South West Nova District Health Authority Medical Staff Rules and Regulations

Transcription

1 South West Nova District Health Authority Medical Staff Rules and Regulations These Rules and Regulations, adopted by the Medical Staff, have been developed by the District Medical Advisory Committee and approved by the Governing Board of the South West Nova District Health Authority in accordance with sections 13.1 and 13.2 of the By-Laws. In accordance with section 13.3 of the By-Laws it is acknowledged that, in the event of a conflict between these Rules and Regulations and the By-Laws, the By-Laws will take precedence. The District Medical Advisory Committee may recommend changes to these Rules and Regulations to the Board from time to time. Such changes will require a 2:1 vote in favor at a regular meeting of the District MAC. 1.0 CODE OF ETHICS The Code of Ethics, which will govern the Medical Staff, will be the Code of Ethics of the Canadian Medical Association. 2.0 MEDICAL STAFF CATEGORIES No physician may hold an appointment in more than one category at a health care facility at the same time and where a DHA grants privileges at more than one hospital site, the privileges granted to a physician shall not conflict between hospital sites. The Medical Staff shall consist of the following categories: Active Associate Consulting Courtesy Dental Honorary Itinerant Consultant Locum Tenens Residents and Medical Students 2.1Active Staff: The Active Staff shall consist of physicians appointed by the Board and who have served as members of the Associate Staff for at least 1year. In exceptional circumstances, a physician may be appointed to the Active Staff without having served as a member of the Associate Staff for at least 1 year or at all. Active Staff members may admit and treat patients, hold office, vote at Medical Staff meetings, and participate in the general business of the Medical Staff. Active Staff members shall attend at least 50% of Medical Staff, departmental, and committee meetings, and may assume responsibility for administrative work as agreed. The Board may, in its discretion, accept justified absences from Active Staff members.

2 Active Staff members shall participate in the on call services of the DHA as outlined in the Rules & Regulations Associate Staff The Associate Medical Staff shall consist of physicians appointed by the Board to this category for a period of up to 12 months; may extend to 24 months with documented concerns and mutual agreement of parties involved. They may admit and treat patients, shall work under the supervision of the Chief of the Department or his designate, and shall participate in the activities of the Medical Staff set out in these Bylaws. They shall not be eligible to: hold office; serve as Chair of any Medical Staff committee. They shall attend at least 50% of Medical Staff, departmental, and committee meetings; and may assume responsibility for administrative work as agreed. Associate Staff members shall participate in the on-call services of the DHA, subject to the Rules & Regulations. 2.3 Consulting Staff: The Consulting Staff shall consist of physicians who are appointed by the Board because of special knowledge, skills, and experience and who may be consulted by members of the Active and Associate Staff. Consulting Staff may not admit but may treat patients admitted by the Active or Associate Staff. They may serve on any committee of the Medical Staff but shall not be eligible to vote or hold office on the Medical Staff. Consulting Staff may attend Medical Staff meetings, but they are not required to do so. 2.4 Courtesy Staff: The Courtesy Staff shall consist of physicians appointed by the Board for the purpose of visiting inpatients and reviewing their charts. Courtesy Staff members may assist at surgical procedures where such privileges have been granted by the Board. Courtesy Staff may attend Medical Staff meetings, but may not vote or hold office. 2.5 Dental Staff The Dental Staff shall consist of dentists who, under the Dental Act, are registered in the Dentists Register and are licensed to practice dentistry, and are appointed by the DHA as part of the Medical

3 Staff on the recommendation of the District MAC. 3 There shall be two categories of Dental Staff: those dentists given operating room privileges and on-call duties, and those dentists given on-call duties only. Dental Staff may admit and treat patients appropriate to the practice of dentistry. Dental Staff shall be expected to provide on-call emergency coverage. Dental Staff may attend Medical Staff meetings, but may not vote or hold office. 2.6 Honorary Staff Honorary Staff shall be appointed by the DHA on the recommendation of the District MAC and shall not have assigned duties, responsibilities, or treatment privileges. Honorary Staff shall consist of physicians who have retired from active service and are of outstanding reputation. Members of the Honorary Staff shall remain so honored until such time that the appointment is withdrawn by the Board. Honorary Medical Staff are not eligible to vote and shall not be required to attend meetings of the Medical Staff. 2.7 Itinerant Consulting Staff: The Itinerant Consulting Staff shall consist of physicians who are appointed by the Board because of special knowledge, skills, and experience and who may be consulted by members of the Active Staff. They may be granted privileges solely to conduct clinics in a health care facility for the purpose of examining and treating patients referred by other members of the Medical Staff. They may not serve on committees of the Medical Staff, nor shall they be eligible to vote or hold office on the Medical Staff. Itinerant Consulting Staff may attend Medical Staff meetings, but are not required to do so. 2.8 Locum Tenens The Locum Tenens Staff shall consist of those physicians appointed by the Board who have been granted privileges for periods not to exceed 24 months in order that they might relieve members of the Medical Staff who may be on vacation or other such extended leaves of absence. A physician s term as a locum tenens staff member may be extended for a further 12-month period if the Board considers it to be necessary to cover an extended leave of absence.

4 4 Locum Tenens Staff will be required to follow the same process for obtaining privileges as any other potential member of the Medical Staff, and the credentials shall be reviewed following the process outlined in the Medical Staff (Discipline) Bylaws. Locum Tenens Staff will be entitled to admit and treat patients according to the privileges granted and will be required to substitute for the absent practitioner in any of the practitioner s regularly scheduled on-call duties. Locum Tenens Staff will not be eligible to vote at any committee, departmental or other Medical Staff meetings, or be elected as an officer of the District Medical Staff Association; but Locum Tenens Staff are permitted to attend Medical Staff meetings. Locum Tenens Staff shall not be bound by attendance requirements. 2.9 Residents and Medical Students Residents and medical students will be assigned to a medical department related to their training. Each resident and medical student will be under the supervision of the District Department Chief; the Chief of the Division or his designate; or the Program Director (where such a position exists). The District Department Chief or Chief of a Division or his designate will ensure that a medical student s orders on the chart of the patient will be countersigned by the physician who is treating the patient. 3.0 RETIREMENT / RESIGNATIONS 3.1 Once a Physicians reaches the age of 65 and wishes to continue his/her practice: a) Must discuss plans for his/her retirement with the Chief of his Department, minimum of 12 months notice is to be given. b) Must have an evaluation of his/her performance carried out and every year thenceforth after the age of 70, performance must be acceptable. 3.2 Once a physician reaches the age of 70, the Department will begin the recruitment process for a replacement and when successful, the physician will be expected to retire. Applications for privileges will be on a yearly basis and granted based on the yearly evaluation of performance by Department head. 3.3 When any member of the Medical Staff resigns from South West Nova District Health Authority, he/she shall notify the District Department Chief in writing not less than three (3) months prior to the date the resignation takes effect, and shall comply with any Exit policies, which are in place at that time. In exceptional circumstances (ie. illness) shorter notice will be accepted at the discretion of the District Department Chief after consultation with the District Chief of Staff. 4.0 MEDICAL STAFF ORGANIZATION (DEPTS AND DIVISIONS) GENERAL BY-LAWS 8.1 The Medical Staff shall be divided into the following Departments and Divisions though this may be changed from time to time

5 5 Departments and Divisions Department of family medicine Divisions, Yarmouth Regional Hospital Digby General Hospital Roseway Hospital Department of Anesthesia Department of Diagnostic Imaging Department of Emergency Medicine Department of Internal Medicine Department of Obstetrics/Gynecology Department of Pediatrics Department of Psychiatry Department of Surgery Departments shall meet at least 9 times per year. Minutes of these department meetings are to be kept and copies of these minutes are to be forwarded to the Chief of Staff. Quorum at Department meetings shall be 50% of members. Motions to be passed by simple majority of those present. It is expected that each member of a clinical Department will attend Department meetings. Repeated absence from Department meetings may be reported to the Chief of Staff, and the Chief of Staff may take such action as is deemed appropriate to deal with the repeat offender. Such actions may include suspension or alteration of privileges, variation of privileges upon reapplication, or filing of a complaint with the College of Physicians & Surgeons of Nova Scotia. There will be a Chief of Staff appointed for the Yarmouth site and Deputy Chief of Staffs at Roseway and Digby General. The responsibilities of the site Chief of Staff will be guided by the General By-Laws section 8.4. In addition this person will be a member of the Credential Committee, and will have responsibilities in the area of recruitment and retention. 5.0 MEDICAL ADVISORY COMMITTEES The following standing Committees of the District Medical Advisory are: - Roseway Medical Advisory Committee - Digby General Hospital Medical Advisory Committee - Credentials Committee - Utilization Committee - Health Records Committee - Ethics Committee - Pharmacy and Therapeutics Committee - Infection Control Committee - Renal Dialysis Committee - Emergency Room Committee - Maternal Child Committee - OBS/GYN Committee - OR Committee - ICU Committee 6.0 THE CHIEF OF STAFF SHALL HAVE THE AUTHORITY: where necessary or appropriate to remove from and assign to another member of the Medical Staff, the responsibility for the care of any patient who, in the opinion of the Chief of Staff, is not receiving proper care; to temporarily suspend or vary the privileges of any member of the Medical Staff at any time if the subject matter of complaint is of a serious nature and requires immediate action, and to assign another member of the Medical Staff to be responsible for the care of the suspended physician s patients;

6 6 and the responsibility for supervision over any matter affecting admission, treatment, and discharge of any patient within the District or Programs operated by the District to which he or she is assigned; to intervene if he or she becomes aware that a serious problem exists in the diagnosis and care or treatment of an inpatient or outpatient within the District or Programs operated by the District and it is not acted upon in a reasonable manner. 7.0 SITE MEDICAL STAFF ASSOCIATION The site medical staff association shall meet at least quarterly and in accordance with the requirements of the bylaws. The meeting held in June shall be the annual meeting in accordance with the By-Laws. The Site Medical Staff Association shall set and collect it s own dues. Quorum for quarterly and annual meetings of the Site Medical Staff Association shall be ¼ of all voting members. Motions will be passed by simple majority of those members of the Site Medical Staff present; voting by proxy will not be permitted; the President shall only vote in the event of a tie. 8.0 DEPARTMENT OF FAMILY MEDICINE a) Physicians who do OR assists. CME requirements are acknowledged to be practical and competency should be reviewed by the Department Heads of Surgery and Obstetrics/Gynecology when application or reapplication for privileges is to be reviewed. Privileges will be issued or renewed subject to the signed approval of the Head of Department of either Surgery or Obstetrics/Gynecology, or the site Chief of Staff. b) Assists is the responsibility of the Surgeon to find OR assistants for elective and emergency cases. c) Physicians with Admitting or Treatment privileges: 50 hours per year averaged over each 3 year recredentialing period (total 150 hours) of which no more than ½ (total 75 hours) may be self directed. Documentary evidence must be supplied on request. 9.0 PHYSICIAN NOTIFICATION AND AVAILABILITY All members of the Medical Staff must carry pagers or digital cell or office phones when on call. All physicians on call must ensure that they are available in accordance with these provisions for the duration of their call. Unless otherwise instructed Pagers or Cell phones are to be the first method used to attempt contact with physicians between the hours of 0800 and Unless otherwise instructed Home phone numbers are to be the first attempted route of contact between 2200 and ON CALL In accordance with the By-Laws as a provision for the granting of privileges members of the Medical Staff will participate in On-Call rotas unless age or years of service exemption. Because we have limited resources, and because of the need for recruitment, participation in on-call rotas will be tied to the distribution or utilization of these resources such as In-patient beds, Operating Room time, Endoscopy time, and Clinic time. No on-call or decreased participation in on-call rotas will result in redistribution of some or all of these resources to other physicians MEDICAL RECORDS 11.1 General Responsibilities

7 7 a) Any member of the Medical Staff involved in the care of a patient must ensure that the records of such care are complete and accurate. b) The requirements of this section with respect to the writing and recording of information shall be satisfied if i) such information is written or recorded by a fully qualified member of the medical staff or ii) written or recorded by a medical student it is countersigned by the receptor iii) records are completed in accordance with current Policies and Procedures c) Reports on certain diagnostic investigations such as x-ray, stress tests and EKG s should be kept in health records The SWNDHA is the custodian of patient s health records and they shall remain on the property of the SWNDHA except where written permission to temporarily remove the records is granted by the CEO. In the case of readmission all previous records shall be made available for the current attending physician Requirements for admission The admitting Physician shall be responsible for seeing that a complete History and Physical is recorded on the chart or has been dictated within 24 hours of admission. The history and physical form is sometimes not filled out by the attending physician if there is a consultant s report, which contains a history and physical on the chart. In this case, it is advised that the Family Physician document a note on the History and Physical form identifying the location of the H&P and attesting to its accuracy and then sign this note. If the patient is to be admitted by the ER Physician, it is suggested that the details of patient s complaints, physical findings, investigations and possible differential diagnosis, initial management plan, etc., are documented on the H&P form, or the Outpatient sheet. The history and physical must be completed within 24 hours of the patient s admission Patient Classification for Admission Patients will be divided into one of three categories by the physicians applying to the Hospital for admission and/or surgery: Emergency Acute injury or illness necessitating immediate treatment. A patient classified in this category should be admitted immediately or at some later time if that is agreed to by the admitting physician Urgent Patients likely to become dangerously ill, or suffer serious deterioration if not shot time period. This patient should be admitted within seven days treated within a Elective A patient requiring admission to one of the Acute Treatment Hospital s in the District, but not included in the above categories. Such a patient will be admitted in an orderly fashion to make the most efficient use of hospital facilities 11.4 Transfer to Other Physician s Service A physician shall not admit a patient to another physician s service without prior approval by that physician. A physician admitting to another physician s service is responsible for that patient and the medical record relating to that patient until the transfer of responsibility has been accepted by a notation in the patient s medical chart by the new attending physician.

8 The transfer of responsibility for a patient from one physician to another physician with admitting privileges shall be acknowledged by the referring physician and the receiving physician in writing on the patient s chart. Any transfer must be understood by the patient or his/her family and be acceptable to them. A patient admitted to the facility as an outpatient or as an inpatient shall, if possible, be given the opportunity to choose a physician from those members of the Medical Staff who hold privileges in that facility, if the physician of the patient s choice agrees to become the attending physician. If the physician of the patient s choice is not immediately available, the patient shall be assigned to a member of the Active staff on duty in the Department to which the illness of the patient indicates assignment. If the physician of choice later becomes available and the patient indicates a continuing preference, the patient shall be given the courtesy of a consultation with that physician, if the physician agrees Progress Notes a) Progress notes shall be written as changes occur in the patient s condition, management or treatment, and anyway not less than weekly. b) Operative Reports. All operative reports shall be dictated within 24 hours of surgery, and a written progress note shall be added to the record immediately following the operation. c) Elective Transfer notes. Should the patient be electively transferred to another facility the attending physician shall supply a transfer note summarizing the patient s condition, progress, and treatment to go with the patient. d) Emergency Transfer. In the event of an emergency transfer the attending physician shall ensure that adequate information is communicated to the receiving physician Discharge Against Medical Advice In the event a patient wishes to leave a hospital facility against the advice of the attending physician or without his/her consent, such patient shall be requested to sign the appropriate hospital form or release confirming such fact. Should the patient refuse or fail to sign such form or release, a report of the circumstances shall be noted in the Progress Notes and shall be in the Discharge Summary for such patient Discharge Summaries a) The preferred form of documentation is dictation. If the summary is written it must be legible or it will be returned to the physician for dictation. b) Record date of admission and discharge, the admission diagnosis and final diagnosis. If these diagnoses are different, information leading up to this conclusion should be included. c) All final diagnoses must be written out in full. Abbreviations cannot be accepted The admitting / attending doctor and family doctor along with any consultants should be listed a) There should be a list of secondary diagnosis especially if these are directly related to the admission problem or the patient. b) Any surgical procedures should be listed A brief but specific history of the presenting complaint and signs and symptoms related to this should be written Following the above, there should be a summary of pertinent Diagnostic Imaging tests, biochemistry, hematology, respiratory test, along with the clinical assessment required to arrive at the final diagnosis The treatment plan can now be outlined on the basis of your working diagnosis and, from this, a summary of the success or failure of treatment, any side effects or complications and change of treatment course should be described under Course in Hospital including any procedures. Under Course in Hospital - summarize stay in hospital, state complications and important clinical information including any procedures.

9 There should be a summary of recommended discharge medications and treatment and follow-up time, place and by whom along with necessary follow-up tests or investigations Finally, the summary must be dated and signed by the attending physician Completion of Medical Records For the purpose of this section where a specific date is mentioned should that date fall on a holiday or weekend the next working day will be used. Reports. All charts should be completed on the 20 th of each month. At month end the Health Records Department will count the uncompleted charts in each Physicians file and will set them aside, and will notify those Physicians by letter. This letter shall be taken as a notice to complete in accordance with section of the Disciplinary By- Laws. These charts should be completed by the 22 nd of each month Temporary reduction of privileges Subject to (1) and (2) below at the end of this grace period any physician who has not yet completed those charts which were set aside shall have their privileges automatically reduced by the CEO, the District Chief of Staff. During this period the physician will not be allowed to admit any patients to hospital but must continue and complete the treatment of any patients already admitted. During this period the physician must continue to honor any on call commitments but must make arrangements with a colleague on the medical staff who will attend any necessary patient admissions. 1) The CEO, District Chief of Staff may delay or modify the imposition of any automatic reduction of privileges if such a reduction might adversely affect in a material way the services provided to the public by the facility. 2) If the failure of a physician to complete such medical records is caused by their illness or absence from the area automatic reduction of privileges shall not take place on the day following the originally assigned chart completion day. The grace period shall start on the day of the physician returns to medical practice Notification The physician whose privileges has been reduced in this manner shall be notified in writing by the responsible person, and reasonable attempts to contact the physician by phone will also be made. The appropriate sites and departments shall also be informed Reinstatement The CEO, District Chief of Staff shall reinstate the privileges that were reduced as soon as possible after notification by the Health Records Department that the charts have been completed. The non-completion of which resulted in the privileges alteration Custody of Records All patient health records are the property of the South West Nova District Health Authority and none may be removed from the premises without the permission of the CEO or designate. A physician whose office is on site within South West Nova District Health Authority premises may sign out a patient health record for clinical or medico legal purposes only, and it must be returned on the same day. If it is impractical for the record to be returned on the same day, and the Coordinator of Health Information Services authorizes it, the physician or dentist shall return the health record within forty-eight (48) hours. If a physician or dentist fails to return a health record within the specified time frame, the Coordinator of Health Information Services may withdraw health record sign-out privileges from the physician or dentist. The Director shall notify the physician or dentist in writing of the withdrawal of the privileges in accordance with South West Health policy. If a physician or dentist removes a health record from the South West Health premises without authorization, the District Chief of Staff may elect to pursue a Special Review pursuant to Section 9 (Discipline Bylaws)

10 Consents Before initiating or ordering any treatment, the attending physician or dentist, or his physician or dentist delegate, shall obtain the patient s agreement to the proposed investigation or treatment. In all cases where the South West Nova District Health Authority consent policy determines that written consent is required, the physician or dentist performing any treatment or procedure shall ensure that an informed consent is obtained from the patient, and any required documentation is recorded and filed in the patient s health record, in accordance with the policy Consultations Consultation Content The physician or dentist requesting the consultation shall indicate the type and extent of involvement being requested from the consultant, or the consultant shall indicate it in his consultation report. Recording of Consultation Both the consultation request and the consultant s report must be recorded in the patient s health record. Consultation reports shall be recorded on the same day as the Consultation, as soon as possible after the patient has been assessed. The attending physician or delegate, shall write, date and sign the request for consultation. The consultant physician or dentist, or his physician or dentist delegate, shall write, date and sign a report of the results of his history and physical examination of the patient and his review of the health record, the opinion and any recommendations for investigation or care of the patient. When it is anticipated that there will be a delay in the transcription of dictated reports, a hand-written note should be placed on the chart, summarizing any important findings or recommendations. Consultation Followed by Medical/Surgical Procedure If the consultation is related to a medical/surgical procedure, the consultation documentation must be recorded in the health record prior to the commencement of the procedure, except in an emergency situation. The nature of the emergency situation must be documented, dated and signed in the health record by the physician or dentist who performs the procedure. Consultant s Orders Consultants write recommendations within the consultation form. These recommendations may include specific orders or recommendations that may be translated into specific orders by the attending physician or his physician delegate. Consultants may write such orders in the patient s health record Medications SWNDHA Formulary a) All medications used in the District must be supplied by the Pharmacy from those listed in the Formulary. Notwithstanding the foregoing, patients will be allowed to use their own medications if they have a specific order from the attending physician to do so under supervision. b) The formulary shall be compiled and maintained by; the District Pharmacy and Therapeutics Committee, and copies shall be available on all Nursing Units. c) The pharmacy may dispense a generic product in place of a specific brand name if the generic product is considered interchangeable, contains the same drug in the same dosage and with the same bio availability. d) The pharmacy may dispense a therapeutically equivalent but chemically different drug from that ordered. Such substitutions will only be from a list compiled and approved by the District Pharmacy and Therapeutics and District Medical Advisory Committees.

11 e) Physicians wishing to order medications not listed in the formulary shall fill out request forms and forward them to the District Pharmacy and Therapeutics Committee for consideration for additions to the formulary. If such medications are needed urgently the Pharmacy will endeavor to supply them and the physician shall fill out the request form after the fact as soon as possible Automatic Stop Orders Automatic stop orders are in place in the formulary, and shall be reviewed by the District Pharmacy and Therapeutics committee Standing Orders Departmental protocol may be formulated by the Chief of the Department with Department members and approved by the Medical advisory Committee as Standing Orders that may be used as guidelines for the treatment of patients. Individual physicians may devise and use personal Standing Orders. These orders must be signed by the physician after he reviews for specific patients prior to being followed Continuing Medical Education Requirements for granting of, and renewing privileges. Specialists: In accordance with the Royal College of Physicians & Surgeons of Canada s Maintenance of Certification (MOCERT) program. MOCERT summaries for each year should be attached to re-application forms. Specialists who do not take part in the MOCERT program shall supply evidence of 80 hours per year (averaged over the reapplication period) of CME, of which at least 40 hours must be in activities other than self directed reading Complaints Should any member of the Medical Staff have reason to complain about a Hospital employee it shall be made to employees immediate superior. All formal complaints will be addressed using the Physician Complaint Protocol approved by each Department Death The death of a patient is to be pronounced by the best qualified person who is present when the patient is found to have died. In the event that the death is unanticipated and there is some chance that the patient could be resuscitated all reasonable efforts should be made to carry out such resuscitation. The attending physician or their designate is to be informed at the earliest possible time of the death. The attending physician will then call the family the Family Physician will fill out the death certificate at the earliest opportunity. Rules regarding which cases are to be referred to the Medical Examiner are appended to these Rules and Regulations and are in accordance with the Fatalities Investigation Act of Nova Scotia No Code In any terminal illness where the attending physician does not wish his/her patient to have cardiac resuscitation, he/she: - Will discuss, where appropriate, the matter with the patient s next of kin, or if he/she sees fit, with the patient his/herself and/or with the person who has the authority (power of attorney) to consent to any medical treatment for the patient, and make a record of this on the Progress Sheet in the Medical Records, and - Will write a note on the Progress Sheet indicating that, in his/her judgment, the patient has a terminal illness and will not benefit from resuscitation measures.

12 - An order should be written on the Physician s Order Sheet that the patient is a No Code. No Code refers only to cardiopulmonary resuscitation and does not preclude continuation of any other reasonable treatment Autopsies In accordance with the educational mission of South West Health, unless the autopsy policy states otherwise, when a patient in a health care facility of South West Health dies, if in the opinion of the attending physician or his physician delegate there may be a medical or educational benefit in completing an autopsy, the attending physician or his physician delegate shall seek consent to perform an autopsy including the extent of the autopsy, from the individual legally responsible for the remains of the patient who has died. Autopsies may also occur at the request of the family in which case consent still needs to be obtained as per preceding paragraph. The physician who obtains the consent shall document the consent in writing and sign it on the approved South West Health form. The requirements and procedures for obtaining and documenting informed consent are set out in South West Health policies. The completed consent form must be filed in the patient s health record. If the circumstances of the death require notification to the Medical Examiner, the physician shall follow the notification procedure stipulated Death Certificate to Funeral Director and Notification to Registrar General When a patient in a health care facility of South West Health dies, the attending physician or his physician delegate shall complete, date and sign a death certificate as soon as possible within twenty-four (24) hours following the death. A copy of the completed death certificate must be filed in the patient s health record. In accordance with The Vital Statistics Act, the completed death certificate must be sent to the funeral director involved for his notification to the Nova Scotia Registrar General Unexpected Death Notification to Medical Examiner When a patient in a health care facility of South West Health dies and it appears the patient died (a) by violence, undue means, or culpable negligence, (b) in a place or under circumstances where an inquest is required by legislation, or (c) from an undetermined cause, or (d) in a jail or prison The patient s attending physician, or his physician delegate, in accordance with South West Health policy, shall notify the Nova Scotia Medical Examiner s Office immediately. The notification may be made by telephone. The physician who makes the notification shall write, date and sign a notation documenting it in the patient s health care record. If the Medical Examiner decides not to perform an autopsy and there is: (a) medical or educational benefit to be gained by an autopsy, or (b) the next of kin have requested an autopsy 20.0 Stillbirth Notification to Registrar General When a patient delivers a stillbirth in a health care facility of South West Health, the attending Physician shall complete, date and sign a notice of stillbirth form within twenty-four (24) hours of the stillbirth. The completed form must be sent to the Nova Scotia Registrar General within the twenty-four (24) hours. A copy must be filed in the patient s health record.

13 Organ Donation Screening and Consent When a patient in a health care facility of South West Health dies, the attending physician or his physician delegate shall ensure a screening evaluation of the patient for potential organ and tissue donations is conducted, in accordance with South West Health organ donation policy. The person who conducts the evaluation shall complete the screening form, date and sign it. The form must be filed in the patient s health record. In accordance with the Human Tissue Gift Act, unless South West Health policy states otherwise, when a patients in a health care facility of South West Health dies or a patient s death appears imminent, the attending physician or his delegate shall request consent from the individual legally responsible for the remains of the patient for a donation after death of organs or tissues, or both, for therapeutic, medical education or scientific research purposes. The person, who obtains the consent, shall document the consent in writing and sign it on the organ donation request form in accordance with South West Health policy. The documentation must detail the extent and uses of the donation. The completed consent form must be filed in the patient s health care record. The requirements and procedures for organ donation requests and obtaining and documenting informed consent are set out in South West Health organ donation and consent policies Suspected Adult Abuse Notification to Minister of Community Services When a physician or dentist, or any person, has information indicating an adult is in need of protection, he/she shall notify and provide the information to the appropriate official in the Nova Scotia Department of Community Services, as required by the Adult Protection Act. This requirement applies whether the information is confidential or not Suspected Child Abuse Notification to Minister of Community Services When a physician or dentist, or his physician or dentist delegate, has reasonable grounds to suspect a child is or may be suffering from abuse, or has suffered abuse, that person shall notify the appropriate official in the Nova Scotia Department of Community Services, as required by the Children and Family Services Act Unsafe to Drive Voluntary Notification to Registrar of Motor Vehicles When a physician is of the opinion that a patient has a mental or physical condition or disability that make it unsafe for the patient to drive, he/she may notify the Nova Scotia Registrar of Motor Vehicles, in accordance with the Motor Vehicle Act Notifiable Diseases Within twenty-four hours after the appearance of any signs and symptoms indicating that a patient has a notifiable disease under Section 12, Nova Scotia Regulation 64/99 under the Health Act, the attending physician shall make a report on an approved form and send it to the District Medical Health Officer. He/she should also as soon as possible report this to the Administration, or Infection Control Nurse, or the Shift Coordinator Pathological examination of tissues All tissues removed from patients are to be submitted for pathological examination