Canyon Vista Medical Center

Transcription

1 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 in the Medical Staff Bylaws shall have the same meanings herein. 2. These Rules and Regulations may be adopted, amended, revised, modified, restated and repealed in the manner set forth in the Bylaws. GENERAL 3. Each member of the Medical Staff who is not a resident of the city or immediate vicinity shall identify in each case, a member of the Active Medical Staff who is a resident of the city or immediate vicinity, who agrees to assume interim responsibility for the care of the patient; this physician shall be designated on the patient s chart. In case of failure to name such a practitioner, the Administrator shall have authority to call any member of the Staff, should it become necessary. 4. The Infection Control Committee, through its Chairman, may have the authority to institute appropriate studies of any infections in the Hospital which are believed to be potentially harmful to patients or personnel and to make recommendations to the regarding the development of control or preventive measures. In an emergent situation, when immediate action is believed to be necessary because of potential harm to patients or personnel, the Chairman or his designee shall consult with the Chief of Staff or CEO and may take appropriate action. 5. Medical Staff members should be familiar with their role in the Canyon Vista Medical Center Emergency Operations Plan and it shall be their responsibility to report to their assigned stations in matters giving rise to implementation of the Emergency Plan. Patient care and safety shall be the joint responsibility of the Chief of Staff and CEO. In their absence, the Vice-Chief of Staff and CMO are next in line of authority. 6. All members of the Medical Staff are expected to be involved with the Hospital's Approved by the January 23, 2008

2 Department: MEDICAL STAFF Page 2 of 14 Peer Review process. Please refer to MS002: Focus/Ongoing Professional Practice Evaluation and MS 145: Steps for Outside Evaluation as part of Peer Review Policies. 7. Medical Staff dues shall be assessed in an amount determined by the Medical Executive Committee. If Medical Staff dues are not paid within sixty (60) days (September 1) of the new Staff year, a fine of $100 will be added to the amount owed. If the dues and fine remain unpaid for an additional thirty (30) days (October 1), the Medical Staff privileges of the practitioner shall be automatically suspended until payment of the entire amount is made. Such action shall not be considered "adverse" and shall thereby not afford the practitioner procedural rights as defined in Article VIII Corrective Action of the Medical Staff Bylaws and the Hearing and Appellate Review Procedure. 8. The dental members of the Medical Staff shall conform to the Rules and Regulations of the Medical Staff with the following additions: 8.1. Complete records, both dental and medical, shall be required on each patient and shall become part of the hospital record The dentist shall be responsible for the written report of operation and any post-surgery recommendations relating to the dental health of the patient. Orders may be written by the dentist relative to dentistry only Oral surgeons who are properly credentialed do not need practitioner consultation. 9. All Medical Staff will comply with the Medical Staff Health Policy and Procedures regarding IC120: Reportable Diseases. Medical Staff will be managed for TB Screening, per MS111: Tuberculosis Control Program control policies and procedures. ADMISSIONS, TRANSFERS, DISCHARGES, OUTPATIENT ORDERS 10. Admissions A patient may be admitted to the Hospital only by an Active Medical Staff member, or a Courtesy Staff member specifically granted admitting privileges. Approved by the January 23, 2008

3 Department: MEDICAL STAFF Page 3 of Patients may be admitted and discharged only on order of the attending practitioner or his or her physician designee. The Hospital will not be required to accept cases for which facilities for proper care are not available. Patients should not be admitted as a matter of convenience while only undergoing tests or therapy that could be obtained on an outpatient basis. Patients with a primary diagnosis that is psychiatric or chemical dependency will be screened for admission to the behavioral unit Except in case of emergency admissions, no patients shall be admitted to the Hospital until a provisional diagnosis or valid reason for admission is provided by the physician requesting admission. In the case of an emergency, the statement shall be recorded as soon as possible. A copy of the emergency service record shall accompany the patient to the nursing unit The attending physician makes arrangements for the patient's hospitalization and is responsible for the patient until the patient is discharged, or until such time as the attending physician transfers the care of the patient, through a written order on the chart, to another physician who has agreed to assume responsibility for the care of the patient The admitting physician is responsible for providing the following information concerning a patient to be admitted: any source of communicable or significant infection; known behavioral characteristics that may disturb or endanger others; and the need for protecting the patient from self harm The attending physician must see the patient within the time frames provided below: The admitting practitioner shall see all stable patients he has admitted (including newborns) within twenty-four (24) For ICU patients: Unstable patients shall be seen immediately. Stable patients will be seen within six (6) hours Hospital response time by phone or in person for those on call: Thirty (30) minutes Practitioners shall abide by the Hospital's utilization review plan, including the appropriateness and medical necessity of admissions, continued stay, supportive services, and discharge planning. 11. Transfers In general, consideration for transfer or bed assignment will be considered in Approved by the January 23, 2008

4 Department: MEDICAL STAFF Page 4 of 14 the following priority: (1) Patients requiring intensive or cardiac care; (2) patients requiring protective care (isolation); (3) Patients in the Emergency Department awaiting accommodation; (4) Patients in-house in medical beds who are scheduled for surgery; (5) new admissions A patient shall be transferred to another medical care facility only upon the order of the attending physician and only after arrangements have been made for admission with the other facility, including the receiving facility's consent to receive the patient, and only after the patient is considered sufficiently stabilized for transport. All pertinent medical information necessary to insure continuity of care shall accompany the patient upon transfer, including documentation of accepting physician Transfers either to or from CVMC shall be made in accordance with the Hospital ADM107: Provision of Emergency Services; COBRA Policy, in accordance with Federal law. 12. Discharges, AMA, Deaths: A patient shall be discharged only on the order of the attending physician or his designee. Patients refusing treatment or hospitalization may be discharged against medical advice (AMA). The Hospital shall attempt to secure the patient's signature on a release relieving the Hospital and the attending physician of any further responsibility for the patient's medical condition Any patient who cannot legally consent to his own care shall be discharged only to the custody of parents, legal guardian or other responsible party unless otherwise directed by the parent or guardian or court of competent jurisdiction. If the parent or guardian directs that the discharge should be made otherwise, the parent or guardian shall so state in writing and the statement shall be witnessed and shall be made part of the patient's medical record In the event of a Hospital patient's death, the deceased will be pronounced dead by the attending physician or his designee within a reasonable time. The attending physician will complete and sign the death certificate. Release of the body shall conform to the statutes of the State of Arizona and the policies of the Hospital. The statutes of the State of Arizona shall apply in the retention or transfer of anatomical organs Every member of the Medical Staff shall be actively interested in securing Approved by the January 23, 2008

5 Department: MEDICAL STAFF Page 5 of 14 meaningful autopsies whenever a death occurs, including all unusual deaths and cases of medico-legal and educational interest. Such cases will be reviewed by a pathologist if an autopsy is not ordered. The autopsy shall be performed by a pathologist. The provisional anatomic diagnosis must be provided in three (3) days, and the complete record in sixty (60) days. No autopsy shall be performed without the attending physician's order and written consent of the deceased's nearest relative or legal representative. Please refer to the MS104: Autopsy Indications/Requests for full procedure. 13. Outpatient Orders Physicians who are not members of the Medical Staff may order hospital outpatient services as follows: The non-medical staff physician has demonstrated that he or she holds a current Arizona Medical or Osteopathic license in good standing; or the physician is Active Military; and The order is for medical imaging services, respiratory therapy services, laboratory, rehab therapy, nutritional services and cardiopulmonary If a medical staff member provides outpatient services ordered by a nonmedical staff member, that medical staff member shall assume direct responsibility for the patient while the patient is receiving such outpatient services If a non-physician practitioner provides outpatient services ordered by a nonmedical staff member, the Medical Director of the clinical department in which the services are provided shall supervise or oversee the practitioner, as appropriate based on the practitioner s privileges. EMERGENCY SERVICES 14. Members of the Medical Staff shall accept responsibility for emergency care in accordance with Medical staff and emergency department policies and procedures. Rosters designating Medical Staff members on call for primary coverage or specialty consultation shall be posted in the emergency care area. 15. When a patient presents to the Emergency Department (ED) for care and specifies a specific private attending physician, that physician shall be informed as to the Approved by the January 23, 2008

6 Department: MEDICAL STAFF Page 6 of 14 treatment of the patient. The private attending physician may request a specialist or staff physician of his choice on-call to consult. If there is a conflict with the patient regarding the on-call physician, the ED physician will discuss this issue with the oncall physician, and the issue will be resolved between them. The on-call physician is responsible for the care of the patient until a referral physician has agreed to accept and continue the care of the patient. 16. The admitting physician is responsible for seeing the patient in a timely manner and caring for the patient in the Hospital. This responsibility includes writing admission orders for the patient. The admitting physician may choose to allow the ED physician to write admission orders on behalf of the admitting physician, but the admitting physician remains responsible for the content of those orders and the care of the patient. 17. Each patient's emergency medical record shall be signed by the ED physician who shall be responsible for its clinical accuracy. GENERAL CARE OF PATIENTS 18. A physician member of the Staff shall be responsible for the medical care of each patient in the Hospital. The attending practitioner will be responsible for treatment and 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 any referring practitioner. Whenever these responsibilities are transferred to another practitioner, a note covering the transfer of responsibility shall be entered on the order sheet of the medical record. The practitioner transferring his responsibility shall personally notify the other practitioner to ensure the acceptance of that responsibility is clearly understood. 19. Each member of the Medical Staff who is not available for the care of his admitted patient shall name a member of the Medical Staff with appropriate privileges who is available and who will accept responsibility for continuing care of the Staff member's patient in the Hospital, including discharge or transfer when medically indicated. In case of a failure to name such a Staff member, the Chief of Staff or the Administrator shall have the authority to call any member of the Staff to provide necessary care. Approved by the January 23, 2008

7 Department: MEDICAL STAFF Page 7 of Please refer to these specific policies for other aspects of patient care: PCS139: Restraints and Sedation Policy ; PCS185: Advance Directives, DNR; Withholding/Withdrawal of Life-Sustaining Treatment ADM162: Domestic Violence ADM123: Elder/Vulnerable Adult Policy ADM160: Child Abuse Policy/Neglect, Actual or Suspected MEDICAL RECORDS 21. General The medical record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the hospital course, results, and promote continuity of care among providers. Entries in the medical record must be legible (please refer to the MS003: Physician Illegible handwriting Policy.) The medical record is the property of the Hospital and is maintained for the benefit of the patient, the physician, and the Hospital. No record shall be removed from the premises without court order, subpoena, or to meet other statutory requirements. The Hospital shall safeguard the information contained in the records against loss, effacement, tampering, alteration, or use by unauthorized persons All original x-ray films, imaging studies, pathology slides, and tissue blocks are the property of the Hospital and shall not be removed unless authorized Free access to medical records of all patients shall be accorded to duly constituted committees of the Medical Staff for the purpose of medical care evaluation and review of utilization consistent with preserving the confidentiality of personal information concerning the individual patients. Subject to the discretion of the Administrator, former members of the Medical Staff shall be permitted free access to information from the medical records of their patients covering all periods during which they attended such patients in the Hospital All clinical entries and summaries of the patient's medical record shall be accurately dated, timed, and signed. The date and time shall be the date and Approved by the January 23, 2008

8 Department: MEDICAL STAFF Page 8 of 14 time the entry is made, regardless of whether it relates to a previous date or time Only symbols and abbreviations approved by the Medical Executive Committee may be used in medical records. There shall be one meaning for each symbol and each abbreviation Stamped signatures are not acceptable on any medical record In the event it is necessary to correct an entry in a medical record, the person shall line out the incorrect data with a single line in ink, leaving the original writing legible, and initial the cross-out. Appropriate cross-referencing shall be placed in the record when necessary to explain the correction. The correction shall never involve erasure or obliteration of the material that is corrected. In addition, all blanks left in dictated reports must be filled in by the dictating physician at the time the report is authenticated. Any cross-outs with or without re-entries in the report should be noted as "error", dated and initialed. No changes may be made in the completed medical record after it has been subpoenaed or released to an attorney; the physician will be notified of the subpoena of his or her medical record Medical records shall be purged and/or discarded only in accordance with HIM251: Destruction and Storage of Medical Records policy as approved by the Board, in accordance with State law. 22. Documentation The attending physician shall be held responsible for the preparation of a complete and legible medical record for each patient. This record shall be pertinent and current and kept on file in the Health Information Department and shall contain at least the following: identification data; medical history including reason for admission, details of present illness, relevant past medical and surgery history, social and family histories, and review of systems; physical examination consistent with the patient's age; diagnostic and therapeutic orders; appropriate and informed consent clinical observations, including results of therapies, progress notes, and laboratory and diagnostic reports; Approved by the January 23, 2008

9 Department: MEDICAL STAFF Page 9 of provisional and final diagnosis; medical and surgical treatments; operative reports; discharge summary, including discharge diagnosis, reason for hospitalization, significant findings, procedures performed, treatment rendered, condition on discharge, instructions given for further care such as medications, diet, limitations of activity, and information pertinent to the education of the patient and family; and autopsy report if one is performed Pediatric/adolescent records must also include the patient's development age, immunization status, and the family's involvement in the care of the patient All patients admitted for inpatient care (excluding acute behavioral health inpatients) will have a complete medical history taken and an appropriate physical examination (H&P) and required updates performed by a qualified physician or licensed independent practitioner who has been granted such privileges. (Refer to Policy MS114: Histories & Physicals All acute behavioral health inpatients will receive medical clearance prior to admission to the behavioral health inpatient unit. Psychiatric evaluation must be complete within 24 hours of admission. 23. Operative Reports Operative reports of procedures performed shall be dictated immediately after surgery and contain the pre-operative diagnosis, a description of the findings; the technical procedures used; the specimens removed; the post-operative diagnosis; and the name of the primary surgeon and any assistants and anesthesiologistsor CRNAs, and the EBL. 24. Consents In addition to the general consent for diagnosis and treatment signed at the time of admission, each staff member shall obtain additional informed consents signed prior to diagnostic, therapeutic, or operative procedures. In the case of emergencies involving a minor, a patient who is unconscious or otherwise incompetent to render an informed consent, or when a patient's life Approved by the January 23, 2008

10 Department: MEDICAL STAFF Page 10 of 14 is in jeopardy, and suitable consent cannot be obtained, the circumstances shall be fully recorded in the medical record, and an Emergency Consent Certificate of Medical Necessity shall be completed per policy A notation in the patient's record regarding informed consent should be made where appropriate In the treatment of minors, consent of the parent or guardian shall be obtained in writing, if possible, or by telephone if neither a parent nor guardian is available, with two personnel as witnesses. In cases of telephone consent, or in a life-threatening situation where care is rendered before the parent or guardian s consent can be obtained, the parent's or guardian's consent should be obtained in writing, All consents shall be obtained in accordance with policy PCS133: Consent Informed and Implied. 25. Orders Upon admission, all attending physicians will indicate the level of resuscitative effort appropriate for the patient, should the need arise. In the absence of such orders, full resuscitative measures shall be initiated. Living wills/advanced directives should be addressed with the patient by his or her physician; these directives shall be taken into consideration. (See policy PCS185: Advanced Directives, DNR, Withholding/Withdrawal of Life- Sustaining Treatment All diagnostic and therapeutic orders shall be in writing. Only authorized individuals may make entries in medical records. In lieu of written orders, telephone orders may be accepted by qualified nursing personnel, except for those specific personnel defined below: dietician or dietary technicians may take telephone dietary orders; laboratory personnel may take telephone orders for laboratory examinations; respiratory therapists may take telephone orders for respiratory therapy modalities; physical therapists may take telephone orders for physical therapy; occupational therapists may take telephone orders for occupational therapy; Approved by the January 23, 2008

11 Department: MEDICAL STAFF Page 11 of speech therapists may take telephone orders for speech therapy; pharmacists may take telephone orders for medications; radiology technologists may take telephone orders for radiology orders; rehab Services Plans of Care must be signed by the referring physician Verbal orders shall be taken only in emergencies The order shall be authenticated by the physician responsible for the patient at his next visit (within 24 hours) All orders for patient care shall be canceled upon transfer to another level of care (refer to hospital policy). It shall be the responsibility of the attending physician to initiate or renew orders promptly for the continuation of patient care. 26. Medication Orders Automatic stop orders shall be in force for those categories of drugs or specific drugs as recommended by the Pharmacy & Therapeutics Committee, and approved by the There will be automatic cancellation of medication orders as outlined in the PCS102: Medication Reconciliation and PCS001: Communicating Telephone, Verbal & WrittenOrders & Critical Test Results Only drugs listed in the Hospital formulary shall be stocked and inventoried. Substitution by the pharmacist of an equivalent drug from a different manufacturer shall be permitted, unless otherwise specifically indicated by the physician. Any exceptions shall be on written order of the physician attending the patient. Such drugs shall be purchased only in the quantities to fill each written order and in accordance with Hospital pharmacy as outlined by the Pharmacy and Therapeutics Committee and the Medical Executive Committee. Practitioners will be notified if the drugs are not available For Automatic Stop Orders, please refer to policy PHM108: Automatic Stop Orders Off-label usage of medications shall only be dispensed in accordance with policy MS005: Hospital Institutional Review Board. Approved by the January 23, 2008

12 Department: MEDICAL STAFF Page 12 of Progress Notes A progress note shall be recorded or attested to daily by the attending practitioner Progress notes shall give a chronological picture of the patient's progress and be sufficient to permit identification of the patient's needs, the patient's response to treatment, significant changes occurring in the patient's diagnosis, and continuity of care and transferability. Progress notes should be written or countersigned daily by the attending physician. 28. Record Completion The attending physician shall complete the medical record at the time of patient discharge, including progress notes, final diagnoses and discharge summary. Where this is not possible because final laboratory or other essential reports have not been received at the time of discharge, the medical record will be made available to the attending physician for completion. A final progress note must be written in the medical record which reflects the appropriate disposition of the patient. A final progress note is also required on all patients who are admitted for outpatient surgery A discharge/transfer/death summary shall be written or dictated on all medical records of patients hospitalized over 48 hours and for seriously-ill patients hospitalized less than 48 hours. In all instances the content of the medical records should be sufficient to justify the diagnosis or the treatment and end results. For normal newborns, normal obstetrical patients, or patients hospitalized less than 48 hours with only minor problems, a final progress note may substitute for the discharge summary. The final progress note should include condition on discharge, medications, diet, and activity, instructions given to the patient and family, and follow-up plans. All summaries should be signed by the responsible practitioner The medical record must be complete, with the information at hand, within thirty (30) days of discharge. SURGICAL CARE AND INVASIVE PROCEDURES Approved by the January 23, 2008

13 Department: MEDICAL STAFF Page 13 of Before surgery, the patient s physical exam and medical history, any indicated diagnostic tests and a pre-op diagnosis must be recorded in the patient s medical record. 30. When such history and physical examination report is not present in the patient's medical record before the time stated for inpatient surgery, ambulatory surgery, other invasive procedures, administration of anesthesia, or conscious sedation, the procedure shall be canceled. In the event that a history and physical cannot be completed, or the dictation is not recorded on the patient's chart prior to a procedure, and the procedure is deemed to be medically emergent, an appropriate admission note documenting pertinent information of the patient's condition shall be written in the progress notes. 31. The attending surgeon will be responsible for determining the level of surgical assistance needed for each procedure. Qualified surgical assistants shall be required on surgical cases at the discretion of the attending surgeon 32. Tissues and appropriate specimens removed during surgery shall be sent to Pathology, as outlined in Policy POS153:,Care and Handling of Specimens. 33. All tissue or foreign bodies removed during any invasive procedures shall be documented as to disposition in the operative report or on the operating room record. Surgeons shall be specific as to the types of studies to be performed on the tissue sent to Pathology. 34. The practitioner administering anesthesia is responsible for writing a pre-anesthetic note in the medical record prior to the patient's transfer to the operating area and before administration of preoperative medication. This note shall indicate the choice of anesthesia, alternatives, the surgical procedure anticipated, and the patient's prior anesthetic history. The practitioner administering the anesthesia is responsible for writing a post-anesthetic note after the patient has completed post-anesthesia recovery care which includes at least a description of the presence or absence of anesthesia-related complications. Approved by the January 23, 2008

14 Department: MEDICAL STAFF Page 14 of 14 CONSULTATIONS 35. Refer to Policy MS Approved by the January 23, 2008