MEDICAL STAFF RULES AND REGULATIONS. Sturgeon Bay, Wisconsin

Transcription

1 MEDICAL STAFF RULES AND REGULATIONS Sturgeon Bay, Wisconsin

2 Rules and Regulations Table of Contents Admission and Discharge of Patients...3 Informed Consent...4 Hand Off Communication...4 General Orders and Medication Orders...5 Patient Self Referrals...6 History and Physical Requirements...6 Consultations (Within the Hospital Setting)...6 General Rules Regarding Surgical Care...8 o Consent for Operation...8 o Requirements Prior to Induction of Anesthesia...8 o Dental Surgery...8 o Podiatric Surgery...9 Medical Screening and Transfer Certification...10 The Patient s Medical Record...10 Inpatient Admissions...12 Outpatient/Ambulatory Surgery Admission to Outpatient Medical Unit...15 Observation Beds...16 Hospice Admissions...17 Respite...18 Clinical Practice Protocols and Guidelines...19 Physician Call Responsibilities Peer Review...21 Departmentalization...21 Credentialing...21 CME Continuing Medical Education...21 Accountability...21 (Updated November 2013) Page 2 - Medical Staff Rules and Regulations

3 MINISTRY DOOR COUNTY MEDICAL CENTER STURGEON BAY, WISCONSIN RULES AND REGULATIONS MEDICAL STAFF I. ADMISSION and DISCHARGE of PATIENTS A. A patient may be admitted only by a physician with admitting privileges. 1. Active (Provisional) staff may admit an unlimited number of patients. 2. Courtesy staff may admit up to six (6) patients/year. B. A provisional diagnosis is provided by the attending physician prior to the patient's admission, except in cases of emergency, in which case the diagnosis is given as soon as possible after admission. C. Admissions to and discharges from intensive care units, and other special care areas, shall be in conformity with the specific policies developed for such units. D. The attending physician's responsibility includes: 1. Care and treatment of the patient. All inpatients will be seen on a daily basis by an appropriately credentialed physician. 2. Prompt completeness and accuracy of the Physician's portion of the patient's medical record. 3. Instructions to hospital personnel regarding the patient's care. 4. Providing reports of the condition to the patient, if appropriate to the patient's relatives and if applicable to the referring physician. E. The admitting physician is responsible for providing information necessary for the protection of other patients and the hospital staff (Example: Communicable diseases), and to provide such information as may be necessary to protect the patient from self harm, except when excluded by law. F. Each staff member provides the name(s) of the physician(s) who is (are) to be called in the attending physician's absence. The staff member or his/her designee must be accessible by telephone within fifteen (15) minutes. If no alternate physician is available in an emergency, the chairman of the relevant clinical department or his/her designee provides for the patient's care. In emergency situations this may be the Emergency Room Physician. The Physician on call will be expected to be accessible by telephone within fifteen (15) minutes and in person within one hour when deemed essential by the emergency physician. G. Physicians cooperate with the utilization review function. H. Patients are discharged only on the order of the attending Physician, unless the patient completes an "Against Medical Advice" (release from responsibility) form. Page 3 - Medical Staff Rules and Regulations

4 I. If death occurs, the deceased patient is pronounced dead by the attending physician or another member of the medical staff within a reasonable time. II. INFORMED CONSENT A. It is the physician's responsibility to inform his or her patient about procedures and treatments, including risks and benefits and alternatives. This will apply to both outpatients as well as inpatients. This will be consistent with the hospital policy on Informed Consents. III. HAND OFF COMMUNICATION A. Hand off communication including an opportunity to ask and respond to questions is completed by physicians in the following instances: when transferring complete responsibility to another physician, transferring on-call responsibilities to another physician, anesthesia provider report to PACU recovery room. This hand off communication contains any pertinent findings the physician feels is necessary for the care of the patient. B. A physician appointee to the medical staff shall be responsible for the medical care and treatment of each patient in the hospital, for the prompt completion and accuracy of the medical record, for necessary special instructions and for transmitting reports of the condition of the patient, if appropriate, to the referring practitioner. C. Whenever these responsibilities are transferred to another practitioner, the communication necessary to convey transfer of responsibility for patient care shall be executed including direct communication between practitioners so that there is the opportunity for the accepting practitioner to have questions answered regarding patient status and care. Accepting practitioners include primary care, on-call practitioners, hospitalists, specialists, emergency room providers, and others that may be involved in the patient s care. D. Direct verbal communication shall be performed for hand-off of responsibilities to another practitioner. E. Information that should be communicated through the hand-off process includes diagnoses, current condition with recent changes in condition, other services involved, guidelines implemented, treatment plan, anticipated changes in condition, and what concerns are for the next interval of care. F. At no time is it acceptable to request the Health Unit Clerk or a non physician be responsible to communicate the hand off report. The HUC may notify a physician that they have a patient in the hospital. If that physician has issue with accepting that patient they need to communicate that with the referring physician. G. Hand-off communication needs to be up-to-date and accurate to meet goals of patient safety. Page 4 - Medical Staff Rules and Regulations

5 IV. GENERAL ORDERS AND MEDICATION ORDERS A. Medications to be administered to patients shall be those listed in the hospital formulary, unless otherwise specified by the physician. B. Orders must be clearly written or entered and be specific to the medications the practitioner wishes to prescribe for the patient. Range or blanket orders, such as Resume or Continue Home Meds are not acceptable. For example, resume digoxin mg po daily is the proper way to resume an order. C. Orders which are illegible or improperly written will not be carried out by the staff until rewritten or explained. D. As needed (PRN) orders shall contain the frequency to be given and intended use. E. Hold orders shall contain parameters to not give the medication, i.e. hold metoprolol if SBP<90. If no parameters to hold are given i.e. hold metoprolol, the order will be discontinued. F. Titrating orders shall contain patient specific parameters. For example, titrate nitroglycerin drip to keep SBP<120. G. Orders for medications to be compounded or not commercially available shall contain the ingredients and their concentrations so pharmacy can compound the product. H. Herbal products are not to be ordered while patients are in the hospital. I. Discharge medications will be written on the patient s discharge medication list. Medication, dose, route and frequency shall be included, as well as any special instructions such as take with food or take on empty stomach. J. When a patient goes to surgery, previous orders are cancelled and new orders must be written immediately post-operatively. K. An order may be countersigned by another Physician/LIP if the Physician/LIP has: 1. Personal knowledge of the patient's condition, care and treatment, and 2. Privileges within the scope that the order has been written. L. All orders shall be signed, timed and dated by the ordering Physician/LIP. M. Orders may only be carried out by personnel that are duly authorized to accept and implement medical orders within his/her scope of practice. This may include a Registered Nurse, Licensed Practical Nurse, Health Unit Secretary, Radiology Technician, Laboratory Technician, Physical Therapist, Occupational Therapist, Speech Therapist, Pharmacist, Respiratory Therapist, Medical Assistants, and Dietician. With the exception of an R.N., the orders must concern their area of specialty. N. Telephone orders shall be signed, timed, and dated within 48 hours of receipt by the Page 5 - Medical Staff Rules and Regulations

6 responsible Physician/LIP or by another Physician/LIP that has knowledge of the patient s condition, care and treatment and privileges within the scope of the order. The person receiving the order will read it back to the person giving the order. O. Verbal orders are not allowed unless in an emergency situation and are defined as orders given face to face. They are appropriate if given to personnel that are duly authorized to accept and implement medical orders within his/her scope of practice. The person receiving the order will read it back to the person giving the order. Verbal orders must be signed, timed and dated within 48 hours of receipt by the responsible physician/lip or by another physician/lip that has knowledge of the patient s condition, care and treatment and privileges within the scope of the order. V. PATIENT SELF-REFERRALS A. Patient self-referrals are acceptable for: occupational therapy, physical therapy, and speechlanguage pathology services in outpatient settings in accordance with State of Wisconsin Practice Acts and regulatory and reimbursement guidelines. VI. HISTORY AND PHYSICAL REQUIREMENTS A. H&P's may only be performed by practitioners that are credentialed (privileged) at MDCMC to perform this service. B. Inpatient Admissions All patients being admitted to the hospital must have: 1. An H&P completed within 24 hours of admission, or 2. An H&P completed within 30 days prior to the admission/ procedure. If using an H&P completed within 30 days, an assessment and update of the patient s condition must be completed upon admission. C. All patients undergoing an operation or procedure under anesthesia (with the exception of local anesthetics) must have a History and Physical (H&P) documented and updated in the chart prior to the start of the operation or procedure. Local anesthetic cases must have a basic assessment completed. 1. The H&P shall be completed no more than 30 days prior to, or within 24 hours after, registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services. 2. In all cases an assessment and update of the patient s condition must be completed prior to the start of the operation or procedure. 3. In instances that the H&P is over 30 days old, the H&P is invalid and a new H&P must be provided prior to the start of the operation or procedure or the operation or procedure will be delayed or cancelled. 4. In life threatening situations, when there is no time to complete the H&P or provide an update, this requirement will be waived. VII. CONSULTATIONS (WITHIN THE HOSPITAL SETTING) Page 6 - Medical Staff Rules and Regulations

7 A. Consultation is encouraged when diagnostic studies fail to identify the nature of the patient s problem or when the results of a treatment plan deviate substantially from the range of anticipated results. Any qualified practitioner with clinical privileges in this Hospital can be called for consultation within his area of expertise. The attending practitioner or his designee must order the consultation and the reason for the consultation must be documented in the patient s medical record. B. The attending practitioner or his designee is primarily responsible for requesting consultation when indicated, except in an emergency. C. Consultation is required when requested by a mentally competent patient or by the legally responsible party for a patient who is incapacitated or not competent. D. Consultation is required for each active medical problem or procedure for which the requesting practitioner does not hold clinical privileges. E. If a nurse or other hospital health care professional believes that appropriate consultation is needed and has not been obtained, he shall follow the Medical Staff Chain of Command Policy and bring the matter in question to the attention of the attending physician. If unresolved, he shall bring the matter to the attention of his immediate supervisor, who shall then refer the question to the attending practitioner or his designee. If the matter remains unresolved, it may be referred to the appropriate Department Chair or Medical Staff President. Where circumstances are such as to justify such action, the Department Chair or Medical Staff President may then himself request the consultation. F. It is expected that requests for consultations will be by personal contact between the attending practitioner and the consultant. At the time of such contact, the purpose and urgency of the consultation is to be communicated to the consultant. In addition to personal request, the attending practitioner or his designee shall enter time-dated order for consultation and its purpose on the order section of the patient s medical record. G. Completion of a consultation shall occur appropriate to the seriousness and urgency of the problem being addressed. Consultation notes shall be dictated within 24 hours of the time the consultation has been performed. H. It is appropriate that the consultant summarize preliminary findings and recommendations in a written note on the medial record at the time the patient is seen and that they communicate directly to the referring practitioner. I. Consultation notes shall include patient identification data, requesting practitioner, date and time of the consultation, pertinent information from the history of the present illness and past medical history, a directed physical examination as appropriate, pertinent hospital study results, a statement of conclusions or impressions, and recommendations. VIII. GENERAL RULES REGARDING SURGICAL CARE Page 7 - Medical Staff Rules and Regulations

8 A. Policies regarding Surgical Care will be reviewed and recommended by the Surgery and Anesthesiology Department. B. Consent for Operation 1. Written, signed, and informed surgical consent shall be obtained prior to the operative procedure except in those situations wherein the patient's life is in jeopardy and suitable signatures cannot be obtained due to the condition of the patient. 2. In emergencies involving a minor or unconscious patient in which consent for surgery cannot be immediately obtained from parents, guardian, or next of kin, the circumstances should be fully explained on the patient's medical record. A consultation in such instances may be desirable before emergency procedure is undertaken, if time permits. 3. Signed, informed consent must be obtained before any procedure is performed which may render a patient sterile. Should more than one operation be required during the patient's stay in the hospital, each additional operative procedure requires a specific consent before it is undertaken. 4. If two or more specific procedures are to be carried out at the same time and this is known in advance, they may all be described and consented to on the same form. C. History and Physical Requirements See Section VI D. Requirements Prior to Induction of Anesthesia 1. Proper identification of the patient shall be made prior to induction of anesthesia. 2. Except in severe emergencies, the pre-operative diagnosis, the history and physical examination (at least in dictated form), and the required laboratory tests must be recorded on the patient's medical record prior to any surgical procedure. Laboratory workups must have been performed within a reasonable amount of time prior to surgery. In an emergency, the physician shall make at least a note including a tentative diagnosis and pertinent findings on the progress sheet prior to induction of anesthesia and start of surgery. E. The anesthetist or anesthesiologist shall maintain a complete anesthesia record to include evidence of preanesthetic evaluation, choice of anesthesia (general, regional, spinal, or local), and post- anesthetic followup of the patient's condition. F. Dental Surgery A patient admitted as an inpatient for dental surgery is a dual responsibility involving the dentist and physician member of the medical staff. 1. Dentist's Responsibility Page 8 - Medical Staff Rules and Regulations

9 a. A detailed dental history justifying hospital admission. b. A detailed description of the examination of the oral cavity and preoperative diagnosis. c. A complete operative report describing the findings and technique. In cases of extraction of teeth, the dentist shall clearly state the number of teeth and fragments removed. Tissues removed will conform to the Surgery Department policies and procedures regarding pathology specimens. d. Progress notes as are pertinent to oral condition. e. Clinical resume (or summary statement). 2. Physician's Responsibility a. Medical history pertinent to the patient's general health. b. A physical examination to determine the patient's condition prior to anesthesia and surgery. c. Supervision of the patient's general health status while hospitalized. 3. The discharge of the patient shall be on written order of the dentist member of the medical staff. If the patient has a medical problem, the dentist should discharge the patient to the care of the attending physician. 4. Postoperative orders are the joint responsibility of the attending physician and the dentist. G. Podiatric Surgery The patient admitted as an inpatient for podiatric surgery is a dual responsibility involving the podiatrist and physician member of the medical staff. 1. Podiatrist's Responsibility a. A detailed podiatric history justifying hospital admission. b. A detailed description of the examination of the foot and preoperative diagnosis. c. A complete operative report describing the findings and technique. Tissues removed will conform to the Surgery Department policies and procedures regarding pathology specimens. d. Progress notes as are pertinent to the postoperative condition. e. Clinical resume (or summary statement). 2. Physician's Responsibility a. Medical history pertinent to the patient's general health. b. A physical examination to determine the patient's condition prior to anesthesia and surgery. c. Supervision of the patient's general health status while hospitalized. d. The discharge of the patient shall be on written order of the podiatrist member of the medical staff. If the patient has a medical problem, the podiatrist should discharge the patient to the care of the attending physician. Page 9 - Medical Staff Rules and Regulations

10 3. Postoperative orders are the joint responsibility of the attending physician and the podiatrist. IX. MEDICAL SCREENING AND TRANSFER CERTIFICATION A. Medical Screening All patients requesting medical care (or those who have care requested upon their behalf) shall receive an appropriate medical screening by a qualified medical provider (MD, DO, NP, PA, or RN) to determine whether an emergency medical condition exists. B. Transfer Certification The physician is responsible to complete and sign a certification that, based upon the information available at the time of the transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the individual or, in the case of a woman or unborn child, from being transferred. The certification must include a summary of the risks and benefits upon which the transfer is based. All transfers will be in accordance to the organizational Transfer Policy. X. THE PATIENT'S MEDICAL RECORD A. The physician's portion of the patient's medical record, like the patient, is the responsibility of the attending physician. The record must include the following components: Provisional Diagnosis Diagnostic and Therapeutic Orders History and Physical Examination Statement of the course of action planned for the patient Progress notes Consultation; if appropriate Operative report and/or procedure and code note; if appropriate Discharge Summary Final documentation on the face sheet Documentation of decision to not proceed with ordinary measures considered the usual standard of care B. Written consent of the patient is required for release of medical information to persons not otherwise authorized to receive this information. C. Records may be removed from the hospital only in accordance with a court order, subpoena, or statute. Unauthorized removal of patient records from the hospital by a physician is grounds for suspension of the physician for a period to be determined by the Medical Executive Committee. D. Professionals whose entries in the medical record that do not have to be cosigned by the provider are as follows: registered nurse, licensed practical nurse, dietician, physical therapist, occupational therapist, speech therapist, respiratory therapist, pharmacist, social worker, dentist, or another licensed physician. Entries made on the record by medical students or physician assistant students shall be co-signed by their supervising physician. Page 10 - Medical Staff Rules and Regulations

11 E. Co-signatures are required by the Supervising Physician for Physician Assistants for the following items: History and Physical for hospital admission or surgical intervention, Consults, and Discharge Summaries. No rubber stamp signatures will be allowed. F. Symbols and abbreviations may be used in the patient's record only when they have been approved by the medical staff. An official record of approved abbreviations will be kept on file in the Health Information Management Department and the patient care areas. Page 11 - Medical Staff Rules and Regulations

12 PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES - INPATIENT ADMISSIONS Approved MEC 01/17/06; MEC 11/7/95; Revised/Approved MEC 4/00; MEC Revised/Approved 10/2012 Document Responsible Provider Completion Time Components of Document Required History & Physical Admitting Physician Within 24 Hours of admission or if the H&P was completed within 30 days prior to admission/procedure, then an assessment and update of the patient s condition must be completed upon admission Prenatal History and Physical Admitting Physician An up-to-date prenatal history and physical may serve as the H&P required within 24 hours of admission, providing an interval progress note indicating any changes has been documented on the record upon admission. In the event the patient requires a cesarean section, a history and physical is required. Operative Report Surgeon Immediately Following Surgery Initial Assessment/screening of physical, psychological, and social status to determine the need for care or treatment, the type of care or treatment to be provided, and the need for further assessment. MDCMC Components should include: chief complaint; history of present and past illness; family history; social history; systems review; metabolic status; habits; allergies; current medications and physical exam. Initial Assessment/screening of physical, psychological, and social status to determine the need for care or treatment, the type of care or treatment to be provided, and the need for further assessment. MDCMC Components should include: chief complaint; history of present and past illness; family history; social history; systems review; metabolic status; habits; allergies; current medications and physical exam. Description of the findings, the technical procedures used, the specimen removed, the postoperative diagnosis, and the name of the primary surgeon and any assistants participating in the surgery. Post Anesthesia Evaluation Anesthesiologist or Certified Registered Nurse Anesthetist Within 48 Hours The elements of an adequate post-anesthesia evaluation should be clearly documented and conform to current standards of anesthesia care, including: Respiratory function, including respiratory rate, airway patency, and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration. Consultation Consulting Physician Within 24 Hours Findings of consultation. Verbal Orders Ordering Physician Within 48 Hours Discharge Diagnoses Attending Physician On Discharge Complete listing of all final diagnoses including complications and comorbidities. Discharge Summary Attending Physician Within 15 Days of Discharge Summarization of the reason for hospitalization, the significant findings, the procedures performed and treatment rendered, the patient's condition on discharge, and any specific instructions given to the patient and/or family, as pertinent (information on DISCHARGE ORDER pertinent). Admitting Physician: Attending Physician: The physician who either makes the decision to admit the patient or accept the patient to his/her service. The physician who provides and maintains primary responsibility for the patient's care during the inpatient admission; this may be the admitting physician and/or the surgeon. *This physician will be responsible for the majority of physician orders/progress notes in the record. *This physician is not necessarily the discharging physician. Page 12 - Medical Staff Rules and Regulations

13 PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES OUTPATIENT/AMBULATORY SURGERY Approved: MEC 06/2011/ BOD 07/2011 TYPE OF ANESTHESIA Local or Topical Anesthesia, or No Anesthesia Moderate Sedation Not required. History and Physical Examination History minimal documentation must include: *Indications/symptoms for procedure; *current medications and dosages; *any known allergies; and, *existing comorbid conditions, if any. Requirements Pre procedure Note Minimum documentation must include: *Indications/symptoms for procedure; *current medications and dosages; *any known allergies; *an assessment of mental status and *Site- specific exam. Additional documentation is at the discretion of the surgeon/provider as appropriate to the patient s medical condition. This may be accomplished via office note, progress note of short form H&P. A note on the day of surgery which evaluates the patient s current status for surgery. *The note can be written by a physician, operating practitioner or individual qualified to administer anesthesia. Physical Examination minimal documentation must include: *Mental status assessment; *ASA class; *Airway assessment; *examination specific to the proposed procedure and any comorbid conditions; and, *examination of the heart and lungs by auscultation. *A note is not required when the history and physical is performed (documented) on the day of surgery. General, MAC, Spinal or Epidural Anesthesia Regional Block History minimal documentation must include: *Indications/symptoms for procedure; *history of present/past illness *family history, social history *current medications and dosages; *any known allergies; and, *existing comorbid conditions, if any. Physical examination minimal documentation must include: *Mental status assessment; *exam specific to the proposed procedure and any comorbid conditions; *examination of the heart and lungs and, *assessment and written statement about the patient s general condition. A note on the day of surgery which evaluates the patient s current status for surgery. *The note can be written by a physician, operating practitioner or individual qualified to administer anesthesia. *A note is not required when the history and physical is performed (documented) on the day of surgery. In emergency situations where there is inadequate time to record the required level of H&P exam and documentation, a brief note including the pre-procedural diagnosis, indications and plan will be recorded prior to such procedure followed by the full documentation as soon as the provider is able following the procedure. When the above documentation requirements are not on the chart before the procedure, it shall be cancelled unless the practitioner states in writing that such delay would be detrimental to the well-being of the patient. Page 13 - Medical Staff Rules and Regulations

14 PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES OUTPATIENT/AMBULATORY SURGERY Revised/Approved MEC 10/2012 Document/Item Responsible Provider Completion Time Components Required Admission Order Progress Notes Anesthesia Record Operative Report Admitting/Attending Physician On Admission Timed/dated order for admission of the patient for Ambulatory/ Outpatient Surgery. Attending Physician/Surgeon As needed. Written at the discretion of the physician to reflect changes in the patient status. Anesthesiologist or Certified Registered Nurse Anesthetist Surgeon At time of procedure by CRNA or Anesthesiologist. Anesthesiologist must provide review within thirty days on those cases where he/she is not providing care. Immediately Following Surgery Post Procedure Note Surgeon A post-procedure note must be on the chart prior to the patient leaving the PACU (unless the OP report is on the record.) Post Anesthesia Evaluation Discharge Documentation (see form) Anesthesiologist or Certified Registered Nurse Anesthetist Within 48 Hours Documentation that the anesthesiologist has reviewed and approved (signed-off) on every case involving anesthesia. Description of the findings, the technical procedures used, the specimens removed, the postoperative/procedure diagnosis, estimated blood loss, and the name of the primary surgeon and any assistants participating in the surgery. Documentation must include: Pre-Diagnosis Post Operative Diagnosis Procedure and Assistants Specimens removed Intra-Operative Complications Estimated Blood Loss Condition of Patient The elements of an adequate post-anesthesia evaluation should be clearly documented and conform to current standards of anesthesia care, including: Respiratory function, including respiratory rate, airway patency, and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration. Attending/Discharging Physician On Discharge See form which addresses: diet, pain, activity, special considerations, follow-up appointment with surgeon, problems, etc. Discharge Diagnoses/Procedures Performed Attending/Discharging Physician On Discharge Complete listing of pertinent diagnoses and procedures performed. Page 14 - Medical Staff Rules and Regulations

15 PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES ADMISSION TO OUTPATIENT MEDICAL UNIT Approved MEC 06/15/04; 11/17/09 Revised MEC 08/17/04, 11/17/09 Document/Item Responsible Provider Completion Time Components Required Physician Orders (Notify the Outpatient Medical Unit to schedule outpatient medical procedures and treatments.) Admitting/Attending Physician Optimally 24 hour or more advance notice. Hand Off Communication Documented Note Nurse (from Ordering Physician) to OPMU Nurse Admitting/Attending Physician Upon Order Must accompany the physician order. Note must include (at a minimum) the diagnosis and current condition of the patient and the plan. The documented note may be the clinic note, current H&P, or Discharge Summary Page 15 - Medical Staff Rules and Regulations

16 PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES - OBSERVATION BEDS Approved at MR/UR Meeting - 08/16/95 MEC - 11/7/95 Document/Item Responsible Provider Completion Time Components of Document Required Admission Order Admitting Physician On Admission Timed/dated order for admission of the patient to an Outpatient Observation Bed. Initial Assessment/ History & Physical Admitting Physician Immediately/Within 24 Hours of Admission Initial Assessment/screening of physical, psychological, and social status to determine the reason why the patient is being admitted to an Observation Bed, the type of care or treatment to be provided, and the need for further assessment. MDCMC Components should include: chief complaint; history and time of onset illness; pertinent past history, family history; social history; systems review; metabolic status; habits; allergies; current medications and physical findings. An extensive ER note or progress note documented by the admitting physician which encompasses the criteria defined above will suffice as an initial assessment/h&p. This document may be written in the Progress Notes or dictated. Progress Notes Attending Physician Within 8 Hours - With Subsequent Notes Documented as the Patient s Condition Warrants. 24 Hour Re- Assessments Should be Documented Progress notes should reflect the status of the patient s condition, the course of treatment, the patient s response to treatment and any other significant findings apparent at the time the progress note is documented. Reassessments should include plan for 1) discharge or transfer; 2) conversion to IP or 3) continued OBS with evaluation and rationale. Verbal Orders Ordering Physician/ Physician Involved With Patient s Care May Co-Sign Within 48 Hours Verbal orders are tagged at the Nurses Station and should be completed as soon as possible after the order is transcribed. Discharge Order Discharging Physician On Discharge Timed/dated order for discharge from the Outpatient Observation Bed status. Discharge Diagnoses Discharging Physician On Discharge Complete listing of all final diagnoses including complications and comorbidities. Discharge Note Attending Physician On Discharge Preferably or Within 15 Days of Discharge Summarization of the reason for the Observation Bed admission, the outcome, follow-up plans and patient disposition, and discharge instructions (diet, activity, medications, special instructions). Admitting Physician: Attending Physician: This document may be written in the Progress Notes or dictated. The physician who either makes the decision to admit the patient or accept the patient to his/her service. The physician who provides and maintains primary responsibility for the patient's care during the inpatient admission; this may be the admitting physician. Page 16 - Medical Staff Rules and Regulations

17 PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES - HOSPICE ADMISSIONS Document Responsible Provider Completion Time Components of Document Required History & Physical Admitting Physician Within 24 Hours of Admission of Inpatient* Admission or Direct Hospice Admission *If the patient is transferred in to Hospice from an inpatient admission, the initial H&P will serve as the Hospice admission H&P. Operative Report Surgeon Immediately Following Surgery Initial Assessment/screening of physical, psychological, and social status to determine the need for care or treatment, the type of care or treatment to be provided, and the need for further assessment. MDCMC Components should include: chief complaint; history of present and past illness; family history; social history; systems review; metabolic status; habits; allergies; current medications. Description of the findings, the technical procedures used, the specimen removed, the postoperative diagnosis, and the name of the primary surgeon and any assistants participating in the surgery. Consultation Consulting Physician Within 24 Hours Findings of consultation. Verbal Orders Ordering Physician Within 48 Hours Discharge Diagnoses Attending Physician On Discharge Complete listing of all final diagnoses including complications and comorbidities. Discharge Note/ Summary Attending Physician Within 15 Days of Discharge Summarization of the reason for hospice, the significant findings, the procedures performed and treatment rendered, the patient's condition on discharge, and any specific instructions given to the patient and/or family, as pertinent (information on DISCHARGE ORDER pertinent). This information can be covered in one document for both and inpatient and hospice discharge. Attestation Statement Attending Physician Upon Completion of Coding Miscellaneous Notes Diagnostic Studies: Hospice Forms: Release of Information: Approved: MEC 2/11/97 Hospital Board 3/19/97 Diagnostic studies from inpatient and/or swing bed admissions may be copied and placed in the active hospice admission. These copies may be destroyed on discharge as the original documents will exist in the previous admissions. Forms originated by the Hospice Program shall be integrated into the same sections as the MDCMC forms within the medical record. Through the contractual agreement between MDCMC and Hospice, a formal ROI or Authorization for Release is not required when asked to provide copies of MDCMC Hospice patient records to Hospice staff members. Page 17 - Medical Staff Rules and Regulations

18 PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES - RESPITE ADMISSIONS Respite Admission: An admission facilitated by the hospice agency to allow a break for the patient s caregivers (up to five days). The patient does not require medical treatment, but does require some supervision which may temporarily not be available within the home (per Unity Hospice 12/15/97). Document Responsible Provider Completion Time Components of Document Required History & Physical N/A N/A Not required for Respite Care Patient. Progress Note Attending Physician During Admission Brief note/synopsis of reason for admission, diagnosis or symptoms indicating need for admission, progress of case, physical findings, change in diagnosis, condition on discharge, instructions to patient, etc. Daily Progress Notes Attending Physician At time of Encounter Daily visits by the physician are not required; however, if they do occur, a note should be documented in the record. Standing Orders Attending Physician Within 24 Hours of Admission Pre-printed Unity Hospice Standing Orders/Protocol - Requires Physician Signature. Verbal Orders Ordering Physician Within 48 Hours Only if applicable. Discharge Diagnoses Attending Physician On Discharge May be indicated in progress note (reason for admission). (No discharge summary is required for this type of admission.) Discharge Instructions Attending Physician On Discharge Not required; may be documented by physician. Miscellaneous Notes Unity Hospice has a standing order/protocol for hospice/respite patients. Documentation requirements for respite patients are minimal and basically at the discretion of the attending physician. It is desirable to obtain at least one progress note for the admission to respite. Diagnostic Studies: Hospice Forms: Release of Information: Diagnostic studies from inpatient and/or swing bed admissions may be copied and placed in the active hospice admission. These copies may be destroyed on discharge as the original documents will exist in the previous admissions. Forms originated by the Unity Hospice Program shall be integrated into the same sections as the MDCMC forms within the medical record. Through the contractual agreement between MDCMC and Unity Hospice, a formal ROI or Authorization for Release is not required when asked to provide copies of MDCMC Hospice patient records to Unity Hospice staff members. Page 18 - Medical Staff Rules and Regulations

19 XI. CLINICAL PRACTICE PROTOCOLS AND GUIDELINES A. As a condition of consideration for continued appointment, every credentialed provider agrees to the following: To comply with clinical practice protocols and guidelines that are established by, and must be reported to, regulatory or accrediting agencies or patient safety organizations, including those related to national patient safety initiatives and core measures, or to clearly document the clinical reasons for variance. To also comply with clinical practice protocols and guidelines pertinent to his or her medical specialty, as may be adopted by the Medical Staff or the Medical Staff leadership, or clearly document the clinical reasons for variance. XII. PHYSICIAN CALL RESPONSIBILITIES A. It is the policy of Door County Medical Center (MDCMC) to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA requires that any patient who presents on the Hospital premises in need of emergent care or at the Emergency Department must receive an appropriate medical screening examination by a physician or allied health professional as designated by the MEC to determine if that patient has an emergency medical condition. If so, the patient s condition must be stabilized prior to discharge/transfer. B. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or with respect to a pregnant woman or her unborn child) in serious jeopardy; serious impairment or dysfunction of any bodily organ or part; or with respect to a pregnant women who is having contractions. C. The purpose of this policy is to ensure compliance with EMTALA by explaining the obligations of oncall physicians under the law and under the regulations of the DCMH MEC. Both the Hospital and oncall physicians have obligations under EMTALA, violations of which can give rise to patient claims for any resulting injuries as well as the possibility of significant expenses, fines or other financial penalties. D. All physicians on the Active medical staff shall participate in call sharing arrangements with others in their specialty. Exceptions may be allowed by the MEC at his or her request, on the basis of age, health status, or for other reasons. The MEC shall consider the request following the receipt of a recommendation of a simple majority of the members of the respective department of the requesting physician. E. Physicians requesting call schedule changes are responsible to arrange alternate EMTALA compliant call coverage and must notify the appropriate Hospital personnel of any changes, (i.e., acceptance of the change by another physician having clinical privileges consistent with those of the assigned physician). F. The on-call physician must come to the Hospital ED when requested by the ED physician, another physician, or any Hospital employee making the request on behalf of a physician who is not available to Page 19 - Medical Staff Rules and Regulations

20 call the on-call physician directly. Seeing the patient in the on-call physician s office or clinic is not an option until the patient is determined to be stable and thus able to be discharged, or not to have an emergency medical condition, as those terms are defined under EMTALA. G. If the on-call physician disagrees about the need to come to the Hospital ED, the on-call physician must come to the Hospital and render care irrespective of the disagreement. The on-call physician may address the disagreement with the appropriate individual at the Hospital at a later time. H. In the event an on-call physician fails to respond in a reasonable time period (as determined by the ER physician) and the patient must subsequently be transferred to another facility, unless not available, the on-call physicians name, specialty, and address are to be included with the records accompanying the patient. I. If requested, the on-call physician shall be physically present in the Hospital ED to assist in providing an appropriate medical screening examination, as well as in the ongoing stabilization and treatment of an ED patient prior to transfer or treatment. The on-call physician shall remain in the ED until released by the ED physician. J. Neither the Hospital, the ED physician nor the on-call physician shall consider the patient s financial circumstances, the patient s insurance or means of payment in the decision to respond to, treat, or transfer the patient. K. For conditions requiring admission to the Hospital, the on-call physician has one hour to provide verbal orders or to present to the ED in order to evaluate the patient and write admission orders. Time response requirements commence when the first page or call is made to, and connects with the on-call physician. L. Except under unusual circumstances, the on-call physician must be physically present in the Hospital ED within 30 minutes of being requested for assistance or emergency stabilization of the patient.. Response time requirements commence when the ED physician, nurse, or other Hospital worker makes the first attempted (page or call) to, and connects with the on-call physician. M. The on-call physician is not required to interrupt critical care that is, care that requires his or her personal management which he or she is providing to a specific patient when contacted for on-call services. Immediately after the physician finishes caring for the specific patient, he or she will contact the requesting unit, respond if requested, and give an estimated time of arrival if determined to be needed by the ED physician. N. Unless other arrangements are made, the on-call physician shall provide timely follow-up patient care throughout the episode of injury or illness. The on-call physician may not condition the first follow-up office visit on advance payment or otherwise condition continued care upon the patient s ability to pay. O. Any violation of this policy by an on-call physician will be reported by any person with direct knowledge of the facts to the Medical Staff President and/or Department Chairman of the physician involved. The Medical Staff President or Department Chair will notify the President/CEO or designee covering Administrative call. Except in the case of a flagrant violation, for the first incident, the on-call physician may receive counseling, a rebuke, and an official warning. A copy of the warning will be placed in the physicians Quality file. Page 20 - Medical Staff Rules and Regulations

21 P. If the on-call physician commits a flagrant or second violation, he or she will be reported to the Department Chair, who will request corrective action which may result in a suspension of privileges or termination of medical staff membership. The Department Chair shall also provide a written report to the MEC. Q. The MEC may then take action as indicated by the Medical Staff Bylaws. In determining whether a violation is flagrant, the Department Chair or MEC shall consider the total circumstances, including, but not limited to, whether the violation was deliberate, the seriousness of the patient s condition and outcome, and how disruptive the violation was to Hospital operations. XIII. PEER REVIEW A. Information regarding the peer review process may be accessed in the Medical Staff Bylaws and the Peer Review Policy. XIV. DEPARTMENTALIZATION A. Information regarding Departmentalization may be referenced in the Medical Staff Bylaws. XV. CREDENTIALING A. Information regarding Credentialing may be referenced in the Medical Staff Bylaws. XVI. CME CONTINUING MEDICAL EDUCTION A. Medical Staff members will obtain Continuing Medical Education credits as State Code requires. Such CME must relate, at least in part, to the privileges granted. XVII. ACCOUNTABILITY A. In the event a physician/provider fails to comply with established elements set forth in the Medical Staff Rules & Regulations or Policies and Procedures, the following actions will occur: 1 st Occurrence Department Chair will speak with physician/provider. 2 nd Occurrence Discussion and Letter from Medical Staff President. 3 rd Occurrence Physician/Provider required to attend Medical Executive Committee meeting for review of occurrence. 4 th Occurrence Reported to the Chief Executive Officer, action to be determined per contract, medical staff bylaws etc. B. Events will be reported through Incident Comp Web (located on the Ministry Door County Medical Center Intranet site) and routed to the Medical Staff Department Chair by the Chief Quality Officer. C. Each occurrence will be documented by the Department Chair or Medical Staff President and placed in their Medical Staff Quality File and Human Resources File (as applicable.) Page 21 - Medical Staff Rules and Regulations

22 Ministry Door County Medical Center Medical Staff Rules and Regulations Adoption and Approval Initially Adopted by the Medical Staff of Door County Memorial Hospital on July 11, 1986 and Approved by the Board of Directors August 20, The Rules and Regulations were amended upon adoption of the Medical Executive Committee, on behalf of the Medical Staff of Door County Memorial Hospital, and approval of the Door County Memorial Hospital Board on Directors on the following dates: March 1987 May 1987 July 1987 September 1993 September 1994 November 1994 January 1996 December 1998 September 1999 April 2000 October 2002 December 2002 June 2004 November 2004 June 2005 February 2006 April 2006 February 2007 May 2007 September 2007 March 2008 May 2009 September 2009 November 2009 July 2011 May 2012 November 2012 May 2013 September 2013 November 2013 Adopted by the Medical Executive Committee on behalf of the Medical Staff of Door County Memorial Hospital, Sturgeon Bay, Wisconsin on September 15, Medical Staff President - Signature on File Approved by the Door County Memorial Hospital Board of Directors on September 23, Hospital President/CEO - Signature on File Board of Directors Chairman - Signature on File Page 22 - Medical Staff Rules and Regulations