Proposed Medical Staff Rules & Regulations November 2015 - - PowerPoint PPT Presentation

Proposed Medical Staff Rules & Regulations

November 2015

Transferring Care

1.1e Whenever a physician's responsibilities are transferred to another staff member, the transfer of responsibility shall be entered in an

• rder in the medical record.

ICU Timeframe Requirements

• Patients admitted to critical care areas should

be seen by the attending physician or their AHP as soon as possible after admission to the unit, but no later than twelve (12) hours after admission or sooner if warranted by the patient’s condition.

Med/Surg/Peds Timeframes

• Patients admitted to

medical/surgical/pediatric units should be seen within sixteen (16) hours following admission and within twenty-four (24) hours following admission to the nursery unless the patient’s condition warrants an earlier visit.

Documentation Requirements

• 1.5c The Attending Physician is required to

document the need for continued hospitalization prior to expiration of the designated length of

• stay. This documentation must contain:
• (1) Adequate documentation stating the reason

for continued hospitalization. A simple reconfirmation of the diagnosis will not be considered adequate;

• (2) Estimate of additional length of stay the

patient will require; and

• (3) Plans for discharge and post-hospital care.

Unanticipated Outcomes

• 1.8 In the event of an unanticipated outcome
• r adverse event, the patient’s treating and/or

consulting physician shall participate in discussion of the outcome or event with the patient, family and/or legal representative to the extent appropriate under the hospital’s Policy on Disclosure of Treatment Outcomes.

Operative Report Requirements

• An operative progress note must be entered

immediately, and before the patient is transferred to the next level of care, if the

• perative report is not placed in the record

immediately after surgery.

• Operative/procedural reports shall be made a

part of the patient's current medical record within twelve (12) hours after completion of surgery.

Abbreviations

• 2.9 Abbreviations and symbols utilized in

medical records are to be those approved by the MEC and filed with the Health Information Management Department.

• Abbreviations and symbols may not be used in

the final diagnostic statement or in documentation of an operative procedure.

Order Sets

• 2.14 b (ii) Use of preprinted and electronic order

sets that are consistent with nationally recognized and evidence-based guidelines will be permitted in this facility subject to approval by the Medical Staff.

• The Medical Staff delegates to the Network

Physician Champions and the Clinical Content Review Team (CCRT) in consultation with nursing and pharmacy leadership the responsibility for approving all updates.

Previous Orders

• All previous orders will be reviewed and

revised as needed following surgical procedures.

Delinquent Medical Records

• A record shall be considered delinquent when

it remains incomplete more than thirty (30) days after discharge.

• By the first and fifteenth of each month, the

medical records department will mail a letter to physician’s with incomplete medical records for fifteen or more days.

• The physician will have five days to complete

the records.

Delinquent Medical Records

• A chart which is not completed within thirty (30)

days of discharge will trigger suspension of the responsible physician’s privileges.

• Suspended physicians can not provide inpatient
• r outpatient care.
• The suspended physician must provide the name
• f another physician who will take over care of

his/her patients and EMTALA call.

• If an MD suspended for seven calendar days

he/she will be referred to MEC for further action.

Practitioners Ordering Treatments

• 3.8 When a practitioner who is not a

member of the Medical Staff orders treatment (i.e., home health, cardiac rehabilitation, physical therapy, chemotherapy), licensure and Medicare/Medicaid eligibility will be verified.

• In addition, it will be confirmed that the

practitioner is ordering within his/her scope of practice.

Treatment of Family Members

• 3.9 Treatment by practitioners of immediate

family members or self-treatment should be reserved only for minor illnesses or emergency situations where no other viable alternative is available.

• Practitioners may not self-prescribe or

prescribe to immediate family members any controlled substances.

Dentist’s & Podiatrists

• Patients admitted for dental care or podiatry

care will be the dual responsibility of the general dentist/podiatrist and a physician member of the medical staff.

High-Risk Pediatric Care

• 5.1 Only by those physicians who have

training in high risk infant resuscitation and care will provide pediatric care for newborns at high risk for complications. High risk for these purposes will be defined as:

– Premature infants less than thirty-five (35) weeks gestation, with or without complications; – All premature infants with complications; and – Full term infants with complications requiring invasive intervention

OB Patients

• 5.4 PATIENTS PRESENTING TO LABOR AND

DELIVERY UNIT: The physician shall be required to come to the Hospital within thirty (30) minutes

• f being requested by the nurse to come to the

Hospital due to a change in condition or deviation from the standard course of progress.

• A patient admitted to the Labor and Delivery Unit

should be seen by the Attending Physician at any time that her condition warrants, but in any event no later than sixteen (16) hours after admission.

OB ICU Patients

• When a pregnant woman or a woman in the

postpartum period is admitted to the intensive care unit, the patient's care will be co-managed by the ICU team, the MFM team, and the OB attending as needed.

• The ICU team will collaborate actively with the

MFM care team to manage critical and complex medical conditions.

EMTALA Call Lists

• A physician who has been called from the

rotation list may not refuse to respond.

• The Emergency Department physician’s

determination shall control whether the on-call physician is required to come in to personally assess the patient.

• Any such refusal may constitute grounds for

revocation of the physician’s Medical Staff appointment and clinical privileges.

• Physicians called are required to respond to

Emergency Department call by telephone within thirty (30) minutes.