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All Physicians and Practitioners
All Specialties

Section 1. Admission of Patients:
Medical Staff members of the Hospital may admit patients for diagnostic, surgical and
therapeutic care in accordance with their granted privileges. Exceptions are patients with
serious burns and acute psychiatric diagnoses requiring locked facilities.

1.1 Admitting

Patients will be admitted to the hospital only by Medical Staff members with admitting privileges. Medical Staff members without admitting privileges, including Dentists, must co-admit with a physician who has privileges and who will be responsible for the medical aspects of the patient's care. 1.1-1 Responsibility of Admitting Physician
The admitting physician will:
 provide a written order for admission to the assigned level of care
 provide a provisional diagnosis on scheduled admission to the hospital. In the instance of emergency admission, such a provisional diagnosis will be stated as soon as feasible.  be responsible for completing or arranging for the completion of a history and physical examination within twenty-four (24) hours  see all non-critical patients within 24 hours of patient admission to the Medical Center and record daily progress notes in the medical record by the attending physician or primary rounding physician  provide hand-off communication for appropriate patient care transitions, and  a non-ob/gyn physician who is admitting an obstetrical patient is responsible for notifying Critical Care Units
Physicians admitting or transferring patients to the Critical Care Units will write their own orders, but will additionally accept protocols of the Units, and abide by the Units special Rules and Regulations. (B) The patient admitted to the Critical Care Unit must be seen by the attending physician, or by a consulting physician assuming care of the patient, within TWO (2) hours of admission unless the patient was seen by the physician in the physician’s office or in the Emergency Department or was transferred within the last four (4) hours.
1.3 Clinical

Responsibility for clinical care is that of the attending physician or on call physician. If neither is able to respond or be contacted, responsibility defers to that physician’s specialty Section chair and, if unavailable, responsibility defers to the Division chair to locate another member of that specialty.
As originally approved by SMRMC Community Board 9/25/01
Section 2. Emergency Coverage:
Emergency Room coverage is an obligation of the medical staff as delegated by the Board of
Trustees. Assignment will be determined by each specialty.
Assignment to the Call Panel
Assignment to the Call Panel will be made by the Division and/or Section Chair. The Sections of Pathology and Radiology provide on call services and an on call schedule that is accessed by contacting these specialties directly as needed. Changes to the Call Panel Schedule
After the Call Schedule has been published, each physician is responsible for the assigned
date of coverage. If unable to fulfill their obligation or desiring to make a trade in the call
schedule, the physician will arrange alternate coverage and notify the Medical Staff Office and
Emergency Department in writing (by mail or fax) of the physician who has agreed to provide

When the physician is unable to obtain alternate coverage for an assigned date for which
he/she cannot because of unavoidable and/or unforeseen circumstances provide coverage,
he/she must arrange coverage through the Division or Section Chair.
Assignment of Patients
All patients presenting to the Emergency Department and requesting examination or treatment should receive an appropriate medical screening examination and stabilizing treatment, unless the patient refuses care. The patient’s private physician may come to the hospital to treat a patient who presented to the Emergency Department with an emergency medical condition under the following circumstances: (A) The patient has been screened and stabilized and no longer has an emergency (B) The patient has an emergency medical condition, but has refused treatment by the Emergency Department Physician or the on-call panel specialist; or (C) The patient is not stable and has not refused services by the on-call panel specialist, but the private physician elects to come to the hospital to care for the
patient. In this case, the patient’s physician must arrive at the hospital within the
thirty (30) minute response time that governs the response time of the on-call
specialty panel physician. In no case will treatment of an emergency medical
condition be delayed by the fact that the private physician has chosen to provide
care to the patient.)
In cases where the patient requires hospital admission and/or additional consultant(s), the patient’s private physician, if he has one, (or the covering physician for the group) or the on-call panel specialist will be responsible for arranging this. If either of these physicians requests that another consultant or member of the specialty call panel admit and attend the patient, the private physician or the on-call specialist shall arrange for this. The Emergency Department As originally approved by SMRMC Community Board 9/25/01 physician may, as a courtesy, contact the appropriate specialist and arrange for the consultation or admission. If there is disagreement between the member(s) of the on-call panel or the patient’s own physician about who should care for and/or admit the patient, the Emergency Department physician will decide which physician should care for the patient and which service to admit the patient to, based upon the patient’s best interests. Obligations of On-Call Physicians
While on call for unassigned ER patients, private practice patients, or consultation requests, physicians are required: Respond without discrimination on the basis of the patient's race, ethnicity, religion, national origin, citizenship, age, sex, pre-existing medical condition, physical or mental handicap, insurance or economic status, or ability to pay for medical services except to the extent that such circumstance is medically significant to the provision of appropriate medical care to that individual. (B) Assist in the diagnosis and treatment of the patient, and when the patient's condition so warrants, accept continuing primary responsibility for the patient's care, including admission to the hospital and/or subsequent outpatient care. (C) Assist in the decision and arrangement for transfer in concurrence with the Emergency Department physician when the patient's condition so warrants and in accordance with all applicable transfer protocols. (D) Respond to the Emergency Room in a timely manner. After being contacted by the ED staff, the on call physician must respond by phone to the ED within 15 minutes.
The physician is expected to assume the care for the critical patient within 30 minutes
and for a non-critical patient, within 2 hours. If unable to do so, he/she must inform the
nurse of his/her back up physician. When no back up is available, or the critical
patient's stay in the ED is prolonged, the ED Physician will notify the Chief of that
specific section. The Chief of Section will then arrange for appropriate care for the
In the event that the private admitting physician is detained and unable to respond to
the ED within the 2 hour time frame or chooses not to give verbal orders to the ED
nursing staff, at the request of the private admitting physician, the Emergency
Department physician may write “Transfer of Care/Admission Orders” on stable
after consultation with private admitting physician. These orders will safely
initiate the medical management of the patient until the private admitting physician can
evaluate the patient. The orders will expedite admission of the patient to a safe, more
comfortable environment. The orders will be time-limited for a maximum of 6 hours or
less based upon the Emergency Physician’s assessment of the patient’s condition. If
the Emergency Physician is uncomfortable with writing “Transfer of Care/Admission
orders” for any reason, they have the right to refuse and hold the patient in the
Emergency Department until the private admitting physician can evaluate the patient.
“Transfer of Care/Admission orders” will not be written for patients requiring admission
to a critical care unit, direct to the operating room, (or to the care of the hospitalist).
The private admitting physician who has been consulted by the Emergency Physician
assumes the responsibility for the admission of the patient and ongoing care of the
patient after transfer from the Emergency Department to the in-patient bed. Patient care
beyond the Emergency Department is the responsibility of the private admitting
As originally approved by SMRMC Community Board 9/25/01 physician. Any issues or further orders will be directed to the private admitting MD by the nursing staff.
When a patient is in need of immediate medical attention, he/she is seen by the emergency
physician on duty. If the patient lists a private physician, that physician will be contacted as
soon as possible. When no private physician is given, the appropriate on call specialist
(physician) will be notified by phone.
When two or more specialties are involved such as hand call or facial fracture call, the
preceding will prevail. It is the responsibility of whoever is on call either to cover the patient
themselves or to obtain coverage or the EDP will immediately place a call to the physician’s
specialty chairperson or, if unavailable, to the Chief of Staff for disciplinary measures to be
Failure to Fulfill On Call Obligations Due to Lack of Response
 If after multiple contact attempts have been documented by the Emergency
Department Physician and the on call physician has not responded, And  The ED physician feels that patient care has been compromised by the delay, Then  The Section Chief will be notified immediately by the EDP at the time of the occurrence followed by a written report documenting the event by the EDP, And  Subsequently, the following sequence of corrective actions will be followed: Occurrences Within a 12-mo. Period First Instance A written warning by the Section Chairman will be sent. A second written warning, sent by the Chief of Staff, will be sent requesting a plan of corrective action to eliminate the frequent occurrence of these instances. The physician will also be referred to the Physician Aid Committee for mediation and intervention if necessary. Upon notification of third instance, the Credentials and Privileges Committee will recommend suspension pending a hearing by the Section. 2.6 Transfers
Patients who request transfer to another hospital or who require services not provided at this
facility, or patients with insurance not in effect at this hospital, may be transferred to a more
appropriate facility, but only after:
The patient has been evaluated by the Emergency Room Physician and/or appropriate consultants, and has been found to be medically stable for transfer, unless within reasonable medical probability, the expected medical benefits of the transfer outweigh the risks posed by the transfer and the patient, or the patient's surrogate decision maker, requests the transfer, after the physician(s) have explained the risks and benefits for the transfer. (C) The receiving facility and a responsible physician at that facility both accept and As originally approved by SMRMC Community Board 9/25/01 Staff and equipment necessary to effect safe transfer is available. The appropriate transfer paperwork is completed and a copy provided to receiving facility. Refusal of Treatment
In the event that a patient, or the patient's family or legal representative refuses treatment or a dispute arises between the patient and the Call Panel physician, Emergency Room physician will be immediately notified. (B) Assumption of "Refusal of Treatment" will not be made until the Emergency Room physician and/or the Call Panel physician have fully informed the patient or patient's surrogate decision maker of the benefits of treatment offered and the risks of refusing such treatment. (C) If treatment is refused, a written informed refusal of treatment form will be presented for the signature of the patient or the patient's surrogate decision maker. If the patient or the surrogate decision maker decline to sign the informed refusal of treatment, the Emergency Room physician and/or the consulting physician(s) will make written notation of that fact on the informed refusal form. Referrals from the Emergency Department
All physicians who are on the daily call list for the Emergency Department are responsible to
see patients who require follow up care for the presenting problem they have been evaluated
for in the Emergency Department and referred for after care. The ED physician will attempt
contact with the private physician in cases deemed necessary for immediate follow up or
instruct the patient to alert the office that they were seen in the ED and instructed to follow up
within two weeks of the ED visit for the same presenting complaint.

Section 3. Consultations:
A consultation will be obtained in a timely manner when a patient presents with an unusually
difficult medical problem, obscure diagnosis, or requires services beyond the scope of the
attending physician’s expertise or for cases involving treatment or procedures for which a
physician does not have privileges. When a physician is requesting the consult of another
physician, the referring physician is responsible for contacting the consultant and for
documenting the consult request in the medical record.
A neonatology consult with a certified neonatologist will be obtained for all patient admitted to
the NICU.
Section 4. Patient Isolation and Patient Cultures:
Patients with an infectious disease will be placed in appropriate isolation per hospital protocol.
The Chairman of the Infection Control Committee or designee and/or the Infection Control
Coordinator has the authority to institute any surveillance, prevention and control measures or
studies when there is reason to believe that any patient or personnel may be in danger. The
Infection Control Coordinator or a physician member of the Infection Control Committee has
the authority to order a culture or appropriate isolation.
Section 5. No Code Documentation:
Documentation is required in the patient's chart that the patient and/or family have been
counseled by the physician whenever a patient is identified as "no-code" status.
As originally approved by SMRMC Community Board 9/25/01

Section 6. Informed Consent:

Physician Responsibility:
The physician is responsible for providing the patient or an incompetent patient’s surrogate decision-maker with the information that is necessary to allow an “informed decision” to be made. The topics that must be addressed, at a minimum are:  The nature of the operation or procedure, including other care, treatment or  Potential benefits, risks or side effects of the operation or procedure, including potential problems that might occur during recuperation;  The likelihood of achieving treatment goals;  Reasonable alternative and the relevant risks, benefits and side effects related to such alternatives, including the possible results of not receiving care or treatment; and  Any independent medical research or significant interests the doctor may have related to the performance of the proposed operation or procedure;  Any limits on the confidentiality of information learned from or about the patient. Procedures That Require an Informed Consent:
a. Complex procedures: Informed consent must be obtained for procedures that are
“complex” in that they involve material risks that are not commonly understood.
Specifically informed consent must be obtained for all procedures performed
in the operating room (inpatient and outpatient) - for any radiology or cardiology procedure that involves the administration of for the administration of medications marked in the formulary - for the insertion of central lines and insertion of PIC lines including those If there is a doubt as to whether a procedure requires an informed consent, it is appropriate for the physician to obtain one. b. Special Requirements: In addition, informed consent will be obtained as required by law, and consistent with the special legal requirements for the following procedures: - Blood - Bilateral tubal ligations, hysterectomies and other procedures that result in Involuntary commitment for psychiatric disorders As originally approved by SMRMC Community Board 9/25/01 c. Discontinuing Life Sustaining Treatment. When the Emergency Exception Applies: When a patient lacks capacity to make a
healthcare decision and treatment is immediately necessary to prevent death or permanent disability or to alleviate severe pain, and a surrogate decision-maker cannot be contacted, treatment may proceed because it is an emergency and consent will be implied in such circumstances. The physician will document in the medical record:  the inability to obtain consent and efforts to do so  that an emergency exists and the medical justification for proceeding with treatment

Section 7. Physicians Treating Family Members:

Physicians are not to treat immediate members of their families or themselves when inpatients
or surgical patients at Saint Mary's Regional Medical Center (immediate family members are
defined as parents, spouse, children, siblings or in-laws or step relationships in the same
This policy is based on the concern that professional objectivity may be compromised when a
family member or the physician is the patient. Concerns regarding patient autonomy and
informed consent are also relevant when physicians attempt to treat members of their family.
In emergency situations, physicians may treat family members until another physician becomes
available. In special circumstances, exceptions may be granted by the Chief of Staff.
Section 8. Guidelines for Autopsy:
8.1 Deaths in which autopsy may help to explain unknown and unanticipated medical
complications to the attending physician.
8.2 All deaths in which the cause of death is not known on clinical grounds.
8.3 Deaths in which autopsy may help to allay concerns of the family and/or the public
regarding the death, and to provide reassurance to them regarding same.
8.4 Unexpected or unexplained deaths occurring during or following any dental, medical,
surgical or diagnostic procedures and/or therapies.
8.5 Deaths of patients who have participated in clinical trials (protocols) approved by
institutional review boards.
8.6 Unexpected or unexplained deaths which are apparently natural and not subject to forensic
medical jurisdiction.
8.7 Natural deaths which are subject to, but waived by, a forensic medical jurisdictions such as
(a) persons dead on arrival at hospital or within 24 hours of admission and (b) deaths in which the patient sustained or apparently sustained an injury while 8.8 All obstetric deaths.
8.9 Deaths at any age in which it is believed that autopsy would disclose a suspected but
unconfirmed illness which also may have a bearing on survivors or recipients of transplant
8.10 Deaths known or suspected to have resulted from environmental or occupational hazards.
8.11 Until appropriate facilities are available to adequately handle high risk cases, requests are
denied for autopsy for AIDS, JAKOB-Creutz Feldt Disease and certain other extremely high
As originally approved by SMRMC Community Board 9/25/01 risk cases. Such arrangements can be made by the Coroner’s Office. (Intradepartment review
will be done for unusual cases.)
8.12 Cases with recent insertion of radioactive needles or beads will be evaluated with the
Radiation Safety Officer of the Medical Center for proper precautions and handling of body,
tissues, instruments, and cleanup.
8.13 Autopsies: Every member of the medical staff is expected to be actively interested in
securing autopsies. No autopsy shall be performed without written consent of legally responsible
person or persons. All autopsies shall be performed by the hospital pathologist or by a physician
to whom he may delegate the duty. The pathologist shall notify the attending physician of the time
of autopsy when necessary.

Section 9. Pathology Specimens:

9.1 Emergency Department Specimens: All tissue of potential diagnostic value removed in
the Emergency Room shall be sent to the hospital pathologist for examination. Other tissues,
such as fragments from debridement of wounds, etc., and foreign bodies removed in the
Emergency Department shall be submitted at the discretion of the physician performing the
9.2 Operative Specimens: Material removed from the patient by operative procedure shall
remain in the hospital laboratory for sufficient time to allow the pathologist to make a
permanent record of same. It shall be the duty of the surgical nurse in charge of the operating
room to see that all material removed from operative cases shall be promptly delivered to the
respective laboratory.
Unless felt necessary by the attending physician or if it appears that the tissue is questionable,
the following do not need to be routinely sent to Pathology when removed in Surgery (name of
tissue or name of procedure)
Teeth (number and/or fragments are to be documented in op report) Placenta from normal delivery and routine C-sections are not to be sent to the Laboratory unless requested by the physician; twin placentas and abnormal placentas are to be sent to the Laboratory at the discretion of the physician Cataracts* (cataracts includes lens extractions) Excess skin with no obvious lesions removed for cosmetic purposes Partial meniscectomy with suction done arthroscopically Normal appearing bone or soft tissue when laminectomy is done for decompression for spondylolisthesis or spinal stenosis (disc material should be sent when laminectomy is done for herniated disc) Boney spur removed for nerve root compression Hernia sac in cases of indirect hernia repair As originally approved by SMRMC Community Board 9/25/01 Muscular tissue from correction of strabismus
Section 10. Blood Utilization Review Process
The Blood Bank screens every case of blood/blood product use using current SMRMC
established criteria. Currently, Saint Mary’s transfusion service performs a retrospective audit
whereby transfusions are investigated further when:
 RBCs are given when the Hgb is 10.0 g/dl or higher  FFP is given when the INR is 1.3 or less, and  Platelets are given when the count is 50 or greater. These parameters are not to be used as transfusion triggers (generally guidelines recommend
transfusion at values lower than these thresholds, and this depends on the clinical setting), but
rather are used as flags for retrospective audit.
10.2 If the preceding criteria is not met, a pathologist employs their clinical judgment in
reviewing the case for appropriateness.
10.3 If the pathologist’s focused review of the case fails to find an
appropriate indication for the use of the blood/blood products, the case will be forwarded for
focused review to the Medical Director of Quality and the Chief Medical Officer.
If these two persons do not find an indication for the appropriate use of blood/blood products in this case, the Medical Director of Quality will communicate with the
ordering physician to ask him/her to clarify the indication for the use of the blood/blood
10.5 If the Medical Director of Quality’s focused review fails to find an appropriate use of the
blood/blood products, the case will be forwarded to Chairperson of the Peer Review
10.6 The Chairperson of the Peer Review Committee may bring any single case of
inappropriate use of blood/blood products and make a recommendation for corrective action or
progressive disciplinary action to the MEC. This corrective action or progressive disciplinary
action may include:
 Further education in the use of blood/blood products;  Proctoring of the use of blood/blood products for a specified period of time or number of  And modification or suspension of medical staff membership and privileges.
Section 11. Deaths:
A physician must pronounce death. However, an RN may pronounce death if a physician has
written prior authorization to do so in the patient’s medical record and if the patient is DNR.

Section 12. Notification of Changes to Bylaws, Rules & Regulations, and Policy:
A current copy of the Bylaws, Rules & Regulations, and Policies is available upon request to
Medical Staff Services. These documents are also available on the Medical Staff Services
Website at When changes are recommended by the Medical
Executive Council for these documents, among the methods by which that information is
published to the medical staff is in newsletters, by the internet, and with postings of notices.
When significant changes are made to the Bylaws, a notice will be sent to all members and
individuals with delineated clinical privileges so they may be provided with, or have access to,
revised texts of these documents.
As originally approved by SMRMC Community Board 9/25/01 II. MEDICAL RECORDS
All Physicians and Practitioners
All Specialties

Section 1. General:
All medical records are the property of the hospital. A medical record will be initiated and
maintained for every individual assessed or treated.
(A) Medical records may be removed from the hospital’s jurisdiction and safekeeping only in accordance with a court order, subpoena, or state or federal law. (B) Unauthorized removal of medical records from the hospital or breach of confidentiality of the medical record will be grounds for corrective action against the medical staff member.
1.1 Contents
The attending physician shall be held responsible for the preparation of a complete medical
record for each patient. The contents of the medical record should include:
(A) Identification Data – When not obtainable, the reason shall be entered in the medical
(B) Diagnosis – Provisional and final (primary and secondary) diagnoses, recorded in full,
without use of symbols or abbreviations. (C) History and Physical
A history and physical examination (“H&P”) report shall be dictated or handwritten and
include all pertinent positive and negative findings resulting from an inventory of
1. A “full” H&P is required for all patients admitted for inpatient care, with the
exception of obstetric patients admitted for vaginal deliveries. Outpatients requiring general anesthesia also require a full H&P. A full H&P should address the following: a. A chief complaint. b. Details of the present illness. c. Past medical and surgical history. d. Relevant Past Psycho-Social History (appropriate to the patient’s age). e. A physical examination inventoried by body systems. Unless relevant to the chief complaint or necessary to establish diagnosis, a pelvic and/or rectal exam need not be performed. f. A statement on the conclusions or impressions drawn from the history and g. A statement on the course of action planned for the patient for that episode of 2. A short form H&P may be used for outpatient cases such as those using only
local stand-by anesthesia and for obstetric patients admitted for vaginal deliveries and OSS under 48 hours. A short form H&P should address the following: a. A chief complaint. As originally approved by SMRMC Community Board 9/25/01 b. Details of the present illness. c. Past medical and surgical history pertinent to the operative or invasive d. Relevant Past Psycho-Social History pertinent to the operative or invasive e. A relevant physical examination of those body systems pertinent to the operative or invasive procedure performed, but including at a minimum appropriate assessment of the patient’s cardiorespiratory status. f. A statement on the conclusions or impressions drawn from the history and g. A statement on the course of action planned for the patient for that episode of 3. A focused history and physical is required for outpatient invasive procedures or
any procedure using Procedural Sedation (cath lab, endoscopy, interventional radiology and imaging. A focused H&P should address the following: a. Clinical indications for procedure b. Significant medical, surgical, or psychological history c. Any significant current findings 4. A complete H&P is required if the patient subsequently requires inpatient
admission or an obstetric patient requires a cesarean section or other operation. 5. An Interval H&P may be used to update a full H&P in the circumstances listed
below. It should be appended to or cross reference the full H&P, record that a valid full or abbreviated H&P has been reviewed and that: a. There are no significant changes to the findings contained in the full or abbreviated H&P since the time such H&P was performed, or b. There are significant changes and document what those changes are. 6. Time Frames for Completion of H&P Report a. The H&P shall be completed and placed on the record no later than 24 hours after the patient’s admission, unless the patient will be taken to surgery before that time in which case the H&P report must be placed in the patient’s chart (and signed) immediately before the patient is taken to surgery. If it is impossible to have a dictated H&P report prepared and placed in the chart prior to surgery (e.g., it is a life-threatening emergency), the physician shall include a handwritten report in the record. b. If a complete H&P was performed within 30 calendar days prior to the patient’s admission to the Hospital for elective surgery, a reasonably durable, legible copy of the report may be used in the patient’s medical record in lieu of the admission H&P, provided the report was completed by a Hospital Medical Staff Member. This H&P must be reviewed and updated immediately prior to surgery. c. If the patient is readmitted to the Hospital within 30 days of a previous discharge for the same or a related condition, an interval admission review must be completed and documented in a note stating the reason for readmission and any changes in the H&P report may be written in lieu of a complete H&P report. The interval admission note must be placed in the chart within 24 hours of the admission. A copy of the original H&P report shall be placed in the patient ‘s medical record. a. The H&P report shall be prepared by the patient’s physician, unless he or she delegates this responsibility to another Practitioner or Allied Health Professional As originally approved by SMRMC Community Board 9/25/01 or he or she is required by the Hospital Medical Staff Bylaws or Rules to delegate or share this responsibility with another Practitioner. b. If a licensed dependent practitioner (e.g., a nurse practitioner or physician assistant) is granted privileges to perform part or all of an H&P, the findings, conclusions, and assessment of risk must be confirmed or endorsed by a qualified physician. c. Use of an H&P provided by a Licensed Independent Practitioner (LIP) who is not a member of the hospital’s Medical Staff is permissible provided that the H&P is reviewed by a LIP with staff privileges following an assessment to confirm the information and findings. The Medical Staff member must sign and date the outside H&P as well as the note on his or her assessment. d. Oral and Maxillofacial surgeons may perform an H&P if they possess the clinical privileges to do so in order to assess the medical, surgical and/or anesthetic risks of the proposed operative and/or other procedure. e. Doctors of dentistry or podiatry are responsible for that part of the patient’s history and physical examination that relate, respectively, to dentistry and podiatry whether or not they are granted clinical privileges to take a complete history and perform a complete examination. Doctors of dentistry or podiatry may perform a complete H&P if they possess the clinical privileges to do so. If the Dentist or Podiatrist does not possess such privileges, then a qualified physician must perform the H&P.
(D) Progress Notes
a. Acute setting: A daily progress note is required, or more often when warranted 2. The progress notes should document the course and results of treatment, give a chronological picture of the patient’s progress, and be sufficient to permit continuity of care. 3. Allied Health Professionals may document progress notes within their scope of 4. Residents may document progress notes, and co-signature by the attending (E) Consultation Reports
Every consultation report should contain a written opinion by the consultant
that reflects, when appropriate, an actual examination of the patient and review of the
patient’s medical record(s).
(F) Orders
1. Orders may be generated in the patient’s medical record by a. Practitioners who are members of the medical staff with privileges to attend patients. Practitioner is defined as all licensed physicians and dentists who are privileged to attend patients in the hospital. b. Residents – orders generated by a resident must be countersigned within 24 hours by the attending physician. Residents are required to use their dictation number after their signature for identification purposes on all orders. (amended 04/26/05) As originally approved by SMRMC Community Board 9/25/01 c. Allied health professionals functioning within their scope of practice who are 2. All orders must be legible and shall contain the following patient identification: a. Patient name (first and last) b. Medical record number or date of birth. 3. Handwritten orders will be considered complete when an identifiable signature, date 4. Orders shall be obtained prior to initiating treatment, procedures or therapy and remain in effect until discontinued. When the patient goes to surgery, or is transferred to a different level of care all orders must be reviewed, modified or discontinued and new orders given as appropriate. 5. The admitting/attending physician must order admission for treatment and evaluation and when there is a change in the level of care. Patient placement will be made based on patient acuity and diagnosis. On initial admit all patients shall be admitted into either acute inpatient, observation short stay, surgery center extended recovery, or bedded outpatient per Case Management Assignment Protocol. 6. Physician orders must specify the location to which the patient is being admitted or transferred (i.e. Med, Surg, ICU, or other monitored bed). 7. If an inpatient is being moved/admitted to rehab, a discharge and readmission order is required (i.e. discharge from Med/Surg and admit to Rehab Unit). 8. Treatment programs or diagnostics (i.e. physical, occupational, communication therapy) must be specific for the modality, frequency and duration of the requested service. The person prescribing the order for the service shall approve these programs and any modifications. 9. Orders shall not include the use of Do Not Use abbreviations. 10. Physician Order sets: a. Require a patient-specific physician signature or verbal order before a. Verbal orders shall be discouraged and shall be accepted only when it is not practical for them to be given in writing or electronically entered. b. All verbal and telephone orders will be placed electronically by the person receiving the order. The order will go to the issuing practitioner’s IN Box for co c. Verbal/telephone orders may be accepted by the following staff for patients only under their care and only within the scope of their professional practice: (1) Registered Advanced Practice Nurse (APN, e.g. Midwife, Nurse Practitioner) Licensed rehabilitation therapist (i.e. PT, OT) Licensed medical technologists and Laboratory Staff d. Verbal/telephone orders will be authenticated by the prescriber within 48 hours As originally approved by SMRMC Community Board 9/25/01 (amended 09/06) with the following exception (amended 11/01 & 4/02): When a prescribing physician gives a verbal order, it is acceptable for a covering physician to co-sign the verbal order of the prescribing physician. The signature indicates that the covering physician assumes responsibility for his/her colleague’s order as being complete, accurate and final. e. Verbal / Telephone orders for “Do Not Resuscitate” orders are acceptable. In the case of a verbal or telephone order, two RN’s or one RN and one licensed personnel (LPN, social worker, case manager, clinical specialist or nurse practitioner) must hear the order given, read back, and document such. f. Orders for restraint according to policy #GA 319. g. Faxed orders shall meet the following requirements (1) Orders received that have a typed physician name or have no physician signature require a phone conversation between the licensed healthcare provider and the physician confirming a fax transmission and reviewing the content of the orders. (2) Faxed orders with physician signature, date, time and patient identification (3) If physician signature is present, countersignature is not necessary. A typed physician name must be countersigned by the physician. h. Verbal orders cannot be accepted from an RN except when received from: (1) An Advanced Practice Nurse privileged by the hospital. (2) An RN transmitting verbal orders from the physician, as an agent for the physician performing surgery or special procedure. a. The following patient specific information is required to be present in the medical record and available to those involved in medication management: Age Sex Current medications Diagnoses, comorbidities, and concurrently occurring conditions Relevant laboratory values Allergies and past sensitivities Weight and height Pregnancy and lactation status b. Medication reconciliation must be documented on admission, transfer to another level of care, service or provider within or outside the hospital and on discharge. c. An electronically entered or written physician or allied health professional order is required for the administration of medications, except in emergencies when the order may be give verbally. e. Medication orders must contain the name of the drug, either by generic or brand name, dosage, route, frequency and limits if applicable. e. Therapeutic Duplication: Only one medication order may be active for each f. Chemotherapy orders must be written or electronically signed by the physician. They may not be given verbally or by telephone. g. The hospital maintains a closed formulary. Non-formulary drugs ordered may As originally approved by SMRMC Community Board 9/25/01 h. PRN Orders: must contain the indication or symptom for administration. Exceptions will be allowed for specified single use medications, approved by P&T Committee, unless otherwise ordered: Indigestion
Dulcolax tablet
Bisacodyl tablet
Dulcolax suppository
Bisacodyl suppository
Milk of Magnesia
Colace Docusate
Surfak Docusate
Metamucil Psyllium Constipation
Cascara Sagrada

Miralax, Glycolax
PEG 3500 Packet
Imodium Loperamide

Lomotil Diphenoxylate/Atropine
Zofran Ondansetron
Anzemet Dolasetron
Ambien Zolpidem
Restoril Temazepam
Dalmane Flurazepam
Halcion Triazolam
Shortness of Breath
Specific Oral Analgesics:
Vicodin, Lortab, Norco, Darvocet, Percocet, Percodan, Ultram, oxycodone i. If a written order is received with an unspecified PRN use for a medication verbal/telephone order, the nurse will ensure an indication for use.  Orders to “hold” a medication must specify the number of doses or holding parameters, and when medication is to be resumed. If the order states “hold until further notice” or “hold” without any specification, the medication is to be discontinued. A new order for the specific medication is required indicating when it is to be resumed  Medications held for hemodialylsis or diagnostic procedures are resumed immediately upon completion of the procedure unless provider orders specify otherwise. Exception: the nurse will check with the provider for hold and resume orders when the patient is receiving biologic agents, such as insulin k. Automatic Stop Orders must contain a date or time to discontinue a medication. l. Titrate Orders must contain a start dose, parameters for increasing or m. Taper Orders must state a specific start date, dose, frequency (time) and As originally approved by SMRMC Community Board 9/25/01 Range doses are discouraged. When an order includes a range of dose or frequency, multi-indications or multi-routes the instructions for determining the dose, frequency, indication or route should be included in the physician’s order. (G) Evidence of advance directives.
(H) Evidence of appropriate informed consents for treatment. When not obtainable,
the reason shall be entered in the medical record.
(I) Anesthesia Notes
1. No anesthetic shall be administered by any person other than a physician or a specially trained and currently competent RN at SMRMC, under the direction of a physician who is credentialed to administer moderate sedation/analgesia. 2. Pre- and post-operative anesthesia assessment, In every case of anesthetic
administered by a physician with the exception of local anesthesia, an anesthesia record shall be completed. 3. There must be an order to release the patient from post anesthesia recovery. 4. There shall be a record of post anesthesia visits, including at least one note describing the presence or absence of anesthesia-related complications. Operative and Special Procedure Reports
1. Preoperative diagnosis shall be written on the patient’s record on all cases
prior to surgery by the practitioner responsible for the patient. 2. A (handwritten) signed, dated, and timed post-operative or post-procedure note will be documented into the progress notes immediately following the surgery or procedure. The note will record the names of the primary surgeon and assistant, finding, technical procedures used, specimens removed, and post-operative diagnosis. 3. Following the surgery or procedure, a full report will be dictated, and will include the pre-operative and postoperative diagnoses, a description of the findings, the procedure performed and techniques used, tissues removed, the name of the surgeon, assistants, and anesthesiologists. The completed operative report is authenticated by the surgeon and filed in the medical record as soon as possible after surgery. 4. Postoperative documentation records shall include:  Medications and blood and blood components  Unusual events or postop complications and management of such events  Patient’s discharge from post-sedation or post-anesthesia care area by the responsible licensed independent practitioner or according to discharge criteria (K) Nursing and Ancillary Department documentation

Discharge Summary
1. The discharge summary is the responsibility of the attending physician of record at
2. The discharge summary will be dictated and completed by the responsible practitioner within thirty (30) days after the patient’s discharge. As originally approved by SMRMC Community Board 9/25/01 3. The discharge summary will contain the admitting diagnosis or reason for admission, significant findings, course and treatment of the case, complications, condition on discharge, prognosis, the recommendations and arrangements for follow-up care, including discharge instructions related to medications, diet and physical activities. 4. A final progress note may be substituted for the discharge summary only for patients with problems and interventions of a minor nature who require less than a 48-hour period of hospitalization and in the case of normal newborn infants and uncomplicated obstetric deliveries. 5. All OSS cases with a length of stay greater than 48 hours require a dictated 6. All death cases require a dictated discharge summary.
7. When a patient is transferred (for example, from acute care to Rehab), a transfer
summary may be substituted for the discharge summary. A transfer summary
briefly describes the patient’s condition at the time of transfer, and the reason for
the transfer. (When the physicians remain the same, a progress note may suffice.)
1.2 Responsibility
The attending medical staff member shall be responsible for the complete medical record of the
1.3 Readmissions
When a patient is readmitted, all previous records shall be available to the attending
physicians, whether or not they previously attended the patient.
1.4 Handwritten Entries
All entries including signature in the medical record must be:
1. legible. (Illegible is defined as impossible to read by at least two professionals) 2. written in black or blue ink. Pencil entries are not permitted. 3. complete 4. signed by the person making the entry, dated and timed. The date and time will be the date and time that the entry is made, regardless of whether the content of the note relates to a previous date or time. 1.5 Electronic Entries
All electronic entries in the medical record are automatically dated, timed and authenticated
with an electronic signature.
1.6 (AHP) Countersignature
All data, summaries, progress notes, directions or other information entered in the medical
record of a patient by a Physician’s Assistant or Nurse Practitioner must be countersigned by
their supervising physician within 24 hours.
1.7 Correction of Record
In the event it is necessary to correct an entry in the paper medical record, the practitioner will
line out the incorrect entry with a single line in ink, leaving the original entry legible. The
person shall note the reason for change, date and time of striking and sign the note. Erasure
or obliteration of corrected material will not be done. All blanks left in dictated reports will be
initialed and/or filled in by the dictating practitioner at the time the report is signed. Any cross-
outs with or without entries will be dated and initialed.
As originally approved by SMRMC Community Board 9/25/01
In the event it is necessary to correct an entry in the electronic medical record, the practitioner
will electronically void or modify the entry and change will be electronically recorded with time,
date and signature.
1.8 Abbreviations
Only abbreviations approved by the Medical Staff may be used in the medical record.
Abbreviations may not be used in recording the final diagnosis or operative/diagnostic
procedures. Abbreviations appearing on the Prohibited Abbreviation List shall not be used.
1.9 Timely Completion
Entries should be made as soon as possible after clinical events occur to ensure accuracy and
provide information relevant to the patient’s continuing care.
1.10 Incomplete Medical Records
The medical record must be completed within 30 days of the patient’s discharge. If records are
not completed within that time period, the physician’s privileges will be suspended.
(A) Suspended privileges include but are not limited to: 1. Right to admit or schedule patients for surgery or other procedures; 2. Right to consult; 3. Right to act as surgical assistant (B) Exemption from suspension for incomplete medical records may be granted when justified if the Chief of Staff is notified in advance in writing, or by telephone with subsequent written confirmation, of the time period and reason for the exemption. Acceptable reasons include, without limitations: 1. Illness 2. A practitioner who plans to be absent from his/her practice for a period of greater than five (5) days must notify the Health Information Department prior to departure and complete the available incomplete medical records prior to departure. 3. Dictated reports awaiting hospital personnel to transcribe them. (C) When a physician, while under suspension, requests emergency admission and/or surgery for a patient in his/her care, the Division Chairperson may grant approval after ascertaining the bona fide nature of the emergency, and with the proviso that the physician will immediately complete his/her delinquent medical records or obtain alternate physician coverage for the hospitalized patient. (D) Physicians with incomplete medical records that are 90 days post discharge will be demoted in staff status. If the status of the physician is “associate” then the physician will be deemed to have resigned from the staff and his/her associate staff membership will be terminated. Regaining staff membership will require a new application. (E) A medical record will not be permanently filed until it is completed, or until all efforts to complete a medical record have been exhausted. In the latter instance, the Chief of Staff may then authorize the Director of Health Information to file the record with a notation explaining the circumstances under which the record remains incomplete. Medical records may be filed as incomplete when the practitioner has expired, moved from the area, or resigned and is unwilling or unable to fulfill his/her responsibility. As originally approved by SMRMC Community Board 9/25/01 1.11 Confidentiality
Each practitioner will respect the confidentiality of physician-patient communications, of
information obtained in the course of diagnosing, treating or consulting patients, and of the
entire medical record (including electronic) in general. Access to medical records shall be
afforded to staff physicians for treatment, peer review, performance improvement, bona fide
study and research consistent with preserving confidential patient information and in keeping
with the HIPAA Privacy regulations.
As originally approved by SMRMC Community Board 9/25/01


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