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RULES AND REGULATIONS
OF THE MEDICAL-DENTAL STAFF
Patients who are known to be suffering from drug abuse, alcoholism, and mental illness shall not be admitted unless proper safety precautions can be taken to safeguard the patient, other patients, and employees.
Only practitioners granted Staff membership and clinical privileges may admit patients to this health center except as provided in the Staff Bylaws, Rules and Regulations. Only practitioners granted clinical privileges may treat patients at this health center. All practitioners with authority to admit patients shall be governed by the official admitting policy of the health center.
Dentists and Podiatrists with authority to admit patients to the health center must obtain a physician member of the Staff or an Allied Health Practitioner to perform and/or sign off on an admitting history and physical for the patient being admitted.
A member of the Staff shall be responsible for the medical care and treatment of each patient in the health center, for the prompt completeness and accuracy of the medical record, for necessary special instructions and for transmitting reports of the condition of the patient to the referring practitioner and to relatives of the patient.
Except in an emergency, no patient shall be admitted to the health center until a provisional diagnosis has been stated. In the case of an emergency, such provisional diagnosis shall be recorded as soon as possible.
A patient admitted for surgery may select a surgeon of his or her choice.
If a patient is admitted on an emergency basis and does not have a family physician in the applicable service to attend to him, a member of the Active Staff, on duty in the service, will be assigned to the patient on a rotational basis. The history and physical and the provisional diagnosis must be supplied by the admitting physician.
Each member of the Staff who does not reside in the immediate vicinity shall name a member of the Staff who is a resident in the area who may be called to attend his patients in an emergency or until he arrives. In case of failure to name such an associate, the Chief Executive Officer, President of the Staff or chief of the service concerned shall have the authority to call any member of the Active Staff in such an event. Each practitioner must assure timely, adequate professional care for his patients in the health center by being available or having available through his office an eligible alternate practitioner with whom prior arrangements have been made and who has at least equivalent clinical privileges at the health center. Failure of an attending practitioner to meet these requirements could result in
loss of clinical privileges. A practitioner who will be away from his practice should, indicate in writing, in a prominent place at each nursing station, switchboard, the admitting offices of the general health center and Pinecrest Manor, the name of the practitioner who will assume responsibility for the care of the patients during his absence.
Any staff physician who is not available to his practice must designate a practitioner to cover his service and shall not refer all patients automatically to the physician on emergency call for consultation. Failure to meet these requirements may result in loss of clinical privileges.
The admitting office will admit patients on the basis of the following order of priorities:
Within 24 hours following an emergency admission, the attending practitioner shall furnish a signed, sufficiently complete documentation of need for this admission. Failure to furnish this documentation or evidence of willful or continued misuse of this category of admission will be brought to the attention of the Executive Committee for appropriate action.
This category includes those so designated by the attending practitioner and shall be reviewed as necessary by the President of the Staff or his designee to determine priority when all such admissions for a specific day are not possible.
This includes all patients already scheduled for surgery. If it is not possible to handle all such admissions, the President of the Staff or his designee may decide the urgency of any specific admission.
This will include elective admissions involving all services.
Patient Transfers: Transfer priorities to acute care general beds shall be as follows:
Emergency Room to appropriate patient bed.
From obstetric patient care area, when medically indicated.
From intensive care/coronary care unit to general care unit.
From Pinecrest Manor, when medically indicated.
From temporary placement in an inappropriate clinical service area to the appropriate area for that patient.
From the Short Procedure Unit to an appropriate care unit for that patient.
No patient will be transferred without such transfer being approved by the responsible practitioner.
The admitting practitioner shall be held responsible for giving such information as may be necessary to assure the protection of the patient from self-harm and to assure the protection of others whenever this patient might be a source of danger from any cause whatever.
For the protection of patients, the medical and nursing staffs and the health center, precautions to be taken in the care of the potentially suicidal patient includes:
Any patient known or suspected to be suicidal in intent shall be admitted when possible to ICU. Every attempt shall be made to have such patients under continuous observation by some combination of relatives, private duty nursing, or health center staff. The patient shall be referred, if possible, to another institution where suitable facilities are available.
Any patient known to be suicidal, or who has taken a chemical overdoes, must have consultation by a member of the psychiatric staff, within twenty-four (24) hours or transferred to the care of a psychiatrist.
Admissions and Discharges to Intensive Care/Coronary Care Unit: a.
Any physician with hospital admitting privileges may admit patients to ICU/CCU. Patients may be admitted to the ICU/CCU directly upon admission to the health center or they may be transferred from other areas in the health center. Each admission should be processed through the Admitting Office in the same manner as regular admissions. Specific physician orders may be submitted to ICU personnel (R.N.’s). All previous orders will be discontinued on admission to ICU/CCU. If any questions should arise regarding the validity of an admission to the Unit, the decision is to be made through consultation with the medical director of ICU/CCU. When a critically ill patient requires admission to the ICU/CCU and beds are not available, the medical director of ICU/CCU shall determine priorities and arrange transfer of the least critically ill patient to another area of the health center after notification of the attending physician.
Patients suitable for admission will include, but not be limited to:
life threatening, long standing but poorly
Coronary occlusions (or suspected occlusions) for monitoring in the acute phase
Respiratory insufficiency or apnea requiring special equipment or tracheostomy
Post-op vascular surgery patients and other post-op patients as determined by attending surgeon and/or anesthesiologist
Priority determinations for admission or retention of patients in the ICU/CCU shall be the responsibility of the medical director of ICU/CCU. The following are meant to be guidelines for making this determination: Unstable angina Acute respiratory distress Hyper-hopotensives receiving I.V. medications for blood pressure control Acute head injuries Critical multiple trauma patients Shock Chronically ill patients requiring long term care shall not routinely be admitted to the ICU/CCU except in the course of an acute phase of illness, as needed. Terminally ill patients, with a DNR status, shall not be admitted to the ICU/CCU unless medication and/or procedures are not available on other units.
ICU patients will be given priority for beds in general areas and will be transferred as soon as possible. The attending physician will order the transfer from the unit. Each transfer should be processed through the Admitting Office in the same manner as regular transfers. Specific physician orders may be submitted to ICU nursing personnel and charts must be complete and notations up to date upon transfer. All previous orders will be discontinued on transfer from the ICU. The ICU/CCU Medical Director is responsible for making final decisions when conflicts occur relative to delays in transfer The decision to discharge remains with the attending physician based on good medical care. The following criteria are guidelines for discharging patients from the
ICU/CCU: Non-Cardiac Patients No Code I No deterioration for 72 hours Vital signs stable for 24 hours Output sufficient for intake No apparent bleeding Blood studies within normal limits No acute respiratory problems Cardiac Patients Vital signs stable for 24 hours No ECG changes for 48 hours Pain free for 48 hours Pain relieved by Nitroglycerin or Sorbitrate or oxygen or calcium antagonists Enzyme studies normal
The attending practitioner is required to document the need for continued hospitalization in progress notes as follows:
An adequate written record of the reason for continued hospitalization. A simple reconfirmation of the patient's diagnosis is not sufficient.
Patients shall be discharged only on a written order of the attending physician. Should a patient leave the health center against the advice of the attending practitioner or without proper discharge, a notation of the incident shall be made in the patient's medical record.
In the event of a patient death occurring in the health center, the patient shall be pronounced dead by the attending practitioner, his designee or a registered nurse 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 Staff. Exceptions shall be made in those instances of incontrovertible and irreversible terminal disease wherein the patient's course has been adequately documented to within a few hours of death.
It shall be the duty of all Staff members to secure meaningful autopsies whenever possible
except for coroner's cases. An autopsy may be performed only with a written consent
signed in accordance with state law. All autopsies shall be performed by the health center
pathologist or by a practitioner delegated this responsibility. Provisional anatomic
diagnosis shall be recorded on the medical record within twenty-four (24) hours and the
complete protocol should be made a part of the record within three (3) months.
It is the responsibility of the attending staff member to notify the coroner of any cases considered a coroner’s case.
The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current. This record shall include identification data, complaint, personal history, family history, history of present illness, physical examination, special reports such as consultations, clinical laboratory and radiology services, and others, provisional diagnosis, medical or surgical treatment, appropriate consent forms, operative report, pathological findings, progress notes, final diagnosis, condition on discharge, summary or discharge note (clinical resume), autopsy report when performed, summary of the patient’s psychosocial needs; conclusions or impressions drawn from the admission history and physical examination; a statement on the course of action planned for the patient; diagnostic and therapeutic orders; clinical observation; records of donation and receipt of transplants and implants; and discharge instructions to the patient or family.
A complete history and physical examination (as shown in Appendix I) shall be recorded on the patient’s chart and signed not more that seven (7) days before and within twenty-four hours following admission/outpatient surgery. In the case of obstetrical patients, the practitioner’s prenatal record can be used in place of a history and physical for normal spontaneous vaginal deliveries. A history and physical would meet this requirement if:
The H&P was performed within thirty (30) days prior to the hospital admission/outpatient surgery; and
An appropriate assessment, which should include a physical examination of the patient to update any components of the patient’s current medical status that may have changed since the prior H&P or to address any areas where more current data is needed was completed with seven (7) days prior to admission/outpatient surgery or twenty-four (24) hours after admission confirming that the necessity for the procedure or care is still present and the H&P is still current; and
The physician or other individual qualified to perform the H&P writes an update note addressing the patient’s current status and/or any changes in the patient’s status regardless of whether there were any changes in the patient’s status, within seven (7) days prior to the admission/outpatient surgery or within twenty-four (24) hours after admission. The update note must be on or attached to the H&P; and
The H&P, including all updates and assessments, must be included within twenty-four (24) hours after admission in the patient’s medical record for this admission. The H&P, including all updates and assessments, must be included in the patient’s medical record, except on emergency surgery, prior to surgery.
This report shall reflect a comprehensive, current physical assessment by a Medical Staff member or appropriate allied health professional who has been granted privileges or given permission by the Health Center to perform histories or physical examinations, in accordance with Section 3 of the Section.
A medical doctor (M.D.), doctor of osteopathy (D.O.), or in the case of a patient admitted only for oral maxillofacial surgery, an oral maxillofacial surgeon must be responsible for the performance and documentation of the medical history and physical examination for each patient admitted to the Health Center. The M.D., D.O. or oral maxillofacial may delegate the task of performing the history and physical examination to one of the following practitioners who has been granted clinical privileges to perform history and physical examinations, i.e. Physician Assistants and Nurse Practitioners. Whenever the task of performing the history and physical examination is delegated to a practitioner other than an M.D., D.O. or oral maxillofacial surgeon, the M.D., D.O. or oral maxillofacial surgeon attending the patient must take full responsibility for the history and physical, and must authenticate the history and physical examination documented to the record no later than twenty-four (24) hours following the patient’s admission.
Before any operative, invasive or noninvasive procedure that will involve risk to the patient (but not including administration of medications alone) or the administration of moderate or deep sedation or anesthesia, a provisional diagnosis and complete assessment of the patient’s health shall be recorded in the medical record. In addition, the patient must be reevaluated immediately prior to any such procedure.
When the history and physical examination are not recorded before an operation or any potentially hazardous diagnostic procedure, the procedure shall be canceled unless the attending practitioner states, in writing, that such delay would be detrimental to the patient. Failure to record an H&P in designated time frames will result in relinquishment of admission privileges until an H&P is completed.
Pertinent progress notes shall be recorded at the time of observation sufficient to permit continuity of care and transferability. Whenever possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatment. Progress notes shall be written at least daily, or as often as indicated, on acutely or critically ill patients and those where there is difficulty in diagnosis or management of the clinical problem.
Operative reports shall include a detailed account of the findings at surgery, the names of the primary surgeon and al assistants, specimens removed, as well as the details of the surgical technique, i.e. pre and post diagnosis, procedure performed, anesthesia, complications, EBL. Operative reports shall be written or dictated within 24 hours following surgery and the report promptly signed by the surgeon and made a part of the patient's current medical record. Failure to complete an OR report in the specified time frame will result in relinquishment of admission privileges until report is completed. If an operative report is not placed in the medical record immediately after surgery, a progress note is entered immediately.
A postoperative note will be documented immediately following any operative procedure and will include pre- and postoperative diagnoses, anesthesia, EBL, vital signs and level of consciousness, medications (including intravenous fluids), blood and blood components,
any unusual events or postoperative complications, and management of such events. The completion of the immediate post-operative note will be monitored and if not completed, Health Information personnel will be notified. Admission privileges will be suspended if the post-operative note is not completed within 24 hours of notification.
Consultations shall show evidence of a review of the patient's record by the consultant, pertinent findings on examination of the patient and the consultant's opinion and recommendations. This report shall be made a part of the patient's record. A limited statement, such as "I concur" does not constitute an acceptable report of consultation. When operative procedures are involved, the consultation note shall, except in emergency situations so verified on the record, be recorded prior to the operation.
The current obstetrical record shall include a complete prenatal record. The prenatal record may be a legible copy of the attending practitioner's office record transferred to the health center before admission but an interval admission note must be written that includes pertinent additions to the history and any subsequent changes in the physical findings.
All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated. Authentication means to establish authorship by written signature, identifiable initials or computer key.
Symbols and abbreviations may be used only when the Staff has approved them. An official record of approved abbreviations should be kept on file in the Meditech library.
Final diagnosis shall be recorded in full without the use of symbols or abbreviations and dated and signed by the responsible practitioner at the time of discharge of all patients. This will be deemed equally as important as the actual discharge order.
A discharge summary shall be dictated (as shown on Appendix II) on all medical records of regular admissions and swing bed patients (except for normal obstetrical deliveries and normal newborn infants). In all instances, the content of the medical record shall be sufficient to justify the diagnosis and warrant the treatment and end result. All summaries shall be authenticated by the responsible practitioner.
Written consent of the patient or his legal agent is required for release of medical information to persons not otherwise authorized to receive this information.
Records may be removed from the health center's jurisdiction and safekeeping only in accordance with a court order, subpoena or statute. All records written or electronic are the property of the health center and shall not otherwise be taken away without permission of the Chief Executive Officer. In case of readmission of a patient, all previous records shall be available whether the patient is attended by the same practitioner or by another. Unauthorized removal of charts from the health center or unauthorized access to electronic records is grounds for relinquishment of the practitioner’s privileges for a period to be determined by the Executive Committee. Records may be transported between facilities as necessitated by continuous care, study audits or reasonable need.
Free access to all medical records of all patients shall be afforded to members of the Staff for bona fide study and research consistent with preserving the confidentiality of personal information concerning the individual patients. All such projects shall be approved by the Executive Committee before records can be studied. Subject to the discretion of the Chief Executive Officer, former members of the 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 health center.
A medical record shall not be permanently filed until it is completed by the responsible practitioner or is ordered filed by the Management of Information Team physician representative.
The patient's medical record shall be complete within thirty (30) days following discharge. The patient's chart will be available in a stated place in the medical record room after discharge. If the record remains incomplete after thirty (30) days, the President shall notify the practitioner and the Medical Record Department shall notify affected departments by mail, phone and/or fax that his/her privileges to admit patients, perform procedures or interpret ancillary reports shall be withdrawn. Privileges of such practitioner shall remain relinquished until the records have been completed. Any Medical Staff member who is absent by virtue of vacation or illness will be granted seventy-two (72) hours upon his/her return to complete any delinquent medical records. If a physician has been suspended for incomplete medical records more than five (5) times in any six (6) consecutive months, then that physician will have to reapply for privileges at the health center. The admitting offices of the general health center and the Pinecrest Manor shall be notified of this action.
The following procedure should be followed for "closing" the medical record when the attending physician is unavailable:
The incomplete record is reviewed by the Management of Information Team. After review of the record, the following statement is recorded in the medical record: "The following portions of the record are incomplete (state which portions) due to (state reasons). If a significant discrepancy or finding of medical importance is discovered, the patient or appropriate guardian will be notified by certified mail. Therefore, this record is considered complete." This attestation statement is signed by a Medical Staff representative on the Management of Information team.
Every patient going to surgery shall have a pre-anesthesia and post-anesthesia evaluation and note, preferable as a progress note, which states specific information relative to the anesthesia chosen for the procedure. This notice should be made by one of the personnel in the Anesthesia Department, and countersigned by the Anesthesiologist. The notice shall include compliance with discharge criteria and shall describe the presence or absence of anesthesia-related complication. The notice shall also record the name of the practitioner responsible for the discharge.
For patients admitted to an observation bed, the attending physician must visit the patient prior to discharge and document on the chart the patient's condition at the time of his/her visit.
Consents - It is the policy of the Elk Regional Health Center to establish patient consent prior to provision of medical services offered by the health center.
General consent for medical treatment will be signed by the patient or his legal guardian upon admission to the health center or treatment in the Emergency Room.
Specific informed consent must be obtained for:
All procedures performed in the Surgical Suite.
surgery, which involves entry into the body,
either through incision or through one of the natural body openings.
All procedures in which anesthesia is used, regardless of whether an entry into the body is involved.
Experimental procedures, or the use of experimental or investigational drugs.
patient or involving a risk of change in the patient's body structure and other procedures which the Staff determines requires a specific explanation to the patient. (Any doubts as to the necessity of obtaining informed consent from the patient for the procedure should be resolved in favor of procuring the consent.) Such procedures shall include, but not be limited to, the following: Lumbar Puncture, Endoscopic Procedures, Legal Blood Alcohol Determinations, Cutdown, Paracentesis, Thoracentesis, Cystoscopy, Stress Tests, Bone Marrow Aspirations, Needle Biopsies, Amniocentesis, Therapeutic Nuclear Medicine, Circumcision, ECT, Administration of Chemotherapy, Blood Transfusion and Refusal, Intra-Articular Injections and Specific Radiological Procedures including: Angiogram, Myelogram, Iodine Contrast Procedures, Bronchogram, and others as determined by the Radiologist.
practitioner performing or supervising the procedure. When the written consent does not detail the possible risks and complications related to the procedure, it shall be standard practice for the practitioner to document in the permanent health center record an additional statement which describes the activities surrounding the informed consent.
A general consent form, signed by or on behalf of every patient admitted to the health center, 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 health center. In addition a specific consent that informs the patient of the nature of any risks inherent in any special treatment or surgical procedure should be obtained according to the health center’s consent policy. Appropriate forms for such consents will be supplied.
All acute care inpatients must be seen daily by either the attending physician or the physician covering.
Medications are to be given only on the written order of a practitioner, who is a
member of the Medical Staff or assigned clinical privileges. All orders by
practitioners will be dispensed upon receipt of a direct copy of the order.
Verbal orders may be given by the attending practitioner in a bona fide emergency
situation where time does not permit the writing of the order or the situation does not permit the practitioner to write the order. The RN/GN and/or allied health practitioner shall write such orders on the order form, stating it is a “verbal order” (verbal orders are abbreviate VORB) and sign the practitioner’s name and his/her name and title to the order. The RN/GN and/or allied health practitioner must
repeat the order to the practitioner from the written record for confirmation.
Telephone orders may be accepted by a RN/GN and/or or allied health practitioner
only. The RN/GN and/or allied health practitioner shall write such orders on the
order form stating it is a telephone order (telephone orders are abbreviated TORB)
and sign the practitioner’s name and his/her name and title to the order. The
RN/GN and/or allied health practitioner must repeat the order to the practitioner
from the written record for confirmation. The practitioner must date, time and
countersign this order on his/her next visit to the nursing station, or within 24
Acceptance of a verbal order is limited to the following, with noted restrictions: (1)
A licensed practical nurse (in Pinecrest Manor only)
A certified registered nurse practitioner
A pharmacist who may transcribe a verbal order pertaining to drugs
A respiratory therapist who may transcribe a verbal order pertaining to respiratory therapy treatments
A physical therapist who may transcribe a verbal order pertaining to physical therapy treatments
A registered dietician who may transcribe a verbal order pertaining to dietary regimens.
A certified laboratory technician who may transcribe a verbal order pertaining to a laboratory test.
Medication orders are automatically canceled under the following conditions: (1)
Patient goes to the delivery room or operating room
After seven (7) days for any of the following unless renewed or ordered for
a specific period of time or number of doses: a. Anticoagulants* b.
**(PO/IM/IV combination not to exceed five (5) days total. Will
After fourteen (14) days for any of the following unless renewed or ordered for a specific period of time or number of doses:
NOTIFICATION FOR RENEWAL TO BE GIVEN FORTY-EIGHT (48) HOURS PRIOR TO EXPIRATION OF ORDER.
All drugs and medications administered to patients should be those listed in the
latest edition of the United States Pharmacopoeia, National Formulary, American Hospital Formulary Service of A.M.A. Drug Evaluations. Drugs for bona fide clinical investigations may be exceptions. Investigational use of medication must follow health center’s policy for use of such agents.
Patient’s personal medication may be brought to the health center and administered
only by order of the attending physician with the knowledge of the health center pharmacist and must be ordered by name.
Medication orders should be legibly written and should include the name of the
medication (trade or generic), dosage expressed in the metric system, frequency of
administration, route of administration, date and hour and signature of the
practitioner. The use of “renew”, “repeat” and “continue” orders are not acceptable.
The use of chemical symbols in the writing of medication orders is discouraged.
abbreviations are only permissible if on the approved listing.
Any questions arising from a medication order, should be referred to the
practitioner writing the order. The nurse and/or allied health practitioner should not
be expected to attempt to carry out the order until the question is resolved.
The use of hold orders is not valid unless ordered for a specific time or number
of doses. Other hold orders will be discontinued at once.
The practitioner will specify the time a stat order was written. Documentation will
Any qualified practitioner with clinical privileges in this health center can be called for consultation within his expertise.
Other than in an emergency, consultation should be requested in the following situations:
When the patient is not a good risk for operation or treatment;
Where the diagnosis is obscure after ordinary diagnostic procedures have been completed;
Where there is doubt as to the choice of therapeutic measures to be utilized;
In unusually complicated situations where specific skills of other practitioners may be needed;
In instances in which the patient exhibits severe psychiatric symptoms;
When requested by the patient or his family
When a patient’s status is changed from SDC to Extended Stay for a medical reason.
The attending practitioner is primarily responsible for requesting consultation, when
indicated and for calling in a qualified consultant. He will provide written authorization to
permit another attending practitioner to attend or examine his patient, except in an
If a nurse had any reason to doubt or question the care provided to any patient or believes
that appropriate consultation is needed and has not been obtained, she shall call this to the
attention of her supervisor who in turn may refer the matter to the director of the nursing
service. If warranted, the director of nursing may bring the matter to the attention of the
chief of the service wherein the practitioner has clinical privileges. Where circumstances
are such as to justify such action, the chief of the service may, himself, request a
“Hand-off communication” should occur when there is a change in the level of
care/services/setting or a change of caregivers. When handing off the care of an acutely ill
patient from one physician to another, verbal or written or electronic communication will
be made with the exchange of patient-specific information to include patient status.
Each practitioner has a responsibility for reporting incidents, particularly as they relate to care and treatment of patients, in support of the health center's risk management program.
In compliance with the regulations of the appropriate agencies, a Statement of Patient's
Rights and a Statement of the Patient's Responsibilities shall be posted in prominent places
throughout the health center and Pinecrest Manor.
Self Treatment or Treatment of Immediate Family Members - Physicians generally should
not treat themselves or members of their immediate families. Professional objectivity
may be compromised when an immediate family member of the physician is the patient;
the physician’s personal feelings may unduly influence his or her professional medical
judgment, thereby interfering with the care being delivered. Physicians may fail to probe
sensitive areas when taking the medical history or may fail to perform intimate parts of
the physical examination. Similarly, patients may feel uncomfortable disclosing sensitive
information or undergoing an intimate examination when the physician is an immediate
family member. This discomfort is particularly the case when the patient is a minor
child, and sensitive or intimate care should especially be avoided for such patients. When
treating themselves or immediate family members, physicians may be inclined to treat
problems that are beyond their expertise or training. If tensions develop in a physician’s
professional relationship with a family member, perhaps as a result of a negative medical
outcome, such difficulties may be carried over into the family member’s personal
relationship with the physician. Concerns regarding patient autonomy and informed
consent are also relevant when physicians attempt to treat members of their immediate
family. Family members may be reluctant to state their preference for another physician
or decline a recommendation for fear of offending the physician. In particular, minor
children will generally not feel free to refuse care from their parents. Likewise,
may feel obligated to provide care to immediate family members even if they feel
uncomfortable providing care. It would not always be inappropriate to undertake self-
treatment or treatment of immediate family members. In emergency settings or isolated
settings where there is no other qualified physician available, physicians should not
hesitate to treat themselves or family members until another physician becomes available.
In addition, while physicians should not serve as a primary or regular care provider for
immediate family members, there are situations in which routine care is acceptable for
short-term, minor problems. Except in emergencies, it is not appropriate for physicians
to write prescriptions for controlled substances for themselves or immediate family
Restraints for Medical and Surgical Patients –
A restraint, including a physical restraint or a drug that is being used as a restraint, will be used only if needed to protect the patient or others from harm and less restrictive interventions have been determined to be ineffective.
There must be an order for a restraint by a physician or other practitioner. The order for a restraint may not be written as a standing order or on an as-needed basis. If the order is not issued by the patient’s attending physician, it must be followed by consultation with the treating physician, as soon as possible.
An order for restraint must be in accordance with a written modification to the patient’s plan of care, implemented in the least restrictive manner possible, in accordance with safe and appropriate restraining techniques, and ended at the earliest possible time.
13. Restraints for Behavioral Health Patients –
Seclusion or a restraint, including a physical restraint or a drug that is being used as a restraint, will be used only if needed to protect the patient or others from harm and less restrictive interventions have been determined to be ineffective.
There must be an order for a restraint or seclusion by a physician or other practitioner. The order for a restraint or seclusion may not be written as a standing order or on an as-needed basis. If the order is not issued by the patient’s treating physician, it must be followed by consultation with the treating physician, as soon as possible. A physician or other practitioner must see the patient and evaluate the need for restraint or seclusion within one (1) hour after the initiation of this intervention.
Each written order for a physical restraint or seclusion is limited to four (4) hours for adults, two (2) hours for children and adolescents ages nine to seventeen, and one (1) hour for patients under age nine. The original order may be renewed only in accordance with these limits for up to a total of twenty-four (24) hours. After the original order expires, a physician or practitioner must see and assess the patient before issuing a new order.
An order for restraint must be in accordance with a written modification to the patient’s plan of care, implemented in the least restrictive manner possible, in accordance with safe and appropriate restraining techniques, and ended at the earliest possible time.
A restraint and seclusion order may not be used simultaneously unless the patient is continually monitored face-to-face by an assigned staff member of continually monitored by staff using both video and audio equipment. This monitoring must be in close proximity to the patient.
The condition of the patient who is in a restraint or in seclusion must continually be assessed, monitored and re-evaluated.
Policies, Regulations and Rules for the Surgical Suite.
General Considerations - The chief of surgery along with the Director of the Operating Room and in conjunction with the Director of Anesthesiology shall have the responsibility for the policies and overall operation and supervision of all surgery performed in the health center including the direction of the surgical suite. In cooperation with the supervising nurse of the operating room, he will maintain a written statement of policies governing the operating room including starting time of operations, outpatient operations, care and transport of patients, efficient use of
the operating room, contaminated cases, environment control, and others. The post anesthesia care unit will be under the direction of the Anesthesiologist. In the absence of an Anesthesiologist, the chief of surgery will assume responsibility for the post anesthesia care unit.
Scheduling of Operations - The operating room policy shall define methods of scheduling, definition of priorities including assignment and loss of priorities.
Reservation for Operations - A schedule for proposed operations shall be maintained and operating room policies shall define the method for reservation including special equipment required, information required and the time requested and procedures for changes in schedules.
Emergency Operations - These shall be defined and policies regarding their procedures shall be described.
Anesthesia - Prior to anesthesia for surgery, there must be maintained a policy for proper identification of the patient, pre-operative evaluation and documentation in the medical record containing a record of physical examination and studies pertaining to the patient's condition prior to surgery as well as the preparation of forms indicating that the patient has given informed consent and identification of the procedure and site.
Except in emergencies, the history and physical examination and the pre-operative diagnosis and required laboratory tests must be available prior to any surgical procedure. If not recorded, the operation shall be delayed. In any emergency, the practitioner shall make at least a comprehensive note regarding the patient's condition prior to the induction of anesthesia and the start of surgery.
When a patient is admitted by a member of the dental service for an operative procedure with anesthesia, the admitting dentist shall be required to obtain consultation from a physician member of the Staff to fulfill the following:
Medical history pertinent to the patient's general health.
A physical examination to determine the patient's condition prior to anesthesia and surgery.
Supervision of the patient's general health status while hospitalized.
Anesthesiologist, to be available during dental
anesthesia in case of medical need or emergency.
A detailed dental history justifying health center admission.
A detailed description of the examination of the oral cavity and pre-operative diagnosis.
A complete operative report describing the findings and technique. In cases of extraction of teeth, the dentist shall clearly state the number of teeth and fragments removed.
Progress notes as are pertinent to the oral condition.
The discharge of the patient shall be on written order of the dentist member of the Staff, unless the medical condition of the patient contraindicates discharge.
A patient admitted for podiatric care is the dual responsibility of the podiatrist and a physician member of the Staff.
Podiatrist's Responsibilities - The podiatrist must provide a detailed podiatric history and physical examination and a complete description of any operative procedure performed, progress notes, and a clinical summary.
Physician's/Allied Health Practitioner’s Responsibilities - The physician/allied health practitioner must provide complete physical examination and medical history as well as supervision of the patient's general health while hospitalized.
Written, signed, informed, surgical consent shall be obtained prior to the operative procedure except in those situations wherein the patient's life is in jeopardy and suitable signatures cannot be obtained due to the condition of the patient. In emergencies involving a minor or unconscious patient in which consent for surgery cannot be obtained from parents, guardian or next of kin, these circumstances should be fully explained on the patient's medical record. A consultation in such instances may be desirable before the emergency operative procedure is undertaken, if time permits.
Should a second operation be required during the patient's stay in the health center, a second consent specifically worded should be obtained. If two or more specific procedures are to be carried out at the same time, and this is known in advance, they may be all described and consented to on the same form.
A pre-anesthesia or pre-sedation evaluation shall be documented in the medical
record of all patients undergoing surgery, anesthesia or moderate or deep sedation.
The pre-anesthesia or pre-sedation physical evaluation shall be recorded in the
medical record prior to the surgery or the administration of anesthesia or sedation.
A post-anesthesia evaluation shall be documented in the medical record of all
patients who have undergone surgery, anesthesia, or moderate or deep sedation.
The post-anesthesia evaluation shall be recorded in the medical record by an
individual qualified to administer anesthesia, no more than twenty-four (24) hours
In any surgical procedure with unusual hazard to life, there must be a qualified assistant present and scrubbed. A qualified assistant must be a doctor of medicine or osteopathy or a qualified allied health professional.
Tissues or exudates removed during a surgical procedure shall be properly labeled and sent
to the laboratory for examination by the pathologist, who shall determine the extent of
examination necessary for diagnosis except as provided in this section. The specimen shall
be accompanied by pertinent clinical information, including its source and the pre-operative
and post-operative surgical diagnosis. The following categories of specimens should not be
sent to the pathology department unless specifically requested by the surgeon:
for cosmetic reasons including sectional or
excisional lipectomy, blepharoplasty, panniculectomy, nasal cartilage.
Vertebral lamina removed for spinal stenosis due to degenerative bone disease
All operations shall be fully described by the operating surgeon immediately and copies supplied for the health center medical record.
GENERAL RULES REGARDING OBSTETRICAL CARE:
It will be the responsibility of the chief of surgery in conjunction with the director of The Family Unit to approve and monitor policies and procedures of The Family Unit including the delivery room and obstetrical inpatient unit.
False Labor – Obstetric Registered Nurses who have the necessary knowledge, preparation,
experience and competency may rule out false labor in congruence with Federal EMTALA
The Administration, in conjunction with the Staff, shall adopt a method of providing medical coverage in the emergency services area. This shall be in accordance with the health center's basic plan for the delivery of such services including the delineation of clinical privileges for all physicians who render emergency care.
The duties and responsibilities of all personnel serving patients within the emergency area shall be defined in a policy and procedure manual relating specifically to this outpatient facility. The contents of such a manual shall be developed by the emergency department and approved by the Executive Committee.
An appropriate medical record shall be kept for every patient receiving emergency service and be incorporated in the patient's health center record. The record shall include:
Information concerning the time of the patient's arrival, means of arrival and by whom transported.
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 health center.
Description of significant clinical, laboratory and radiological findings.
Condition of the patient on discharge or transfer.
Final disposition including instructions given to the patient and/or his family, relative to necessary follow-up care.
Notation when a patient needing care leaves against medical advice.
Each patient's medical record shall be signed by the practitioner in attendance who is responsible for its clinical accuracy.
There shall be a daily random sample review of emergency room medical records, to evaluate the quality of emergency medical care. These medical records should first be reviewed for their adequacy as documents. In addition, the records of all patients dying within twenty-four (24) hours of admission to the emergency service should routinely be reviewed by the operative and other invasive procedure team. There shall be monthly review of all transfers to other facilities, EKG and radiology interpretations.
There shall be a plan for the care of mass casualties at the time of any major disaster in conjunction with other emergency facilities in the community. Plans shall be endorsed and supported by the Staff.
There shall be a physician on-call roster for basic and general emergency service, which will be posted in the Emergency Department. Associate and Active Staff members will be assigned to the emergency on-call roster for the specialty in which they have been granted privileges. This will include consults and inpatients.
Any patient who presents to the emergency department will be provided with a timely and appropriate medical screening examination within the capability of the hospital emergency department to determine whether an emergency medical condition exists.
A medical screening is defined as the examination and evaluation process consistently used by a qualified medical person, including ancillary services routinely available to the emergency department to determine or diagnose whether or not the patient has an emergency medical condition.
Emergency medical screenings may be performed by a licensed MD or DO who is a member of the Medical Staff or a member of the Allied Health Practitioners Staff, including Physician Assistants and Nurse Practitioners if they have been credentialed to do so.
For special care units, such as post anesthesia care unit, intensive care units of all kinds, newborn nursery, etc., appropriate committees of the Staff or chiefs of service shall approve specific policies. These regulations shall be submitted for endorsement of the Executive Committee.
Each service is expected, within its collegial framework, to adopt various procedural rules that fit its need.
The annual meeting of the Staff shall take place in October of every other year. Notice regarding time and place shall be mailed to each member of the Staff at least one week in
The President of the Staff shall call two meetings per year. Notice regarding time and place shall be mailed to each member of the Staff at least one week in advance.
Admission to this facility will be based upon need for this level of care, the environment most appropriate for the resident, and the availability of accommodations. Prior to admission, the referral will be reviewed by but not limited to Resident Assessment, Social Service, and Director of Nursing Services at Pinecrest Manor. The information may also be referred to the Medical director and/or the Office of Aging for Option Determination.
Residents are admitted to the facility upon recommendation of any member of the Staff.
Residents shall be placed and remain under the care of a member of the Staff who has maintained his privileges to admit and treat residents at Pinecrest Manor.
Residents under the Medicare, Medicaid, or other insurance plan must be seen by the physician at least once every thirty (30) days for the first ninety (90) days of admission and at least every sixty (60) days thereafter or more often should condition warrant. All other residents must be seen every sixty (60) days or more often, should the resident’s condition warrant.
Medical Findings and Physicians' Orders at Time of Admission
History and Physical must be completed within forty-eight (48) hours of admission when the resident is a direct admission from private residence or attending physician’s office.
Admissions from acute care must have an H&P completed within forty-eight (48) hours of admission except when an examination was performed within five (5) days before admission and the findings are recorded in the medical record on admission. If the H&P does not meet this criteria, the physician must sign admission orders as reviewing and acceptance of hospital records as Admission Evaluation.
MA-51 may be used on the medical evaluation provided the criteria in 3b are met.
Residents admitted from acute care must have a Discharge Summary completed by the physician prior to admission. A Swing Bed Discharge Summary will be acceptable with an addendum that states the resident is transferred to Pinecrest Manor for continued services
Complete blood count, urinalysis and chest x-ray are required for admission. If these studies have been performed within the last sixty (60) days and are acceptable
to the physician, then they will fulfill the requirements for admission to Pinecrest Manor.
The facility shall have a written requirement that the health care of every resident must be under the supervision of a physician who, based on a medical evaluation of the resident's immediate and long term needs, prescribes a planned regimen of total resident care.
A progress note shall be written or dictated by the physician at the time of each visit. Previously dictated progress notes must be signed at this time unless the physician utilized electronic signature.
Physician's orders must be reviewed, signed with original signature, and dated according to required physician visits as stated in 2c
Any documentation, i.e. progress notes, physical exam or orders written by a physician assistant or nurse practitioner, shall be dated and co-signed with original signature by the Supervising Physician within seven (7) days. It is the responsibility of the physician assistant, nurse practitioner, and the Supervising Physician to see that this is completed on a timely basis.
A body shall not be removed from the facility until death has been determined. The physician who is legally responsible for pronouncement of death may give an order for the Licensed Registered Nurse, who has been involved in the care of the resident, to pronounce death. Resident must have expired from natural causes.
complete the name, and section 4, 8d and 23a
through 26 on the death certificate. It is the responsibility of the physician to complete the rest of the death certificate in accordance with Section 502 of the Vital Statistics Law (35P.S.450.502)
Only physicians shall enter or authenticate in any medical record any opinions that require medical judgement in accordance with Staff By-Laws, Rules and Regulations, if applicable. Each physician signs his entries into the resident's medical record.
Restraints shall not be used for convenience or discipline. Restraints shall be used in limited circumstances in which the resident has a medical diagnosis, medical symptoms, presents a clear danger to himself or other residents or the alert and oriented resident requests a device.
LOCKED RESTRAINTS SHALL NOT BE USED AT ANY TIME.
There shall be an order, signed by the physician, for any physical restraint, which indicates specific reason, as well as a specified and limited period of time. Order must also include, remove q2hr and exercise for ten (10) minutes.
Chemical restraints shall have reason documented on the clinical record and shall be reviewed for continued need in accordance with the resident’s total program of care.
Conformance With Physicians' Drug Orders -
Drugs shall be administered in accordance with written orders of the attending physician.
Drugs not specifically limited as to time or number of doses when ordered shall be controlled by automatic stop-orders or other methods in accordance with written policies.
Physicians' oral and telephone orders shall be given only to a licensed registered nurse, pharmacist, or physician and immediately recorded and signed by the person receiving the order. (Oral orders for Schedule II drugs are permitted only in the case of a bona fide emergency situation). Physician shall date and countersign with original signature within forty-eight (48) hours for medications and within seven (7) days for all other orders. Written orders may be by facsimile transmission.
The attending physician shall be notified of an automatic stop order prior to the last dose so that he may decide if the prescription is to be renewed.
Any antipsychotic medication must have a reason for administration documented on the physician order sheet. All psychoactive medications will be discontinued after five (5) days unless a diagnosis is documented and psychiatric consult is addressed.
There shall be a Medical Director to serve the facility. The following articles are a requirement when a Medical Director is appointed:
The physician shall be licensed in the Commonwealth of Pennsylvania to practice medicine or osteopathy.
The Medical Director shall serve on a full time basis.
There shall be a written agreement between the Medical Director and the facility.
The Medical Director shall be responsible for the overall coordination of the medical care in the facility to ensure the adequacy and appropriateness of the medical service provided to residents and to maintain surveillance of the health status of employees.
Incidents and accidents that occur on the premises shall be reviewed by the Medical Director to identify hazards to health and safety. The Administrator shall be given appropriate information to help ensure a safe and sanitary environment for residents and personnel.
The Medical Director shall be responsible for execution of resident care policies.
Medical direction and coordination of medical care shall be provided by the Medical Director. Coordination of medical care includes liaison with attending physicians to ensure their writing orders promptly upon admission of a resident, and periodic evaluation of the adequacy and appropriateness of health, professional, and supportive staff services.
The Medical Director shall be responsible for the development of written by-laws, rules and regulations that are approved by the governing body and include the delineation of the responsibilities of attending physicians.
Any physician who does not routinely (within 10 days) see a resident at Pinecrest Manor per regulations from the Department of Health and CMS (every 30 days for the first 90 days and every 60 days thereafter) will lose Pinecrest Manor privileges until the resident is seen. During this time, the resident will be cared for by the Pinecrest Manor Medical Director or a designated physician named by the physician, resident, or resident’s family. Loss of privileges at Pinecrest Manor does not affect acute care privileges.
If a physician has been suspended more that five (5) times in any six (6) consecutive months, than that physician will have to reapply for privileges at Pinecrest Manor.
TABLE OF CONTENTS
RULES AND REGULATIONS
OF THE MEDICAL-DENTAL STAFF
ADMISSION AND DISCHARGE OF PATIENTS.……………. 1
MEDICAL RECORDS.……………………………. 5
CONDUCT OF CARE.…………………….10
GENERAL RULES REGARDING SURGICAL CARE.…………15
GENERAL RULES REGARDING OBSTETRICAL CARE.……….18
F. EMERGENCY SERVICES.………………………….18 G.
SPECIAL CARE UNITS.……………………………. 20
MEDICAL STAFF MEETINGS.………………………….20
PINECREST MANOR ……….…………………………21
RULES AND REGULATIONS
ELK REGIONAL HEALTH CENTER
Reviewed and Amended 5/1/2000
Reviewed and Amended 4/30/2001
Reviewed and Amended 6/24/2002
Reviewed and Amended 12/6/2004
Reviewed and Amended 7/30/08
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