AKRON CHILDREN'S HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS MEDICAL STAFF RULES AND REGULATIONS

Size: px
Start display at page:

Download "AKRON CHILDREN'S HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS MEDICAL STAFF RULES AND REGULATIONS"

Transcription

1 AKRON CHILDREN'S HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS MEDICAL STAFF RULES AND REGULATIONS July 1, 2012

2 GENERAL RULES G1. Patients shall be attended by their own private Medical Staff members. Patients who have no attending Medical Staff member shall be accepted by and become the responsibility of members of the Medical Staff on service in the department or division to which the nature of the illness of the patient indicates assignment according to applicable policies and procedures. G2. Members of the Medical Staff retain responsibility for the continuous care and supervision of each patient in the hospital for whom he/she is providing services. Members who are not available for patient care responsibilities must make suitable arrangements with another Medical Staff member to act as substitute. Members who are collaborating physicians for Advance Practice Nurses cannot leave their patients solely in the care of the Advance Practice Nurse. In case of failure to make such arrangements, the case will be referred to the Medical Staff member on service. G3. This hospital provides professional graduate medical education. The extent of participation of residents in patient care is defined in the medical staff policy entitled Supervision of Residents and Fellows in Training Programs and by each department involved in graduate medical education. Each departmental policy and procedure manual describes the lines of command and the graded nature of responsibilities. In furtherance of the Hospital's quality assurance and peer review functions, the medical staff policy provides for communication between the Medical Education Committee, Medical Performance Improvement Committee, Medical Staff Executive Committee, and Board of Trustees regarding matters of quality of patient care and resident education. G4. Medical staff members admitting private patients shall be held responsible for giving such information as may be necessary to assure the protection of other patients from those who are a source of danger from any cause whatsoever, or to assure protection of the patient from self-harm. G5. In situations where a member of the Medical Staff is participating in a contractual relationship with The Hospital, termination of said contract shall not constitute termination of the individual's Medical Staff privileges, unless otherwise specifically provided in said contract. These Bylaws are not a part of, and are not to be used in interpreting any contract under which any member of the Medical Staff is participating with The Hospital, including, but not limited to, the Hearing and Appellate Review Procedure under Article IX of these Bylaws. G6. A consultant must be qualified in a field in which he/she is sought. The status of the consultant is determined by the Medical Staff Executive Committee on the basis of an individual's training, experience, and competence. A satisfactory consultation includes examination of the patient and the record. A written

3 opinion signed by the consultant must be included in the medical record. The patient's Medical Staff member is responsible for requesting consultations when indicated. The reason for consultation must be clearly stated. It is the duty of the Medical Staff through its Department Chairpersons, Division Directors and Medical Staff Executive Committee to make certain that members of the Staff do not fail in the matter of calling for consultations as needed. G7. Health care providers are distinguished into two categories, dependent and independent practitioners. Independent practitioners are all individuals permitted by Ohio law and by the Hospital to provide patient care services independently (without supervision by a physician) within the Hospital. All independent practitioners have delineated clinical privileges. Dependent practitioners are individuals who provide medical care under supervision. The determination of status of any given practitioner group, i.e. dependent or independent, or change in status from dependent to independent, is made by the Medical Staff Executive Committee and the Board of Trustees. Presently, independent practitioners are physicians, dentists, psychologists, podiatrists, certain advanced practice nurses, physician assistants and certain qualified laboratory scientific staff. Dependent practitioners include, but are not limited to: certified registered nurse anesthetists, scrub persons, perfusionists, speech-language pathologists, audiologists, genetics counselors and surgical assistants. Certified registered nurse anesthetists practice under the direct supervision of an anesthesiologist. Most dependent practitioners are Hospital employees. Non-Hospital dependent practitioners may be free lance, physician's employees, or practitioners providing contracted patient care. Physician's assistants and certified registered nurse anesthetists are credentialed, privileged, and re-privileged through the medical staff process. Other dependent practitioners are credentialed and authorized to provide care through Hospital processes. G8. All licensed independent practitioners must make formal application for delineated clinical privileges in their respective fields. These applications shall be evaluated by the Credentials Committee and acted on by the Medical Staff Executive Committee and the Board of Directors. G9. Dependent practitioners who are not Hospital employees must make application to the Hospital to provide patient care. Hospital managers and directors are responsible for determining the appropriate qualifications and competence to provide the patient care requested and for providing an orientation that covers the care provider's responsibilities. Hospital managers and directors are responsible for ensuring a consistent standard of care through job descriptions, performance evaluations, and maintenance of applicable current licensure/certification. G10. Administrative physicians desiring appointment to the Medical Staff with or without clinical privileges will follow the same processes for appointment and reappointment as outlined in Credentials Committee policies and procedures.

4 G11. Adverse Information Regarding Medical Staff Members. Information about the conduct, performance and competence of Medical Staff Members is handled through Medical Staff Policies which include the Professional Conduct Policy, Impaired Practitioner Policy, and the Peer Review Policy. G12. Confidentiality of Information: a. The records of the Medical Staff and its committees responsible for the evaluation and improvement of the quality of patient care rendered in the Hospital shall be maintained as confidential. b. Access to such records shall be limited to duly appointed officers, committees, and employees of the Medical Staff for the sole purpose of discharging Medical Staff responsibilities and subject to the requirement that confidentiality be maintained. c. Information which is disclosed to the governing body of the Hospital or its appointed representatives shall be maintained by the recipient as confidential. d. Medical Staff members can review their credentials files in accord with Credentials Committee Policies and Procedures. Personal letters of reference are considered confidential. e. Information contained in Medical Staff, department, division, or committee minutes, files, and records, including information regarding any member or applicant to this Medical Staff, shall be confidential. The disclosure of information from such documents other than when required by law or with the consent of the member or applicant may be made only with the express approval of the Medical Staff Executive Committee or its designee. f. Any breach of confidentiality of the discussions or deliberations of Medical Staff departments, divisions, or committees, except in conjunction with another hospital, professional society, or licensing authority, or as required by law, is outside appropriate standards of conduct for this Medical Staff. If it is determined that such breach has occurred, the Medical Staff Executive Committee may undertake such corrective action as it deems appropriate. G13. Subject to the approval of the Medical Staff Executive Committee, each department may formulate its own Rules and Regulations for the conduct of its affairs and the discharge of its responsibilities. Such Rules and Regulations shall be consistent with these Bylaws, the Rules and Regulations of the Medical Staff as incorporated in the Bylaws, and other policies of The Hospital. G14. New appointees to the Medical Staff are required to attend orientation to Hospital policies, including those pertaining to confidentiality of patient information and compliance, and to complete training on use of the Hospital electronic medical

5 record prior to exercising clinical privileges, except for temporary privileges which may be exercised upon the grant of privileges, in accordance with the Credentialing Policy. Other exceptions and modifications to this rule may be made by the President of the Medical Staff in his or her discretion. CLINICAL RULES C1. Psychiatric treatment must be offered to all patients who have attempted suicide or have taken a chemical overdose. That such services were at least offered must be documented in the patient's record. C2. Therapeutic abortion or sterilization for male or female patients is permitted for medical reasons after concurring consultations by two members of the Medical Staff, one from the Department of Pediatrics and one from the Department of Surgery, and a consultation from a practitioner in the field of specialty practice represented by the medical condition for which the procedure is recommended. No one of the above consultants shall be the one performing the procedure. C3. A uterine cytologic examination (generally a pap smear) for detection of cancer shall be offered every female inpatient 18 years or over. That such services were at least offered must be documented in the patient's record. C4. The use and reasons for special treatment procedures such as restraint, seclusion, behavior modification procedures and other special treatment procedures used for children and adolescents shall be documented in the patient's medical record. Written guidelines governing the use of these procedures shall be included in the policies and procedures of the patient care units. C5. All anesthesia care, or the administration of anesthetics to patients will be provided only by individuals with delineated clinical privileges. This includes all anesthesia, i.e., general, spinal, or other major regional anesthesia, as well as surgery or other invasive procedures requiring intramuscular, intravenous, or inhalation sedation anesthesia that may result in the loss of the patient's protective reflexes. C6. All patients undergoing procedural sedation will be monitored as described in The Hospital's Procedural Sedation and Analgesia Policy. PHYSICIAN ORDERS P1. All orders for patient care shall be in writing, dated, and signed by the attending Medical Staff member.

6 a. The privileged attending Medical Staff member may delegate the responsibility of writing patient care orders to the appropriate house officer or consultant physician. The attending Medical Staff member may not be prohibited from writing orders on his/her patients. Further, staff membership, the holding of clinical privileges and medical staff prerogatives, shall not be made conditional upon the agreement to surrender such responsibility to the house officer. b. Verbal orders shall be dictated to a registered nurse. Other licensed health professionals may take dictated orders pertaining directly to their profession. Verbal orders shall be transcribed with date by the person to whom dictated with the name of the Medical Staff member or house officer per his or her signature. Verbal orders shall be signed according to medical staff policy and procedure. P2. When a patient is transferred to another medical staff member, a transfer order must be written. P3. The prescription for respiratory care, whether written by the patient's primary Medical Staff member or appropriate house officer or developed in consultation, shall specify the type, frequency and duration of treatment, and the type and dose of medication, including dilution ratio, oxygen concentration and precautions to be observed. A written record of the prescription and of any related consultation should be kept in the patient's medical record. In all cases, the responsible Medical Staff member or appropriate house officer must place in the patient's medical record the timely, pertinent clinical evaluation of the results of respiratory therapy. P4. Patient care provided by dependent practitioners must be ordered and supervised by a privileged Medical Staff member. The care provided must be within the scope of patient care privileges defined by the applicable Hospital department/service. All patient care given by dependent practitioners shall be documented in the patient medical record. P5. Medical Staff member's orders will be cancelled at the beginning of a surgical procedure and must be reordered in the medical record following the surgical procedure. DRUG / PHARMACY D1. Drugs used shall meet the standards of the United States Pharmacopoeia, National Formulary, New and Nonofficial Drugs, with the exception of drugs for bona fide clinical investigations. Exceptions to this rule shall be well justified and documented in writing.

7 D2. Automatic stop orders exist for narcotics at the end of each 72 hours or a definite terminating date by a Medical Staff member or appropriate house officer. For antibiotics a stop order exists at the end of a fourteen-day period. The stop date for all other prescription drugs is 30 days. Drugs should not be discontinued without notifying the medical staff member so that orders can be renewed or discontinued. By a majority vote, the Medical Staff Executive Committee may designate automatic stop orders for other drugs or therapies. MEDICAL RECORDS M1. The attending Medical Staff member shall be held responsible for the review and signature of a complete medical record for each patient. a. This record shall include identification data; unit number, if applicable; nearest relative or responsible agent; evidence of appropriate informed consent; complaint; personal history; relevant social and family history; history of present illness; physical examination; inventory of body systems; diagnostic and therapeutic orders; clinical observations; special reports, such as consultations, clinical laboratory, radiology, and others; provisional diagnosis; reason for admission; medical or surgical treatment; operative report; pathological findings; progress notes; principal and secondary diagnosis(es) and procedure(s); complications; condition on discharge or transfer; summary and discharge note; instructions given to the patient and/or his family relative to necessary follow-up care particularly in regard to physical activity limitations, medications and diet; and autopsy when available. b. All entries in the medical record shall be timed and dated. c. In addition outpatient records should also include dates of service as well as identification of other sources of medical care. d. In addition emergency medical records should include information concerning the time of arrival and by whom transported and the pertinent history of the injury or illness. e. Details relative to first aid or emergency care given to the patient prior to arrival at The Hospital may be attached to the record. f. By majority vote, the Medical Staff Executive Committee may designate other items required to constitute a complete medical record. No medical record shall be filed until it is complete, except on order of the Medical Records Committee. M2. To avoid misinterpretation, symbols and abbreviations may be used in the medical record only when they have been approved by the Medical Staff Executive Committee, and when there is an explanatory legend available to those authorized

8 to make entries in the medical record and to those who must interpret them. Each abbreviation or symbol should have only one meaning. Orders involving abbreviations and symbols should be carried out only if the abbreviations and symbols appear on a standard list approved by the Medical Staff Executive Committee. Final diagnosis may not contain abbreviations and symbols. M3. The medical record shall document a current history and physical examination prior to the performance of surgery with general anesthesia. M4. Records on discharged patients shall be completed within 30 days of discharge. What constitutes a complete medical record and applicable sanctions for failures to comply shall be set forth in Medical Staff policies and procedures. M5. Daily progress notes must document the attending physician has seen the patient and concurs with the treatment plan. Pertinent progress notes may be made by others so authorized by the Medical Staff, such as individuals who have been granted clinical privileges and specified professional personnel. Progress notes should be recorded at an appropriate frequency reflecting the nature and course of the hospitalization. All progress notes must be dated and signed. M6. Medical Staff members using preprinted discharge instruction sheets must have copies of the sheets filed in the Medical Records Department. M7. The use of signature stamps are prohibited. Authorized electronic signatures constitute valid signatures. M8. All records are the property of The Hospital and shall be removed from The Hospital's jurisdiction and safekeeping only in accordance with a court order, subpoena, or statute. In case of readmission of a patient, all previous records shall be available for the use of the attending Medical Staff member. M9. Reports of pathology and clinical laboratory examinations, radiology and nuclear medicine examinations or treatment, anesthesia records, and any other diagnostic or therapeutic procedures should be completed immediately and be available in the record within 24 hours of completion if possible. When a necropsy is performed, provisional anatomic diagnoses should be recorded in the medical record within 3 days, and the complete protocol should be made part of the record within 60 days. M10. All tissues and specimens removed at The Hospital shall be sent to The Hospital Pathology Department, unless authorized otherwise by the Medical Staff Executive Committee. The Pathology Department shall make such examinations as may be considered necessary to arrive at a pathological diagnosis and certify the report by written or authorized electronic signature. M11. Authenticated and dated reports of all laboratory tests should also be available promptly with the patient's medical record. Report forms should be formatted to facilitate comparison of each determination with pertinent "normal" ranges, and sequential and related analyses. Reports of quantitative analyses shall include the units of concentration or activity. M12. All electrocardiogram's excluding rhythm strips, performed outside the Division of Cardiology will be submitted to cardiology for interpretation and will become part of the patient's medical record.

9 M13. Follow-up of laboratory, imaging, or other studies/tests that are pending at the time of a hospital discharge will be the responsibility of the attending of record at the time of the patient s discharge. In the Electronic Medical Record, the results will be sent to the Attending s In-Basket, and he/she will have the option of delegating/transferring the managements of the study/test result to another provider if appropriate. SURGERY OR INVASIVE PROCEDURES S1. The Chairperson of Surgery shall have the discretionary power to cancel the surgery if the operating Medical Staff member is not ready to commence operation within 20 minutes after the time scheduled. S2. The responsible surgeon must record and authenticate a preoperative diagnosis prior to surgery. S3. Informed Consent: A surgical operation shall be performed only on consent of the patient or his/her legal representative, except in emergencies. The medical record shall contain evidence of the patient's informed consent for any procedure or treatment for which it is appropriate. This information includes the identity of the patient, the procedure or treatment to be rendered, the name(s) of the individual(s) who will perform the procedure or administer the treatment, authorization for anesthesia if indicated, an indication that alternate means of therapy and the possibility of risks or complications have been explained to the patient and authorization for disposition of any tissue or body parts as indicated. The signature of the patient, parent, or other individual empowered to give consent should be witnessed. The practitioner with clinical privileges who informs the patient and obtains the consent will be identified in the medical record if other than the attending medical staff member. S4. All operations performed shall be fully described by the operating surgeon. A hand written note shall be completed immediately post operatively before the patient is transferred to the next level of care. There must be sufficient information in the medical record to manage the patient at the next level of care. Operative reports shall be dictated within 24 hours. S5. Elective surgical procedures to be done under general anesthesia shall be canceled if the patient is found to have used illicit drugs within 24 hours of the scheduled surgery. These Rules and Regulations were adopted as part of the 2005 Bylaws. Approved by the Active Medical Staff on June 22, 2005, and the Board of Trustees on June 23, Revisions were made to these Rules and Regulations with the approval of the new Bylaws in July of Additional changes regarding EHR training and the removal of the H&P from this document to the Bylaws were made by majority vote May 2012.

UROLOGY SURGERY CENTER OF COLORADO Medical Staff Rules & Regulations TABLE OF CONTENTS

UROLOGY SURGERY CENTER OF COLORADO Medical Staff Rules & Regulations TABLE OF CONTENTS TABLE OF CONTENTS Section I Section II Section III Section IV Section V Section VI Section VII Section VIII Section IX Admissions Scheduling Anesthesia Pharmaceuticals Radiology Medical Records PACU Discharge

More information

Ch. 555 MEDICAL STAFF 28 CHAPTER 555. MEDICAL STAFF MEDICAL STAFF

Ch. 555 MEDICAL STAFF 28 CHAPTER 555. MEDICAL STAFF MEDICAL STAFF Ch. 555 MEDICAL STAFF 28 CHAPTER 555. MEDICAL STAFF MEDICAL STAFF Sec. 555.1. Principle. 555.2. Medical staff membership. 555.3. Requirements for membership and privileges. 555.4. Clinical activities and

More information

Canyon Vista Medical Center

Canyon Vista Medical Center Department: MEDICAL STAFF Page 1 of 14 INTRODUCTION: 1. This document sets forth the Rules and Regulations of the Medical Staff and is subject to the provisions of the Medical Staff Bylaws. The terms defined

More information

Ch. 107 MEDICAL STAFF 28 CHAPTER 107. MEDICAL STAFF GENERAL PROVISIONS

Ch. 107 MEDICAL STAFF 28 CHAPTER 107. MEDICAL STAFF GENERAL PROVISIONS Ch. 107 MEDICAL STAFF 28 CHAPTER 107. MEDICAL STAFF GENERAL PROVISIONS Sec. 107.1. Principle. 107.2. Medical staff membership. 107.3. Requirements for membership and privileges. 107.4. Medical staff status.

More information

RULES AND REGULATIONS OF THE BYLAWS OF THE MEDICAL STAFF UNIVERSITY OF NORTH CAROLINA HOSPITALS

RULES AND REGULATIONS OF THE BYLAWS OF THE MEDICAL STAFF UNIVERSITY OF NORTH CAROLINA HOSPITALS RULES AND REGULATIONS OF THE BYLAWS OF THE MEDICAL STAFF UNIVERSITY OF NORTH CAROLINA HOSPITALS Approved by the Executive Committee of the Medical Staff, November 5, 2001. Approved and adopted by the Board

More information

POLICY and PROCEDURE. TITLE: Documentation Requirements for the Medical Record. TITLE: Documentation Requirements for the Medical Record

POLICY and PROCEDURE. TITLE: Documentation Requirements for the Medical Record. TITLE: Documentation Requirements for the Medical Record POLICY and PROCEDURE TITLE: Documentation Requirements for the Medical Record Number: 13289 Version: 13289.1 Type: Administrative - Medical Staff Author: Joan Siler Effective Date: 8/16/2011 Original Date:

More information

FAIRFIELD MEDICAL CENTER MEDICAL STAFF RULES, REGULATIONS AND POLICIES MANUAL

FAIRFIELD MEDICAL CENTER MEDICAL STAFF RULES, REGULATIONS AND POLICIES MANUAL FAIRFIELD MEDICAL CENTER MEDICAL STAFF RULES, REGULATIONS AND POLICIES MANUAL RULES, REGULATIONS AND POLICIES MANUAL OF THE MEDICAL STAFF FAIRFIELD MEDICAL CENTER TABLE OF CONTENTS PART ONE DEFINITIONS...

More information

RULES AND REGULATIONS OF THE MEDICAL STAFF

RULES AND REGULATIONS OF THE MEDICAL STAFF RULES AND REGULATIONS OF THE MEDICAL STAFF 1. Only physicians who have submitted proper credentials and have been duly appointed to membership on the Medical Staff shall be permitted to admit and treat

More information

Medical Staff Rules & Regulations Last Updated: January 2013. University Hospital Medical Staff. Rules & Regulations

Medical Staff Rules & Regulations Last Updated: January 2013. University Hospital Medical Staff. Rules & Regulations University Hospital Medical Staff Rules & Regulations 1 UNIVERSITY HOSPITAL MEDICAL STAFF RULES AND REGULATIONS The Medical Staff shall adopt Rules and Regulations as may be necessary to implement the

More information

CAROLINAS REHABILITATION

CAROLINAS REHABILITATION CAROLINAS REHABILITATION CURRENT LANGUAGE ORGANIZATIONAL MANUAL OF BYLAWS OF CAROLINAS REHABILITATION (TAB 2) New Language ORGANIZATIONAL MANUAL OF BYLAWS OF CAROLINAS REHABILITATION (TAB 2) ARTICLE II

More information

Rehabilitation Hospital Rules and Regulations

Rehabilitation Hospital Rules and Regulations Rehabilitation Hospital Rules and Regulations REHABILITATION HOSPITAL OF FORT WAYNE MEDICAL STAFF RULES AND REGULATIONS TABLE OF CONTENTS A. ADMISSION AND DISCHARGE OF PATIENTS...2 B. MEDICAL RECORDS...4

More information

THE ORTHOPEDIC HOSPITAL RULES & REGULATIONS INDEX

THE ORTHOPEDIC HOSPITAL RULES & REGULATIONS INDEX P a g e 1 THE ORTHOPEDIC HOSPITAL RULES & REGULATIONS INDEX PAGES ARTICLE I ADMISSION & DISCHARGE OF PATIENTS 1.1 ADMISSION OF PATIENTS 3 1.2 ADMITTING POLICY 4 1.3 SUICIDAL PATIENTS 4 1.4 DISCHARGE OF

More information

MEDICAL STAFF RULES & REGULATIONS

MEDICAL STAFF RULES & REGULATIONS MEDICAL STAFF RULES & REGULATIONS PURPOSE: Rules and Regulations shall set standards of practice that are to be required of each individual exercising clinical privileges in the hospital, and shall act

More information

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT MEDICAL RECORDS CONTENT/DOCUMENTATION

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT MEDICAL RECORDS CONTENT/DOCUMENTATION LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT MEDICAL RECORDS CONTENT/DOCUMENTATION Hospital Policy Manual Purpose: To define the components of the paper and electronic medical record

More information

HIPAA Notice of Privacy Practices

HIPAA Notice of Privacy Practices HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice

More information

SAINT FRANCIS HOSPITAL AND MEDICAL CENTER MEDICAL STAFF RULES AND REGULATIONS

SAINT FRANCIS HOSPITAL AND MEDICAL CENTER MEDICAL STAFF RULES AND REGULATIONS SAINT FRANCIS HOSPITAL AND MEDICAL CENTER MEDICAL STAFF RULES AND REGULATIONS TABLE OF CONTENTS: ARTICLE I INTRODUCTION 1.1 Definitions 1.2 Applicability 1.3 Conflict with Hospital Policies 1.4 Departmental

More information

MEDICAL STAFF RULES AND REGULATIONS

MEDICAL STAFF RULES AND REGULATIONS MEDICAL STAFF RULES AND REGULATIONS Approved by Board of Directors: TABLE OF CONTENTS PAGE 1. GENERAL... 3 2. ADMISSION AND DISCHARGE... 3 3. CRITICAL CARE UNITS... 4 4. EMERGENCY SERVICES... 5 5. MEDICAL

More information

SECTION 5 HOSPITAL SERVICES. Free-Standing Ambulatory Surgical Center

SECTION 5 HOSPITAL SERVICES. Free-Standing Ambulatory Surgical Center SECTION 5 HOSPITAL SERVICES Table of Contents 1 GENERAL POLICY... 2 1-1 Clients Enrolled in a Managed Care Plan... 3 1-2 Clients NOT Enrolled in a Managed Care Plan (Fee-for-Service Clients)..................

More information

STANFORD HOSPITAL AND CLINICS Medical Staff Rules and Regulations. Last Approval Date: May 2014

STANFORD HOSPITAL AND CLINICS Medical Staff Rules and Regulations. Last Approval Date: May 2014 STANFORD HOSPITAL AND CLINICS Medical Staff Rules and Regulations Last Approval Date: May 2014 The Medical Staff is responsible to the Stanford Hospital and Clinics (SHC) Board of Directors for the professional

More information

SECTION IV RULES AND REGULATIONS SECTION OF THE BYLAWS MEDICAL AND DENTAL STAFF CAROLINAS MEDICAL CENTER-UNIVERSITY

SECTION IV RULES AND REGULATIONS SECTION OF THE BYLAWS MEDICAL AND DENTAL STAFF CAROLINAS MEDICAL CENTER-UNIVERSITY SECTION IV RULES AND REGULATIONS SECTION OF THE BYLAWS MEDICAL AND DENTAL STAFF CAROLINAS MEDICAL CENTER-UNIVERSITY APPROVED BY THE BYLAWS COMMITTEE - 08-14-96 APPROVED BY THE MEDICAL AND DENTAL STAFF

More information

RULES AND REGULATIONS OF THE MEDICAL STAFF UNIVERSITY OF COLORADO HOSPITAL

RULES AND REGULATIONS OF THE MEDICAL STAFF UNIVERSITY OF COLORADO HOSPITAL RULES AND REGULATIONS OF THE MEDICAL STAFF UNIVERSITY OF COLORADO HOSPITAL I. PREAMBLE... 2 II. INDIVIDUAL RESPONSIBILITIES... 2 A. CARE OF PATIENTS... 2 B. ANESTHESIA AND SEDATION... 5 C. EMERGENCY CARE...

More information

POLICY and PROCEDURE. TITLE: Documentation Requirements for the Medical Record

POLICY and PROCEDURE. TITLE: Documentation Requirements for the Medical Record POLICY and PROCEDURE TITLE: Documentation Requirements for the Medical Record Number: 13424 Version: 13424.5 Type: Administrative - Medical Staff Author: Martha Hoover Effective Date: 9/24/2014 Original

More information

He then needs to work closely with the Quality Management Director or Leader and the Risk Manager to monitor the provision of patient care.

He then needs to work closely with the Quality Management Director or Leader and the Risk Manager to monitor the provision of patient care. Chapter II Introduction The Director has a major role in the effort to provide high quality medical care with a high degree of clinical safety. He is ultimately responsible for the professional conduct

More information

Physician Assistant Licensing Act

Physician Assistant Licensing Act 45:9-27.10. Short title 1. This act shall be known and may be cited as the "Physician Assistant Licensing Act." L.1991,c.378,s.1. 45:9-27.11. Definitions 2. As used in this act: "Approved program" means

More information

RULES AND REGULATIONS. of the YALE-NEW HAVEN HOSPITAL, INC. for the MEDICAL STAFF JANUARY 27, 1982. (Revised to October 20 May 18, 20101)

RULES AND REGULATIONS. of the YALE-NEW HAVEN HOSPITAL, INC. for the MEDICAL STAFF JANUARY 27, 1982. (Revised to October 20 May 18, 20101) RULES AND REGULATIONS of the YALE-NEW HAVEN HOSPITAL, INC. for the MEDICAL STAFF JANUARY 27, 1982 (Revised to October 20 May 18, 20101) TABLE OF CONTENTS RULES & REGULATIONS ACCEPTANCE OF PATIENTS... -3-

More information

ARTICLE X: RULES AND REGULATIONS

ARTICLE X: RULES AND REGULATIONS ARTICLE X: RULES AND REGULATIONS The Medical Staff shall adopt such rules and regulations as necessary for the proper conduct of its work. Such rules and regulations may be a part of these bylaws except

More information

ST. JOHN S HOSPITAL-ALLIED HEALTH PROFESSIONALS ADVANCED PRACTICE NURSE IN THE EMERGENCY DEPARTMENT

ST. JOHN S HOSPITAL-ALLIED HEALTH PROFESSIONALS ADVANCED PRACTICE NURSE IN THE EMERGENCY DEPARTMENT ST. JOHN S HOSPITAL-ALLIED HEALTH PROFESSIONALS ADVANCED PRACTICE NURSE IN THE EMERGENCY DEPARTMENT (APN) In accordance with the Nursing and Advanced Practice Nursing Act (225 ILCS 65) (the Act ), the

More information

RULES AND REGULATIONS OF THE MEDICAL STAFFS OF NORTH BROWARD HOSPITAL DISTRICT

RULES AND REGULATIONS OF THE MEDICAL STAFFS OF NORTH BROWARD HOSPITAL DISTRICT RULES AND REGULATIONS OF THE MEDICAL STAFFS OF NORTH BROWARD HOSPITAL DISTRICT April 2006 RULES AND REGULATIONS OF THE MEDICAL STAFFS OF THE NORTH BROWARD HOSPITAL DISTRICT TABLE OF CONTENTS PAGE I. RULES

More information

North Shore LIJ Health System, Inc. Facility Name

North Shore LIJ Health System, Inc. Facility Name North Shore LIJ Health System, Inc. Facility Name POLICY TITLE: The Medical Record POLICY #: 200.10 Approval Date: 2/14/13 Effective Date: Prepared by: Elizabeth Lotito, HIM Project Manager ADMINISTRATIVE

More information

2 nd Floor CS&E Building A current UMHS identification badge is required to obtain medical records

2 nd Floor CS&E Building A current UMHS identification badge is required to obtain medical records Location Hours 2 nd Floor CS&E Building A current UMHS identification badge is required to obtain medical records The Health Information Services Department is open to the public Monday through Friday,

More information

CHAPTER 27 THE SCOPE OF PROFESSIONAL NURSING PRACTICE AND ARNP AND CNM PROTOCOLS

CHAPTER 27 THE SCOPE OF PROFESSIONAL NURSING PRACTICE AND ARNP AND CNM PROTOCOLS I. INTRODUCTION CHAPTER 27 THE SCOPE OF PROFESSIONAL NURSING PRACTICE AND ARNP AND CNM PROTOCOLS Advance registered nurse practitioners (ARNPs) and clinical nurse practitioners (CNPs) have their scope

More information

MEDICAL STAFF BYLAWS FOR CHILDREN'S & WOMEN'S HEALTH CENTRE OF BRITISH COLUMBIA AN AGENCY OF THE PROVINICAL HEALTH SERVICES AUTHORITY

MEDICAL STAFF BYLAWS FOR CHILDREN'S & WOMEN'S HEALTH CENTRE OF BRITISH COLUMBIA AN AGENCY OF THE PROVINICAL HEALTH SERVICES AUTHORITY MEDICAL STAFF BYLAWS FOR CHILDREN'S & WOMEN'S HEALTH CENTRE OF BRITISH COLUMBIA AN AGENCY OF THE PROVINICAL HEALTH SERVICES AUTHORITY SEPTEMBER 1, 2004 Board Approved June 24, 2004 Ministry of Health Approved

More information

PEDIATRIC SURGERY SERVICE RULES AND REGULATIONS

PEDIATRIC SURGERY SERVICE RULES AND REGULATIONS LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL PEDIATRIC SURGERY SERVICE GENERAL PEDIATRIC SURGERY, PEDIATRIC SURGICAL SUBSPECIALITIES; CARDIOVASCULAR/THORACIC SURGERY, ORAL MAXILLOFACIAL SURGERY, HEAD & NECK

More information

Standard HR.7 All individuals permitted by law and the organization to practice independently are appointed through a defined process.

Standard HR.7 All individuals permitted by law and the organization to practice independently are appointed through a defined process. Credentialing and Privileging of Licensed Independent Practitioners The following standards apply to individuals permitted by law and the organization to provide patient care services without direction

More information

MEDICAL STAFF RULES & REGULATIONS. St. Ann's Medical Staff

MEDICAL STAFF RULES & REGULATIONS. St. Ann's Medical Staff SUBJECT: RESPONSIBLE PERSONS: Medical Records St. Ann's Medical Staff POLICY: It is the policy of the medical staff to ensure timely completion of medical records in accordance with regulations and quality-of-care.

More information

ALASKA. Downloaded January 2011

ALASKA. Downloaded January 2011 ALASKA Downloaded January 2011 7 AAC 12.255. SERVICES REQUIRED A nursing facility must provide nursing, pharmaceutical, either physical or occupational therapy, social work services, therapeutic recreational

More information

BYLAWS OF THE MEDICAL STAFF

BYLAWS OF THE MEDICAL STAFF (EFFECTIVE 6.25.12) BYLAWS OF THE MEDICAL STAFF CENTRAL MAINE MEDICAL CENTER LEWISTON, MAINE With updates adopted by the Medical Staff on June 25, 2012 Edmund Claxton, M.D. President Approved by the Governing

More information

SHADY GROVE ADVENTIST HOSPITAL DEPARTMENT OF MEDICINE CARDIOLOGY SECTION RULES AND REGULATIONS

SHADY GROVE ADVENTIST HOSPITAL DEPARTMENT OF MEDICINE CARDIOLOGY SECTION RULES AND REGULATIONS DEPARTMENT OF MEDICINE I. Purpose A Cardiology Section, within the Department of Medicine will be established pursuant to Article X, Section 7 of the Bylaws of the Medical Staff. This action is taken primarily

More information

Ratified: June 6, 2013 PROFESSIONAL STAFF BY-LAW

Ratified: June 6, 2013 PROFESSIONAL STAFF BY-LAW Ratified: June 6, 2013 PROFESSIONAL STAFF BY-LAW ARTICLE 1 DEFINITIONS AND INTERPRETATION...4 Section 1.1 Definitions...4 Section 1.2 Interpretation...6 Section 1.3 Delegation of Duties...6 Section 1.4

More information

Interior Health Authority Board Manual 9.3 MEDICAL STAFF RULES PART II TERMS OF REFERENCE FOR THE HEALTH AUTHORITY MEDICAL ADVISORY COMMITTEE

Interior Health Authority Board Manual 9.3 MEDICAL STAFF RULES PART II TERMS OF REFERENCE FOR THE HEALTH AUTHORITY MEDICAL ADVISORY COMMITTEE Interior Health Authority Board Manual 9.3 MEDICAL STAFF RULES PART II TERMS OF REFERENCE FOR THE HEALTH AUTHORITY MEDICAL ADVISORY COMMITTEE Original Draft: 15 December 2006 Board Approved: 17 January

More information

THE LONG ISLAND HOME MEDICAL STAFF BYLAWS

THE LONG ISLAND HOME MEDICAL STAFF BYLAWS THE LONG ISLAND HOME MEDICAL STAFF BYLAWS South Oaks Hospital A Comprehensive Behavioral Health Center Broadlawn Manor Nursing and Rehabilitation Center A Comprehensive Long-Term And Sub-Acute Care Facility

More information

11/01/15 STATE OF OKLAHOMA PHYSICIAN ASSISTANT ACT Title 59 O.S., Sections 519-524 INDEX

11/01/15 STATE OF OKLAHOMA PHYSICIAN ASSISTANT ACT Title 59 O.S., Sections 519-524 INDEX 11/01/15 STATE OF OKLAHOMA PHYSICIAN ASSISTANT ACT Title 59 O.S., Sections 519-524 INDEX 519. Repealed 519.1. Short title 519.2. Definitions 519.3. Physician Assistant Committee--Powers and duties 519.4.

More information

St. Luke's University Health Network RULES AND REGULATIONS OF THE MEDICAL STAFFS

St. Luke's University Health Network RULES AND REGULATIONS OF THE MEDICAL STAFFS St. Luke's University Health Network RULES AND REGULATIONS OF THE MEDICAL STAFFS St. Luke's Hospital - Anderson St. Luke's Hospital Allentown-Bethlehem St. Luke's Hospital - Miners St. Luke's Hospital

More information

RULES AND REGULATIONS OF THE SURGERY DEPARTMENT OF THE MEDICAL STAFF OF PEACEHEALTH SOUTHWEST MEDICAL CENTER

RULES AND REGULATIONS OF THE SURGERY DEPARTMENT OF THE MEDICAL STAFF OF PEACEHEALTH SOUTHWEST MEDICAL CENTER RULES AND REGULATIONS OF THE SURGERY DEPARTMENT OF THE MEDICAL STAFF OF PEACEHEALTH SOUTHWEST MEDICAL CENTER The Chair of the Surgery Department shall have responsibility for enforcing the following Rules

More information

RULES AND REGULATIONS OF THE MEDICAL STAFF OF FORT HAMILTON HOSPITAL

RULES AND REGULATIONS OF THE MEDICAL STAFF OF FORT HAMILTON HOSPITAL RULES AND REGULATIONS OF THE MEDICAL STAFF OF FORT HAMILTON HOSPITAL M E D I C A L S T F F R U L E S & Revised and Approved by the Board of Trustees 1-15-13 R E G U L A T I O N S MEDICAL STAFF RULES AND

More information

MEDICAL STAFF BYLAWS OF PIEDMONT MOUNTAINSIDE HOSPITAL

MEDICAL STAFF BYLAWS OF PIEDMONT MOUNTAINSIDE HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS OF PIEDMONT HEALTHCARE MEDICAL STAFF BYLAWS OF PIEDMONT MOUNTAINSIDE HOSPITAL Adopted by the Medical Staff: April 17, 2013 Approved by the Board:

More information

RULES AND REGULATIONS

RULES AND REGULATIONS MEMORIAL HOSPITAL UNIVERSITY OF COLORADO HEALTH MEDICAL, DENTAL AND PODIATRIC STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS RULES AND REGULATIONS Updated March 23, 2011 This update reflects all revisions

More information

MEDICAL STAFF RULES & REGULATIONS

MEDICAL STAFF RULES & REGULATIONS MEDICAL STAFF RULES & REGULATIONS 1 Table of Contents Rule 1: General... 4 Rule 2: Patient Rights and Responsibilities... 5 Rule 3: Responsibility for Care... 6 3.1 Conduct of Care... 6 3.2 Consultations:...

More information

Check List. Telehealth Credentialing and Privileging Sec. 482.12. Conditions of Participation Governing Body

Check List. Telehealth Credentialing and Privileging Sec. 482.12. Conditions of Participation Governing Body Check List Telehealth Credentialing and Privileging Sec. 482.12. Conditions of Participation Governing Body The Centers for Medicare and Medicaid Services (CMS) final rule on credentialing and privileging

More information

McLaren Greater Lansing Rules of the Department of Emergency Medicine ARTICLE I. PURPOSE AND ORGANIZATION

McLaren Greater Lansing Rules of the Department of Emergency Medicine ARTICLE I. PURPOSE AND ORGANIZATION McLaren Greater Lansing Rules of the Department of Emergency Medicine ARTICLE I. PURPOSE AND ORGANIZATION 1.1 PURPOSE 1.1.1 The purpose of the Department of Emergency Medicine shall be to perform the organizational

More information

DEPARTMENT OF SURGERY RULES AND REGULATIONS

DEPARTMENT OF SURGERY RULES AND REGULATIONS ARTICLE I - ORGANIZATION 1.1 In accordance with the Bylaws of the Medical Staff of Banner Heart Hospital, the Department of Surgery is organized as a Department of the Medical Staff. 1.2 Subcommittees:

More information

THE ORGANIZATION OF AN ANESTHESIA DEPARTMENT

THE ORGANIZATION OF AN ANESTHESIA DEPARTMENT THE ORGANIZATION OF AN ANESTHESIA DEPARTMENT Committee of Origin: Quality Management and Departmental Administration (Approved by the ASA House of Delegates on October 15, 2003, and last amended on October

More information

APP PRIVILEGES IN ORTHOPEDICS

APP PRIVILEGES IN ORTHOPEDICS APP PRIVILEGES IN ORTHOPEDICS Education/Training Licensure (Initial and Reappointment) Required Successful completion of a PA or NP program Current Licensure as a PA or RN in the state of CA Current certification

More information

HUMAN RESOURCES MANAGEMENT POLICY VISITOR & CAREER EXPLORATION PROGRAMS POLICY POLICY 08

HUMAN RESOURCES MANAGEMENT POLICY VISITOR & CAREER EXPLORATION PROGRAMS POLICY POLICY 08 HUMAN RESOURCES MANAGEMENT POLICY VISITOR & CAREER EXPLORATION PROGRAMS POLICY POLICY 08 NOTE: THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE AN EMPLOYMENT CONTRACT BETWEEN THE EMPLOYEE AND THE MEDICAL

More information

Ontario Hospital Association/Ontario Medical Association Hospital Prototype Board-Appointed Professional Staff By-law

Ontario Hospital Association/Ontario Medical Association Hospital Prototype Board-Appointed Professional Staff By-law Ontario Hospital Association/Ontario Medical Association Hospital Prototype Board-Appointed Professional Staff By-law 2011 ONTARIO HOSPITAL ASSOCIATION/ ONTARIO MEDICAL ASSOCIATION HOSPITAL PROTOTYPE BOARD-APPOINTED

More information

1) ELIGIBLE DISCIPLINES

1) ELIGIBLE DISCIPLINES PRACTITIONER S APPLICABLE TO ALL INDIVIDUAL NETWORK PARTICIPANTS AND APPLICANTS FOR THE PREFERRED PAYMENT PLAN NETWORK, MEDI-PAK ADVANTAGE PFFS NETWORK AND MEDI-PAK ADVANTAGE LPPO NETWORK. 1) ELIGIBLE

More information

2013 -- S 0197 S T A T E O F R H O D E I S L A N D

2013 -- S 0197 S T A T E O F R H O D E I S L A N D ======= LC00 ======= 01 -- S 01 S T A T E O F R H O D E I S L A N D IN GENERAL ASSEMBLY JANUARY SESSION, A.D. 01 A N A C T RELATING TO BUSINESSES AND PROFESSIONS - NURSES AND NURSE ANESTHETISTS Introduced

More information

Collaborative Practice Agreement for Nurse Practitioner Management of Patients in the Specialty of Pediatric Critical Care

Collaborative Practice Agreement for Nurse Practitioner Management of Patients in the Specialty of Pediatric Critical Care Collaborative Practice Agreement for Nurse Practitioner Management of Patients in the Specialty of Pediatric Critical Care Purpose Section I Introduction/Overview This document authorizes the nurse practitioner

More information

Interdisciplinary Admission Assessment and

Interdisciplinary Admission Assessment and 06/20/14 - Effective Definitions Policy Licensed Independent Practioner (LIP): Any individual permitted by law and UTMB to provide care and services without direction or supervision within the scope of

More information

(HEALTH INFORMATION MANAGEMENT SERVICES (HIMS)) MEDICAL RECORDS POLICY AND PROCEDURE

(HEALTH INFORMATION MANAGEMENT SERVICES (HIMS)) MEDICAL RECORDS POLICY AND PROCEDURE (HEALTH INFORMATION MANAGEMENT SERVICES (HIMS)) MEDICAL RECORDS POLICY AND PROCEDURE Adopted by the Medical Staff: July 27, 2009 Adopted by the Board of Directors: July 31, 2009 Amended by the Medical

More information

CRAIG HOSPITAL ENGLEWOOD, COLORADO BYLAWS OF THE MEDICAL STAFF ADOPTED AS AMENDED: MARCH 26, 2015

CRAIG HOSPITAL ENGLEWOOD, COLORADO BYLAWS OF THE MEDICAL STAFF ADOPTED AS AMENDED: MARCH 26, 2015 CRAIG HOSPITAL ENGLEWOOD, COLORADO BYLAWS OF THE MEDICAL STAFF ADOPTED AS AMENDED: MARCH 26, 2015 BYLAWS OF THE MEDICAL STAFF 48355590.5 TABLE OF CONTENTS PAGE PREAMBLE... 1 DEFINITIONS...1 ARTICLE I.

More information

Advanced Practice Nurses Authority to Diagnose and Prescribe

Advanced Practice Nurses Authority to Diagnose and Prescribe Advanced Practice Nurses Authority to Diagnose and Prescribe ted ec ot. r p e ht ion th rig mat of ty y r y p s o cie Co inf rte So u l o a dc dic ide Me e t a St ois v ro P n Illi www.isms.org ADVANCED

More information

LONG ISLAND JEWISH MEDICAL CENTER RULES AND REGULATIONS THE MEDICAL STAFF

LONG ISLAND JEWISH MEDICAL CENTER RULES AND REGULATIONS THE MEDICAL STAFF LONG ISLAND JEWISH MEDICAL CENTER RULES AND REGULATIONS OF THE MEDICAL STAFF Signed Chairman of the Medical Board As Amended through April 29, 2015. INDEX A. GENERAL POLICIES...1 B. QUALIFICATIONS FOR

More information

ACT NO BILL NO TWENTY-SIXTH LEGISLATURE OF THE VIRGIN ISLANDS OF THE UNITED STATES. Regular Session

ACT NO BILL NO TWENTY-SIXTH LEGISLATURE OF THE VIRGIN ISLANDS OF THE UNITED STATES. Regular Session ACT NO. 6736 BILL NO. 26-0028 TWENTY-SIXTH LEGISLATURE OF THE VIRGIN ISLANDS OF THE UNITED STATES Regular Session 2005 To amend the title 27 Virgin Islands Code, by adding subchapter V to enact the Advanced

More information

1. PATIENT TYPES AND ADMISSION OF PATIENTS. A. Description

1. PATIENT TYPES AND ADMISSION OF PATIENTS. A. Description LUCILE PACKARD CHILDREN S HOSPITAL Medical Staff Rules and Regulations Last Approval Date: Jan 2014 The purpose of the Lucile Packard Children's Hospital (LPCH) is to furnish quality medical care, treatment

More information

12 LC 33 4683S. The House Committee on Health and Human Services offers the following substitute to HB 972: A BILL TO BE ENTITLED AN ACT

12 LC 33 4683S. The House Committee on Health and Human Services offers the following substitute to HB 972: A BILL TO BE ENTITLED AN ACT The House Committee on Health and Human Services offers the following substitute to HB 972: A BILL TO BE ENTITLED AN ACT 1 2 3 4 5 6 7 8 9 10 11 12 13 To amend Chapter 34 of Title 43 of the Official Code

More information

JOHN C LINCOLN MEDICAL STAFF RULES AND REGULATIONS

JOHN C LINCOLN MEDICAL STAFF RULES AND REGULATIONS JOHN C LINCOLN MEDICAL STAFF RULES AND REGULATIONS Jan 2016 0 Table of Contents 1.0 RESPONSIBILITY 1 1.1 General 1 1.2 Patient Safety 2 1.3 Consideration for Suicidal Patients 2 1.4 Consideration for Suspected

More information

Scope and Standards for Nurse Anesthesia Practice

Scope and Standards for Nurse Anesthesia Practice Scope and Standards for Nurse Anesthesia Practice Copyright 2010 222 South Prospect Ave. Park Ridge, IL 60068 www.aana.com Scope and Standards for Nurse Anesthesia Practice The AANA Scope and Standards

More information

MEDICAL STAFF RULES AND REGULATIONS. Sturgeon Bay, Wisconsin

MEDICAL STAFF RULES AND REGULATIONS. Sturgeon Bay, Wisconsin MEDICAL STAFF RULES AND REGULATIONS Sturgeon Bay, Wisconsin Rules and Regulations Table of Contents Admission and Discharge of Patients...3 Informed Consent...4 Hand Off Communication...4 General Orders

More information

ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE CHAPTER 610-X-5 ADVANCED PRACTICE NURSING COLLABORATIVE PRACTICE TABLE OF CONTENTS

ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE CHAPTER 610-X-5 ADVANCED PRACTICE NURSING COLLABORATIVE PRACTICE TABLE OF CONTENTS ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE CHAPTER 610-X-5 ADVANCED PRACTICE NURSING COLLABORATIVE PRACTICE TABLE OF CONTENTS 610-X-5-.01 610-X-5-.02 610-X-5-.03 610-X-5-.04 610-X-5-.05 610-X-5-.06 610-X-5-.07

More information

STAMFORD HOSPITAL DEPARTMENT OF RADIOLOGY RULES AND REGULATIONS. Preamble

STAMFORD HOSPITAL DEPARTMENT OF RADIOLOGY RULES AND REGULATIONS. Preamble STAMFORD HOSPITAL DEPARTMENT OF RADIOLOGY RULES AND REGULATIONS Preamble Stamford Hospital and its radiology staff shall maintain radiological facilities and services sufficient to meet the needs of the

More information

RULES AND REGULATIONS

RULES AND REGULATIONS DESERT REGIONAL MEDICAL CENTER MEDICAL STAFF RULES AND REGULATIONS ADOPTED: MAY 1993 REVISED: November 2014 Page 1 of 19 CONTENTS INTRODUCTION... 3 A. ADMISSION AND TREATMENT OF PATIENTS... 3 B. ALLIED

More information

49 18.402 DEPARTMENT OF STATE Pt. I

49 18.402 DEPARTMENT OF STATE Pt. I 49 18.402 DEPARTMENT OF STATE Pt. I (3) The medical doctor has knowledge that the delegatee has education, training, experience and continued competency to safely perform the medical service being delegated.

More information

Emergency Department Planning and Resource Guidelines

Emergency Department Planning and Resource Guidelines Emergency Department Planning and Resource Guidelines [Ann Emerg Med. 2014;64:564-572.] The purpose of this policy is to provide an outline of, as well as references concerning, the resources and planning

More information

(128th General Assembly) (Amended Substitute Senate Bill Number 89) AN ACT

(128th General Assembly) (Amended Substitute Senate Bill Number 89) AN ACT (128th General Assembly) (Amended Substitute Senate Bill Number 89) AN ACT To amend sections 4723.01, 4723.06, 4723.48, 4723.482, and 4723.50; to amend, for the purpose of adopting new section numbers

More information

Allied Health Care Provider: Appointment and Re-appointment

Allied Health Care Provider: Appointment and Re-appointment Allied Health Care Provider: Appointment and Re-appointment Document Owner: Lawson, Louise Version: 8 Effective Date: 10/23/2013 Revision Date: 4/26/2015 Approvers: Calkins, Paul; Del Boccio, Suzanne;

More information

DEPARTMENT OF EMERGENCY MEDICINE RULES & REGULATIONS

DEPARTMENT OF EMERGENCY MEDICINE RULES & REGULATIONS DEPARTMENT OF EMERGENCY MEDICINE RULES & REGULATIONS ARTICLE I - Name The name of this clinical department shall be the "Department of Emergency Medicine" of the Medical Staff of Washington Adventist Hospital.

More information

Page ARTICLE I Statement of Purpose 1. ARTICLE II Authority 1. ARTICLE III Responsibilities of the Emergency Department 1

Page ARTICLE I Statement of Purpose 1. ARTICLE II Authority 1. ARTICLE III Responsibilities of the Emergency Department 1 EMERGENCY DEPARTMENT RULES AND REGULATIONS TABLE OF CONTENTS Page ARTICLE I Statement of Purpose 1 ARTICLE II Authority 1 ARTICLE III Responsibilities of the Emergency Department 1 ARTICLE IV Responsibilities

More information

MEDICAL STAFF RULES AND REGULATIONS

MEDICAL STAFF RULES AND REGULATIONS MEDICAL STAFF RULES AND REGULATIONS ARTICLE I. PROFESSIONALISM 1.1 These rules and regulations are intended to provide comprehensive information to members of the Ambulatory Surgery Center in order for

More information

CHAPTER 152 SENATE BILL 1362 AN ACT

CHAPTER 152 SENATE BILL 1362 AN ACT Senate Engrossed State of Arizona Senate Fiftieth Legislature Second Regular Session 0 CHAPTER SENATE BILL AN ACT AMENDING SECTION -0, ARIZONA REVISED STATUTES; AMENDING TITLE, CHAPTER, ARTICLE, ARIZONA

More information

As Introduced. 131st General Assembly Regular Session S. B. No. 110 2015-2016

As Introduced. 131st General Assembly Regular Session S. B. No. 110 2015-2016 131st General Assembly Regular Session S. B. No. 110 2015-2016 Senator Burke A B I L L To amend sections 4723.07, 4723.48, and 4731.72 and to enact section 4723.489 of the Revised Code to authorize administration

More information

SAMPLE WRITTEN SUPERVISION AGREEMENT

SAMPLE WRITTEN SUPERVISION AGREEMENT A. Physician Assistant Information 1. Name: SAMPLE WRITTEN SUPERVISION AGREEMENT 2. Illinois PA License Number: Illinois Mid-Level Practitioner Controlled Substance License Number: Federal Mid-Level Practitioner

More information

100.1 - Payment for Physician Services in Teaching Settings Under the MPFS. 100.1.1 - Evaluation and Management (E/M) Services

100.1 - Payment for Physician Services in Teaching Settings Under the MPFS. 100.1.1 - Evaluation and Management (E/M) Services MEDICARE CLAIMS PROCESSING MANUAL Accessed September 25, 2005 100.1 - Payment for Physician Services in Teaching Settings Under the MPFS Payment is made for physician services furnished in teaching settings

More information

Departmental Policy. Nurse Credentialing and the Nurse Credentialing Committee

Departmental Policy. Nurse Credentialing and the Nurse Credentialing Committee Page 1 of 6 Nurse Credentialing and the POLICY STATEMENT To describe the procedure for credentialing and privileging of Advanced Practice Nurses (APRNs), nurses in expanded roles, and non-hospital employed

More information

MGHS CREDENTIALS MANUAL

MGHS CREDENTIALS MANUAL MGHS CREDENTIALS MANUAL POLICY FOR MEMBERSHIP TO THE MARQUETTE GENERAL HEALTH SYSTEM (MGHS) MEDICAL STAFF Applications for Medical Staff membership to MGHS shall be provided to physicians, dentists, podiatrists,

More information

TITLE: Allied Health Professional Policy

TITLE: Allied Health Professional Policy TITLE: Allied Health Professional Policy Number: Version: Status: Current Type: Medical Staff Policy Author: Medical Staff Original Date: Revised Dates: Review Cycle: Triennial Deactivation Date: Facility:

More information

02- DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION. Chapter 8 REGULATIONS RELATING TO ADVANCED PRACTICE REGISTERED NURSING

02- DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION. Chapter 8 REGULATIONS RELATING TO ADVANCED PRACTICE REGISTERED NURSING 02- DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION 380 BOARD OF NURSING Chapter 8 REGULATIONS RELATING TO ADVANCED PRACTICE REGISTERED NURSING SUMMARY: This chapter identifies the role of a registered

More information

Guidelines for Core Clinical Privileges Certified Registered Nurse Anesthetists

Guidelines for Core Clinical Privileges Certified Registered Nurse Anesthetists Guidelines for Core Clinical Privileges Certified Registered Nurse Anesthetists Copyright 2005 222 South Prospect Park Ridge, IL 60068 www.aana.com Guidelines for Core Clinical Privileges Certified Registered

More information

West Virginia University Hospitals, Inc. Medical/Dental Staff Bylaws

West Virginia University Hospitals, Inc. Medical/Dental Staff Bylaws West Virginia University Hospitals, Inc. Medical/Dental Staff Bylaws ARTICLE I DEFINITIONS 1.1 Board of Directors Board means the Board of Directors which, as established by State Law, is the governing

More information

McLaren Greater Lansing Rules of the Department of Radiology ARTICLE I. PURPOSE AND ORGANIZATION ARTICLE II. DEPARTMENT MEMBERSHIP

McLaren Greater Lansing Rules of the Department of Radiology ARTICLE I. PURPOSE AND ORGANIZATION ARTICLE II. DEPARTMENT MEMBERSHIP 1.1 PURPOSE McLaren Greater Lansing Rules of the Department of Radiology ARTICLE I. PURPOSE AND ORGANIZATION 1.1.1 The purpose of the Department of Radiology (Department) shall be to perform the organizational

More information

GUIDELINES FOR PSYCHOLOGICAL PRACTICE IN HEALTH CARE DELIVERY SYSTEMS

GUIDELINES FOR PSYCHOLOGICAL PRACTICE IN HEALTH CARE DELIVERY SYSTEMS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 GUIDELINES FOR PSYCHOLOGICAL PRACTICE IN HEALTH CARE DELIVERY SYSTEMS INTRODUCTION Psychologists practice in an increasingly diverse range

More information

CHAPTER 331. C.45:2D-1 Short title. 1. This act shall be known and may be cited as the "Alcohol and Drug Counselor Licensing and Certification Act.

CHAPTER 331. C.45:2D-1 Short title. 1. This act shall be known and may be cited as the Alcohol and Drug Counselor Licensing and Certification Act. CHAPTER 331 AN ACT to license and certify alcohol and drug counselors, creating an Alcohol and Drug Counselor Committee, revising various parts of the statutory law. BE IT ENACTED by the Senate and General

More information

UNIVERSITY OF NORTH CAROLINA HOSPITALS

UNIVERSITY OF NORTH CAROLINA HOSPITALS 7 1 BYLAWS OF THE MEDICAL STAFF UNIVERSITY OF NORTH CAROLINA HOSPITALS Approved by the Executive Committee of the Medical Staff, November 5, 2001. Approved by the Medical Staff, December 5, 2001. Approved

More information

Edward W. Sparrow Hospital Association. ("Hospital") Lansing, MI. Medical Staff General Policy and Procedures Manual

Edward W. Sparrow Hospital Association. (Hospital) Lansing, MI. Medical Staff General Policy and Procedures Manual Edward W. Sparrow Hospital Association ("Hospital") Lansing, MI Medical Staff General Policy and Procedures Manual 9/95 Revised: 9/96 Revised: 3/31/98 Revised: 10/27/98 Revised: 03/7/00 Revised: 6/20/00

More information

Credentials Policy Manual. Reviewed & Approved by MEC 8/13/2012 Reviewed & Approved by Board of Commissioners 9/11/12

Credentials Policy Manual. Reviewed & Approved by MEC 8/13/2012 Reviewed & Approved by Board of Commissioners 9/11/12 Credentials Policy Manual Reviewed & Approved by MEC 8/13/2012 Reviewed & Approved by Board of Commissioners 9/11/12 Credentialing Policy Manual Table of Contents I. Application for Appointment to Staff...1

More information

BOARD OF MEDICINE: 2009 SCOPE OF PRACTICE: A COMPARISON OF FLORIDA HEALTHCARE PRACTITIONERS

BOARD OF MEDICINE: 2009 SCOPE OF PRACTICE: A COMPARISON OF FLORIDA HEALTHCARE PRACTITIONERS BOARD OF MEDICINE: 2009 SCOPE OF PRACTICE: A COMPARISON OF FLORIDA HEALTHCARE PRACTITIONERS Anesthesiologist Assistant Medicine - Medical Doctor Medicine - House Physician PROFESSIONS Anesthesiologist

More information

SENATE BILL 1099 AN ACT

SENATE BILL 1099 AN ACT Senate Engrossed State of Arizona Senate Forty-third Legislature First Regular Session SENATE BILL AN ACT amending sections -, -.0, -, -, -, -, -, -, -, - and -, Arizona revised statutes; repealing section

More information

PLEASE NOTE. For more information concerning the history of these regulations, please see the Table of Regulations.

PLEASE NOTE. For more information concerning the history of these regulations, please see the Table of Regulations. PLEASE NOTE This document, prepared by the Legislative Counsel Office, is an office consolidation of this regulation, current to February 12, 2011. It is intended for information and reference purposes

More information

Stanford Hospital and Clinics Lucile Packard Children s Hospital

Stanford Hospital and Clinics Lucile Packard Children s Hospital Practitioners Page 1 of 10 I. PURPOSE To outline individuals who are authorized to provide care as an Allied Health professional as well as describe which categories of individuals who will be processed

More information

MEDICAL STAFF & ALLIED HEALTH PROFESSIONAL STAFF BYLAWS

MEDICAL STAFF & ALLIED HEALTH PROFESSIONAL STAFF BYLAWS MEDICAL STAFF & ALLIED HEALTH PROFESSIONAL STAFF BYLAWS * * * MARYMOUNT HOSPITAL GARFIELD HEIGHTS, OHIO 44125 Board of Trustees Approved 08.18.15 1 TABLE OF CONTENTS PREAMBLE... 6 DEFINITIONS... 7 ARTICLE

More information