and of the infection potential among patients and hospital personnel. (7) The committee reviews and approves, at least every two years, all policies and procedures related to the infection surveillance, prevention, and control program and to infection surveillance, prevention, and control activities in all departments. (8) Reviews and approvals are documented in the minutes of the committee. MEETINGS This committee shall meet quarterly and shall maintain a record that includes the conclusions, recommendations, and actions and a report of this is forwarded to the Performance Improvement Committee, the MEC and the Advisory Board. III.5 MEDICAL STAFF INVOLVEMENT IN SAFETY/DISASTER/RADIOLOGY SAFETY FUNCTIONS III.5-1 STRATEGY The medical staff will actively participate in the safety and disaster plans and activities and comply with the hospital s policies. 9
III.5-2 III.5-3 FUNCTIONS The functions of the hospital s safety/disaster/radiology safety plans and activities are as follows: (a) Manage an ongoing hospital wide process to collect and evaluate information about hazards and safety practices that are used to identify safety management issues. The information collection and evaluation system includes: (1) Summaries of Life Safety Code, fire protection, equipment, and utility system deficiencies or problems, failures, user errors, and relevant published reports of hazards associated with any of these areas; (2) Documented surveys of all areas of the facility to identify environmental hazards and unsafe practices; (3) A system for reporting and investigating all incidents that involve property damage, occupational illness, or patient, personnel, or visitor injury; and (4) Summaries of actions taken as the result of other hospital wide monitoring activities, including performance improvement and risk management; (5) The identification of general areas of potential risk in the clinical aspects of patient care and safety; (6) The development of criteria for identifying specific cases with potential risk in the clinical aspects of patient care and safety, and evaluation of these cases; (7) The correction of problems in the clinical aspects of patient care and safety identified by risk management activities; and (8) The design of programs to reduce risk in the clinical aspects of patient care and safety. (9) Develop and periodically review, in cooperation with the Hospital Administration, a written plan designed to safeguard patients at the time of an internal disaster and require that all personnel rehearse fire drills. (10) Develop and periodically review, in cooperation with the Hospital administration, a written plan for the care, reception and evacuation of mass casualties. Assure that the plan is coordinated with the inpatient and outpatient services of the Hospital, and that it adequately relates to other available resources in the community. Coordinate the hospital s role with other agencies in the event of disasters in the hospital and nearby communities. Assure that the plan is rehearsed. (11) Monitoring of radiology personnel and monthly recording of the cumulative radiation exposure of each individual. (12) Calibration and safety of all diagnostic and therapeutic equipment utilizing radioactive material. (13) Rules for the safe use of radiation emitting equipment. (14) Inspection of leaded shield devices. (15) Radiation protection for non-radiology service personnel. MEETINGS This committee shall meet at least biannually and maintain a record that includes resultant conclusions, recommendations and actions with a copy forwarded to the Safety Committee. III.6 ETHICS COMMITTEE III.6-1 COMPOSITION This committee shall consist of at least the Chief of Staff, representatives from specialties of the Medical Staff with expertise in life support modalities, and the Chief Nursing Officer. III.6-2 FUNCTIONS The functions of this committee shall be: (a) To advise the Medical Staff in such issues as, but not limited to: 1) Do Not Resuscitate 10
2) Do Not Intubate 3) Removal from Life Support 4) Quality of Life versus Quality of Service 5) Transfer to Proper Level of Services 6) Review for Need of Autopsy 7) Chemical Code 8) CPR III.6-3 MEETINGS This committee shall have called meetings as necessary at the request of the Chief of Staff, the Department Chair, the Administrator, the Chief Nursing Officer or any staff member. The committee shall maintain a record of conclusions, recommendations and actions. Results of the meeting shall be forwarded to the Medical Executive Committee and the Advisory Board. III.7 SPECIAL COMMITTEES OF THE STAFF III.7-1 COMPOSITION AND APPOINTMENT A Special Staff Committee may be established (and abolished) by the MEC to perform one or more Special Staff functions. It shall be composed of eligible members of the Medical Staff and may include, where appropriate, representation from Hospital administration, nursing service, medical records service, pharmaceutical service, social service and such other Hospital departments as are appropriate to the function (s) to be discharged. Unless otherwise specifically provided, the Medical Staff Members and the Chairman shall be appointed by the Chief of Staff, and the Administrator shall appoint ex-officio members requested by the Chief of Staff. III.7-2 III.7-3 III.7-4 TERM OF APPOINTMENT Unless otherwise specifically provided, a special committee member shall continue as such until the end of his normal period of Staff appointment and until his successor is appointed. A medical staff special committee member, other than one serving ex-officio, may be removed by a majority vote of the Medical Executive Committee. An Administrative Staff committee member may also be removed by action of the Administrator. FILLING VACANCIES Unless otherwise specifically provided, vacancies on any staff committee shall be filled in the same manner in which original appointment to such committee is made. MEETINGS A special committee established to perform one or more special function(s) should meet as often as necessary to discharge its assigned duties. IV. EMERGENCY SERVICES RULES & REGULATIONS IV.1 GENERAL EMERGENCY DEPARTMENT RULES 1. Members of the Medical Staff who are less than 55 years of age shall be eligible for assignment to the Emergency Department Call List and shall accept responsibilities for emergency service care in accordance with the Medical Staff s Bylaws and Rules and Regulations and departmental policies. 2. Clinical privileges delineated for all practitioners rendering emergency care are in accordance with Medical Staff and Hospital procedures. 3. The Hospital-Based Physician Department shall have overall responsibility for emergency medical care. The Emergency Services Medical Director shall direct 11
and coordinate emergency medical services, including the review of emergency service records, under the auspices of the Department of Hospital-Based Physicians. 4. When appropriate, as determined by the emergency service physician on duty, the patient s care shall be arranged through, and coordinated with, the patient s primary care physician: private physician shall be called in accordance with the individual physician s preference cards located in the Emergency Department; When appropriate, patients should be seen by the patient s primary care physician before consulting or referring to a surgeon or a specialist. 5. The on-call physician will start call at 7:00 am and continue until 7:00 am the following morning. Any unattached patient will be assigned to the on-call physician based on the time of triage by the Emergency Department. 6. If, in the judgment of the Emergency Department physician, a patient needs to be admitted to the Hospital as an inpatient (either for observation or inpatient care), the patient shall be admitted either in the name of the patient s physician (after conferring with the attending physician), or the physician on call. 7. The on-call physician may refuse the admission of a patient to his/her care only if the on-call physician comes to the Emergency Department and assumes responsibility for the disposition of the patient. 8. Except in cases where transfer to surgery is contraindicated in the judgment of the emergency physician or responsible physician, major surgery shall not be performed in the emergency treatment area. 9. An Emergency Department physician shall review radiology reports produced from studies requested in the Emergency Department for discrepancies. In cases where the X-ray interpretation of the radiologist is different from that initially made by the emergency physician, notification of the discrepancy shall be brought to the attention of the radiologist, and the patient s private physician. The Emergency Department physician will contact the patient when there is a discrepancy and be responsible for the coordination of the appropriate care. 10. An appropriate medical record shall be kept for every patient receiving emergency services. The record shall include, at a minimum, the following information: A. Adequate patient identification; B. Information concerning the time of the patient s arrival and by whom transported; C. Pertinent history of the injury or illness including details relative to first aid or emergency care given to the patient prior to his arrival at the Hospital and history of allergies; D. Description of significant clinical, laboratory and x-ray findings; and vital signs; E. Diagnosis including condition of patient; F. Treatment given and plans for management; G. Condition of the patient on discharge or transfer or admission; H. Final disposition, including instruction given to the patient and/or his family, relative to necessary follow-up care; and I. All documentation should be preceded by the time of each entry. J. Orders and a well-documented progress note for admitted patients. 12
11. The practitioner shall sign each patient s emergency medical record in attendance that is responsible for its clinical accuracy. 12. The Emergency Physician Director and the Hospital-Based Physicians committee shall be responsible for monthly patient care evaluation studies concerning the quality and appropriateness of patient care. The Emergency Physician Director and the Hospital-Based Physician committee shall coordinate the review of emergency service records. 13. The original emergency service medical record shall accompany patients being admitted as an inpatient. 14. This record should include written orders to continue any or specific drug regimens a patient is taking prior to admission, the provider will identify and list the specific medications, strengths, and regimens to continue. 15. The following guidelines must be followed to insure practitioner and hospital compliance with COBRA/OBRA Regulations and apply to all transfers: A. All individuals presenting to the hospital must be screened by a physician to determine whether an emergency medical condition exists, or if the individual is in active labor. B. Stabilizing treatment, within the capacity of the hospital, must be provided unless the medical benefits of transfer out weight the risks. C. All individual transferred from the hospital must have a documented physician order with reasons for transfer noted. Nursing will complete a transfer form in accordance with hospital policy. D. The practitioner who transfers an individual must have a receiving physician and hospital that agree to accept the individual. E. The practitioner who transfers an individual must provide an updated medical record that relates the condition of the individual, history and physical, preliminary diagnosis, treatment provided, and diagnostic test results to the receiving hospital. F. The practitioner who transfers an individual must provide physician orders for the care of the patient during transport. These orders must provide for the same level of care the individual received while under the care of the practitioner. 16. Staff physicians may call in or fax treatment/medication orders to the Emergency Department when it is not feasible to perform them in the private physician s office. When this occurs, the patient will be registered as a Day Medicine (outpatient) patient. The treatment will be rendered by the nurse in compliance with appropriate nursing policies and procedures. If an adverse event occurs, the private physician will be notified and the Emergency Department physician will evaluate and render emergency treatment if necessary. 16. The Hospital shall provide an Emergency Department physician who shall be available for rendering emergency patient care 24 hours per day, seven (7) days per week. The evaluation and treatment rendered to any patient who presents himself or is brought to the Emergency Department shall be the responsibility of the Emergency Department Physician, in accordance with any instructions provided by the patient s private physician. 17. Should a patient request treatment by his/her Attending Physician that physician shall be notified and directions for care shall be implemented. If the patient s 13
condition requires immediate medical attention, the Emergency Department Physician shall initiate treatment. IV.2 EMERGENCY DEPARTMENT CALL LIST AND CALL SCHEDULE MANAGEMENT 1. Follow-up care for patients treated in the Emergency Department shall be under directions of their personal Physician. If a Patient does not have a personal physician, the patient will be provided a list of local physicians from which the patient should arrange for follow-up care. 2. If the patient requires specialty consultation, the Emergency Department Physician will utilize schedules posted in the Emergency Department Call Schedule book. 3. The Emergency Department Call List and the Emergency Department Call Schedule will be managed in accordance with policies and procedures established by each department. V. MEDICAL RECORDS RULES AND REGULATIONS 1. Inpatient medical records shall include at least the following: the patient s name, address, date of birth, and medical record number, billing number, the medical history of the patient, chief complaint, details present illness, relevant past social and family history, inventory of body systems, summary of patient s psychosocial needs, conclusions / impressions drawn from examination, medical plan, changes in condition, results of treatment, test results, op reports if applicable, final diagnosis, conclusions at discharge, discharge instruction, results of autopsy if performed, evidence of appropriate informed consent, progress notes, consultation reports, nursing notes and entries by nonphysicians. 2. A complete admission history and physical exam shall be documented within twenty-four hours and on the chart within 48 hours of admission. This admission history should include: A. The chief complaint; B. Relevant past medical, social and family histories appropriate to the age of the patient; C. An inventory of body systems; D. Details of the patient s emotional, behavioral, and social status; E. Medical plan of care; F. Admission diagnosis. In addition, for children and adolescents, an evaluation of the patient s developmental age; consideration of educational needs and daily activities, as appropriate; the parent s report or other documentation of the patient s immunization status; and the family s and/or guardian s expectations for and involvement in, the assessment, treatment and continuous care of the patient. The physical exam should reflect a comprehensive current physical assessment. The recorded history and physical exam must be authenticated by a physician member of the medical staff. 3. A History & Physical (H & P) must be performed within 24 hours of the inpatient admission. An H & P record performed within 30 days of the admission date, or surgery or procedure outpatient services which require an H & P may be utilized provided it contains all of the required elements (H & Ps older than 30 days may not be used). When using an H & P obtained within 30 days of admission, the physician must 14
document on the H & P or progress note 24 hours after admission or at the time of the outpatient surgery or procedure, an appropriate assessment addressing the patient's current status regardless of whether any changes in patient s condition since H & P was composed. This addendum should be dated and signed by the physician. 4. Non-inpatient procedures requiring a history and physical include but are not limited to: a) Ambulatory Services b) Invasive radiology procedures c) Endoscopy d) Procedures involving use of sedation The scope of the assessment for non-inpatient procedures which require a brief H & P will be limited to: a) Cardiac & respiratory history & physical exam b) Current Medications c) History & Physical exam of the operative system d) Airway assessment & anesthesia sedation history for patients who may receive moderate sedation 5. When the history and physical documentation is not recorded before an operation or any potentially hazardous diagnostic procedure, the procedure shall be postponed, unless the attending practitioner believes that such delay would be detrimental to the patient. 6. Pertinent progress notes shall be recorded at the time of observation sufficient to permit continuity of care and transferability. Progress notes shall be written daily on critically ill patients, and those where there is difficulty in diagnosis or management of the clinical problem. Progress notes give a pertinent chronological report of the patient s course in the hospital and reflect any change in condition and the results of treatment. Progress notes shall be written at least daily. 7. Operative (any invasive procedure) reports are documented in the medical record immediately after surgery or procedure and contain a description of the findings, the technical procedures used, the specimens removed, the post-operative diagnosis, and the name of the primary surgeon and any assistant. If the op report was dictated, a brief description, to include the operative procedure, shall be written immediately on the chart after surgery. The Practitioner shall be responsible for obtaining the patient s informed consent prior to treatment. The patient shall be informed of the nature and risks of the procedure and of the possible alternatives. The patient, the practitioner and a witness shall sign the consent form. 8. Each consultation report contains a written opinion by the consultant that reflects, when appropriate, an actual examination of the patient. This report shall be made a part of the patient s record. When operative procedures are involved, the consultation note shall, except in emergency situations so verified in the record, be recorded prior to the operation. Any qualified physician with clinical privileges in this hospital can be called for consultation. 9. A discharge summary shall be documented on all medical records of patients hospitalized over forty-eight hours. In all instances, the content of the medical record shall be sufficient to justify the diagnosis and warrant the treatment and end result. The Discharge summary shall include: A. The final diagnosis and conclusions at discharge, operative procedures performed and discharge instructions, and when appropriate, the autopsy report. B. A final progress note may be substituted in place of a discharge summary when a patient with problems of a minor nature and requires less than a 48 hour period of hospitalization. 15
10. Written consent of the patient is required for release of medical information, which specifically includes psychiatric or substance abuse information. This does not mean that written consent is required for the use in activities such as the following: the automated processing of medical information, use in activities concerned with the monitoring and evaluation of the quality and appropriateness of patient care, departmental review of work performance; official surveys for hospital compliance with accreditation, regulatory and licensing standards, or educational and research purposes. 11. All previous records shall be available for use by the attending physician on admission. 12. Symbols and abbreviations are used in the medical record to avoid misinterpretation only when they have been approved by the MEC. An explanatory legend shall be available to those authorized to make entries in the medical record and to those who must interpret them. Each abbreviation or symbol can have one, and only one, meaning. 13. Records may be removed from the Hospital s jurisdiction and safekeeping only in accordance with a court order, subpoena or statue or contract storage service. All records are the property of the Hospital and shall not otherwise be removed without permission of the Administrator. Any request for records for possible malpractice will be communicated to the physician involved. Unauthorized removal of charts from the Hospital is grounds for suspension of the practitioner for a period to be determined by the MEC. 14. Free access of all medical records for projects shall be afforded to members of the Medical Staff. Confidentiality of personal information concerning the individual patients shall be observed at all times. The Medical Staff shall approve all such projects before records can be studied. Subject to the discretion of the Administrator, former members of the Medical Staff shall be permitted free access to information from the medical records of their patients covering all periods during which they attended such patients in the Hospital. 15. All practitioners shall complete the medical record at the time of the patient s discharge. When this is not possible because of final laboratory or other essential reports have not been received at the time of discharge, the medical record will be made available for completion. 16. The patient s medical record shall be completed at the time of discharge in accordance with all requirements. Physician will receive incomplete record(s) notification on day 15 following discharge. Physician will receive a subsequent notification on day 22 following discharge. Incomplete records will be considered delinquent upon day 30 following discharge. If the record remains delinquent, past the 30, the Administrator shall notify the practitioner by certified mail; return receipt that his privileges to admit and to consult patients are suspended until such practitioner has completed all such delinquent records. The Manager of Medical Records shall notify the appropriate departments of the Hospital of this action. Reinstatement of privileges shall be automatic upon the completion of records and the Manager of Medical Records shall so inform the appropriate departments. If a physician is unable to complete charts due to illness, he is to contact the Manager of Medical Records so that he may be exempted from suspension in the event of the inability of the Medical Records department to process his chart(s) in accordance with these provisions for any reason whatsoever. The admitting office shall be notified of such exemption actions. Three such suspensions of admitting privileges within a twelve (12) month period shall be sufficient cause for permanent suspension of the privileges of that practitioner. If a physician requests appointment again, he must reapply as a new member, and appointment will be pending completion of all delinquent records. 16
17. In the event that a physician dies or leaves his practice with incomplete charts, the Chair of the Department of which he was a member shall make every attempt to complete the physician s charts. If there is insufficient data to complete the charts, the Chair of the Department shall submit a record to the Medical Executive Committee requesting the charts be filed as incomplete. 18. The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. This record shall include identification data; medical history; a summary of the patient s psychosocial needs as appropriate to the age of the patient; reports of relevant physical exams; diagnostic and therapeutic orders; evidence of appropriate informed consent; clinical observations, including the results of therapy; reports of procedures, tests, and their results; and conclusions at termination of hospitalization or evaluation/treatment. 19. Authentication A. All entries in the record shall be dated, and authenticated by the person making the entry. A single signature on the face sheet of a record shall not suffice to authenticate the entire record. Each entry must be individually authenticated by the signature of the individual making the entry, or by a member of the practitioner s group, or by the physician for whom a Locum Tenens physician is providing coverage. Initials and/or signatures must be legible. Signature stamps may only be used in accordance with hospital policy. B. The attending physician shall countersign all orders, the history and physical examination and pre-operative notes when they have been recorded by an intern, resident physician, student physician or physician s assistant. C. Authentication can include written signature, rubber stamp, or computer signature. D. Signature stamps can only be used by the practitioner indicated on such stamp and must be kept secure. E. All orders for treatment shall be in writing. The practitioner s order must be written clearly, legibly and completely. Orders that are illegible or improperly written will not be carried out until rewritten or understood by the nurse. A verbal order shall be considered to be in writing if dictated to a medical professional and validated verbally with the provider. High-risk orders will be authenticated as the Medical Staff deems necessary. F. A Registered Nurse, LPN or Pharmacist will take all medication orders. A respiratory therapist can receive respiratory therapy orders consistent with their scope of care. The social worker may receive orders consistent with their scope of practice. The Sleep Technologists may receive orders consistent with their scope of practice. All orders dictated over the telephone shall be dictated by the practitioner, or his licensed designee, and shall be signed by the appropriately authorized person to whom dictated with the name of the practitioner per his or her own name. Unlicensed office personnel are prohibited from relaying orders. 20. Each member of the Medical Staff with computer terminal access to a Baptist Healthcare System facilities medical records agrees to comply with the information security policies of the Hospital set forth in the Information Security Agreement, System Access Authorization and Remote Connectivity Agreement. Such policies include maintaining assigned passwords that allow access to computer systems and equipment in strictest 17
confidence and not disclosing passwords with anyone, at any time, for any reason. Each member of the Medical Staff understands that the records of the patients maintained in the computer system are confidential and that access to such records should be continuing care of the patient. Failure to comply with the information security policies of the Baptist Healthcare System facilities may result in termination of access to the computer systems. VI. GENERAL CONDUCT OF CARE RULES AND REGULATIONS 1. 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 should notify the attending practitioner whenever such consent has not been obtained. When so notified, it shall, except in emergency situations, be the practitioner s obligation to obtain proper consent before the patient is treated in the Hospital. 2. All previous orders are canceled when patients go to surgery, go to a special care unit, or are transferred from a special care unit, unless the orders are again specified following the patient s movement. 3. All drugs and medications administered to patients shall be those listed in the latest edition of: United States Pharmacopoeia, National Formulary, American Hospital Formulary Service or AMA Drug Evaluations. Drugs of bona fide clinical investigations may be exceptions. These shall be used in full accordance with the Statement of Principle involved in the Use of Investigational drugs in Hospitals and all regulations of the Federal Drug Administration. 4. It is the duty of the Medical Staff through its Department Chair to see that members of the staff do not fail to seek consultations as needed. Consultation is required in the following situations: a) Where the medical problem goes beyond the clinical privileges which have been granted to the practitioner b) When requested by the patient, or immediate family when the patient is unable to make the request c) Where the diagnosis is obscure d) In unusually complicated diseases where specific skills of subspecialists or other practitioners may be needed e) In instances in which the patient exhibits severe psychiatric symptoms. In circumstances of grave urgency or where consultation is required by the rules of the Hospital, the Administrator shall, at all times, have the right to call in a consultant or consultants after conference with the Chief of the Medical Staff and/or member o the Medical Executive Committee or Department Chair involved. 5. All medications brought into the Hospital by a patient must be sent to the Pharmacy for proper identification. The pharmacist will verify the fact that the medications brought in by the patient are in fact those that the physician has prescribed. a) Medications brought into the hospital by a patient or his family will not be given to the patient during his Hospital stay without the expressed authorization of the attending physician. b) All medications received by the Pharmacy will have a receipt, the origin of which will be attached to the patient s chart, and the duplicate retained in the Pharmacy. c) Medications shall be returned to the patient at time of discharge upon presentation of receipt attached to patient s chart. d) Medications not called for by this method will be kept in the Pharmacy for up to 30 days after discharge and then destroyed in an appropriate manner. 6. Oxygen and respiratory therapy will be administered according to the attending physician s orders. In those cases where duration of treatment is not identified or 18