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House Staff Manual
2008-2009 Academic Year

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Interactive Table of Contents
Introduction
 You are GCH
 Overview
 Updates to House Staff Manual
 Hospital Overview
 Department of Medical Education

Requirements for All House Staff
 AOA membership
 Licensure
 COMLEX examination
 NPI number
 GME Program Requirements

GCH Employee Code of Conduct

General Information and Guidelines for All House Staff

Department of Medical Education Policies
 Duty hours
 Outside professional activity (Moonlighting)
 Appointment, advancement and due process
 Medical records
 Program closure or reduction
 Verification of training
 Leave of absence
 House Staff Time Off Request Form
 Out-Rotation Procedures and Forms
 Community Education and Service

Hospital Policies and Procedures
 Hospital policies for employees
 Hospital policies for patient care

Medical Records Documentation Policies

OGME-1 Guidelines
 Hours of duty and scheduling
 Rotation objectives
 Evaluations and logs
 Other requirements

General Residency Guidelines

Sample Forms: available in print version of House Staff Manual and online at www.gchmeded.org

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YOU ARE GARDEN CITY HOSPITAL

Your actions
are what people see when they arrive here

Your voice
is what visitors hear when they ride the elevators
or what patients hear when they try to sleep

Your comments
are what people hear when you think they can’t

Your intelligence and caring
Are what people hope they will find here

If you are noisy… so is the Hospital.
If you are rude…so is the Hospital.

If you are concerned…so is the Hospital.
If you are responsive…so is the Hospital.

If you give great care…so does the Hospital!

We have a stake in your attitude
and in the collective attitude of everyone
who works at Garden City Hospital.
We are judged by your performance.

Make a commitment to strive for excellence!

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Garden City Hospital House Staff Manual
2008-2009 Academic Year

Introduction

This House Staff Manual is provided to all interns, residents and fellows enrolled in graduate medical
education (GME) programs at Garden City Hospital.

For the purpose of this Manual, “house staff” refers to all osteopathic physicians engaged in GME programs
at Garden City Hospital, including interns, residents, and sub-specialty residents or fellows.

Garden City Hospital has adopted the AOA’s preferred designation for GME status, which is the OGME
(osteopathic graduate medical education) year. For example, OGME-1 refers to a physician in their first
postdoctoral year. This is equivalent to PGY (post-graduate year) level.

Training Programs
Garden City Hospital is accredited by the American Osteopathic Association (AOA) to provide GME
programs in the following specialties:
 Cardiology
 Diagnostic Radiology (consortium through Michigan State University)
 Emergency Medicine
 Family Medicine
 General Surgery
 Internal Medicine
 Neurology
 Neurosurgery
 Obstetrics and Gynecology
 Orthopedic Surgery
 Urological Surgery (consortium through Michigan State University)
 Traditional Rotating Internship

Updates to the House Staff Manual
As policies, procedures and requirements are added or revised, copies will be distributed to each current
member of the House Staff in written and/or electronic formats.

The current edition of the House Staff Manual will be posted for each academic year on the Resources page
of the GCH Medical Education website at www.gchmeded.org. House staff will receive a hard copy of the
manual on matriculation into their GME program. Please refer to the online version annually thereafter.
Copies of the House Staff Manual for the current academic year will also be available in the Medical
Education Office and the Medical Library.

Note that policies and procedures described in the House Staff Manual are subject to change from time to
time. All reasonable attempts will be made to ensure that GCH House Staff have up-to-date information
regarding GME and Hospital operations. Any questions or potential discrepancies should be directed to the
Vice President Medical Education.

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Overview of Garden City Hospital

History
Garden City Hospital began as the vision of six osteopathic physicians in March of 1947. Committed to a
high level of healthcare, the physicians pooled their own money and rented a building on Ford Road to
provide a more attentive healthcare facility for the community. The current facility opened its doors in August
1960.

With a medical staff of approximately 350 physicians, comprised of both DO’s and MD’s, Garden City
Hospital has maintained its osteopathic heritage by continuing to provide clinical training to students, interns,
residents and fellows. All training programs are accredited by the American osteopathic Association and are
affiliated with the Statewide Campus System of Michigan State University College of Osteopathic Medicine.
Since the first postdoctoral programs in 1952, more than 1300 osteopathic physicians have received
internship and residency training at Garden City Hospital.

Our Mission
Garden City Hospital is committed to providing health care that improves the well being of the whole person
and the health status of the community at large through the provision of comprehensive health care services,
osteopathic medical education, and health care related programs.

Awards
Garden City Hospital is very proud to have received awards and recognitions, including:

 Named one of Solucient’s 100 Top Hospitals® for 2007
 Recipient of Solucient Top 100 Performance Improvement
Leader Award, 2006
 Recipient of 2003, 2004 and 2005 Governor's Award
of Excellence
 Winner of "Metropolitan Detroit's 101 Best and Brightest
Companies to Work For" by the Michigan Business and
Professional Association
 Three consecutive honorable mentions as "Best Places to Work" in Southeastern Michigan by
Crain's Detroit Business Magazine,
 Recipient of Michigan Health and Hospital Association's Ludwig Community Benefit Award

Hospital Administration
Garden City Hospital’s administrative team consists of the following individuals:

 Mr. Gary Ley President and Chief Executive Officer
 Dr. Gary Moorman Vice President/Medical Administration/CMO
 Mr. Daniel Babb Vice President/Chief Financial Officer
 Ms. Debra Williams Vice President/Chief Nursing Officer
 Mr. Art Greenlee Vice President of Planning/Chief Strategic Officer
 Mr. Mitch Nimmoor Vice President, Human Resources
 Dr. Kirsten Waarala Vice President, Medical Education

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Commitment to Excellence (C2E)

Commitment to Excellence or C2E is the name given to Garden City Hospital’s ongoing effort to create an
effective organizational environment. In such an environment, or corporate culture, the needs of patients,
medical staff, employees and trainees of all types will be met.
At the core of this concept is the “pillar approach” that defines six different areas of emphasis as indicated in
the graphic below. The ability of the organization to support its mission and achieve its vision is based on
excellence in all the pillars. For example, an organization that over-emphasizes productivity and the bottom
line (the Finance Pillar) will not be as good at providing service and quality care.

Patient evaluations of their satisfaction with the care provided are now publicly available on the internet and
in various publications. For this reason much emphasis has been placed on the first pillar—Service.
Employees have been trained to engage with patients, visitors and physicians in specific ways that assure
questions are answered, needs are identified and responses are prompt and appropriate. A set of
standards, included in this Manual, has also been put in place to frame the hospital’s expectations with
respect to employee/patient and employee/employee interactions. The medical staff has a vested interest in
this effort, and is encouraged to learn and apply these concepts to their own interaction.

Much has been done and much remains to be done in order to make Garden City Hospital a preferred
destination for care over the many other quality institutions in the area. The principles of C2E are part of the
journey to excellence. As GCH House Staff, you play an integral role in this ongoing effort. The recognitions
this organization has received, such as being designated a “100 Top Hospital” in the nation, are signs
Garden City Hospital is on the right path.

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Medical Staff
The Medical Staff of Garden City Hospital’s is comprised of approximately 350 physicians in 45 medical
specialties, including approximately 200 D.O.’s. AOA standards and the Medical Staff Bylaws provide for
physician participation in the operations of the hospital through a variety of committees.

Medical Staff Officers

 Dr. Rex Ruettinger Chair
 Dr. Joesph Walkiewicz Past-Chair
 Dr. Louis Tegtmeyer Vice-Chair
 Dr. Richard Ozog Secretary
 Dr. Troy Smith Treasurer

Department Chairs

 Dr. Jeffrey Rosenberg Anesthesiology
 Dr. Gary Pilchak Emergency Medicine
 Dr. William Penn Family Medicine
 Dr. John Brown Imaging
 Dr. Christopher Doig Internal Medicine
 Dr. Ingrid Wilson Obstetrics and Gynecology
 Dr. Mala Sengupta Pathology
 Dr. B. Narasimha Raju Pediatrics
 Dr. Dan Morrison Surgery

Residency Program Directors

 Dr. Emmanuel Papasifakis Cardiology
 Dr. Dennis Vollman Diagnostic Radiology
 Dr. Michael Yangouyian Emergency Medicine
 Dr. Michael Burry Family Medicine
 Dr. Richard Spinale General Surgery
 Dr. Christopher Doig Internal Medicine
 Dr. Anne Pawlak Neurology
 Dr. Louis Jacobs Neurosurgery
 Dr. Sheryl Parks Obstetrics and Gynecology
 Dr. Dan Morrison Orthopedic Surgery
 Dr. William Davidson Urological Surgery

Physician Education Committee (PEC)
The PEC is a committee of the medical staff which oversees osteopathic education at GCH. The committee
is chaired by Dr. Randy Bickle. Members are appointed by the Chief of Staff and include each of the
residency program directors. House staff are welcome to attend meetings, which are held on the first
Monday of the month at 12:30 pm in the Journal Club Room.

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Department of Medical Education

Medical Education Vision Statement

Garden City Hospital will be recognized for outstanding osteopathic medical education programs that
help medical students, interns, residents and fellows provide comprehensive patient care, both during
their training and beyond.

Medical Education Staff and Office
The Medical Education main office is open Monday through Friday from 7:30 am to 4:00 pm. Our telephone
number is (734) 458-4486 and fax number is (734) 458-4496. Staff includes:

 Dr. Kirsten Waarala Vice President, Medical Education
kwaarala@gchosp.org

 Ms. Shiela Julin Medical Education Manager
sjulin@gchosp.org

 Ms. Susan Patterson Executive Secretary
spatterson@gchosp.org

Medical Education Center

The Medical Education Center is located on the lower level of the hospital and includes
 Medical Education offices – see above
 Medical Library – see page 14
 Classroom A/B – Most morning and noon conferences are held here. See Academic Calendar for
schedule. Laptop with internet access and projector is available.
 Journal Club Room – Main site for MSUCOM PCAC lectures; Family Medicine journal club and other
conferences. 24-7 computer access.
 House Staff Lounge. The lounge contains lockers, sleep rooms, shower facilities, mailboxes and
lounge area. A valid ID badge is required for access.

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Requirements for All House Staff

The following are required of all house staff at Garden City Hospital.

AOA membership
All house staff are required to maintain membership in AOA throughout their training. Effective academic
year 2008-2009, Medical Education will arrange to pay the annual dues assessment of $60 per year for all
house staff. If you receive a notification for membership dues or renewal, please disregard it. If you have
already paid for AOA dues, a credit card statement or cancelled check may be submitted to the Department
of Medical Education for reimbursement of this amount. Provide a copy of your AOA membership certificate
to the Department of Medical Education for your academic file.

Licensure
It is the responsibility of each intern, resident and fellow to obtain and maintain active licensure from the
State of Michigan Board of Osteopathic Medicine as a condition of employment. A copy of your current
license will be kept in your academic file. Loss of licensure, through failure to renew or as the result of
disciplinary or other action, will result in immediate suspension from clinical duties and/or termination from
the graduate medical education program.

COMLEX examinations
The AOA requires successful completion of the COMLEX examination series prior to entry into the OGME-3
training year. Therefore, all GCH house staff are required to present copies documenting passage of these
examinations.

Effective July 1, 2008, timelines for the examinations are as follows:

COMLEX-1 Passing score included with ERAS application
COMLEX-2 Passing score required for both parts prior to beginning OGME-1
COMLEX-3 Passing score required prior to beginning OGME-3

All house staff are strongly encouraged to complete the COMLEX-3 examination during OGME-1 and no
later than 6 months into OGME-2. This will permit adequate time to receive scores and, if necessary, to
remediate the examination so that a passing score can be documented prior to the scheduled start date for
OGME-3.

NPI Number
Effective July 1, 2008, all GCH house staff will obtain a National Provider Identification (NPI) number and
submit a copy of the NPI number confirmation to the Medical Education office. This must take place by
August 1 of the academic year. Instructions on how to obtain an NPI number may be found on the Medical
Education website at www.gchmeded.org – click on Resources and Links > GCH Downloads.

GME Requirements
Each graduate medical education (GME) program has a set of standards put forward by the AOA and the
associated specialty college. These standards specify requirements including required rotations,
evaluations, logs and other documentation. It is each resident’s responsibility to be familiar with and abide
by these requirements. The Department of Medical Education and the Residency Program Directors will
assist house staff in verifying that these requirements are met. Current guidelines may be found online at
the AOA website at: https://www.do-online.org/index.cfm?PageID=acc_postdocstdspeclist. Additional
information may be found online through the websites of the respective specialty colleges:

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GME Requirements, continued

Specialty College

Diagnostic Radiology American Osteopathic College of Radiology
www.aocr.org

Emergency Medicine: American College of Osteopathic Emergency Physicians
www.acoep.org

Family Practice: American College of Osteopathic Family Physicians
www.acofp.org

Internal Medicine, Cardiology: American College of Osteopathic Internists
www.acoi.org

General Surgery, Neurosurgery,
Urological Surgery: American College of Osteopathic Surgeons
www.facos.org

Neurology American College of Osteopathic Neurologists
and Psychiatrists

Obstetrics and Gynecology American College of Osteopathic Obstetricians and
Gynecologists
www.acoog.org

Orthopedic Surgery American Osteopathic Academy of Orthopedics
www.aoao.org

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Employee Standards

As employees of Garden City Hospital, all house staff are expected to abide by the Employee Standards.
These standards were developed by GCH employees in alignment with our core values, our Commitment to
Excellence, and to external regulations.

Commitment to Patients
As an employee of Garden City Hospital my commitment to patients will encompass compassionate,
informative, respectful, safe and timely care.
Compassionate
I will compassionately commit to address, and anticipate patients’ needs.
How do I apply the standard of “Compassion”?
 I will be reassuring with patients.
 I will be considerate of patients and their needs throughout my workday.
 I will be understanding when caring for my patients.
Informed
I will commit to keeping patients informed while addressing and anticipating their needs.
How do I apply the standard of “Informed”?
 I will strive to see that all patients’ questions are answered.
 I will educate patients and families.
 I will communicate to other team members involved in the patients care.
 I will apply organizational service principles in my patient communications
Respectful
I will commit to respecting patients, families and visitors.
How do I apply the standard of “Respect”?
 I will keep conversation around and with patients professional at all times.
 I will discuss patient information with appropriate team members in a private setting.
 I will be aware and considerate of cultural and ethnic diversity.
 I will apply the principles of service recovery when needed.
Safe
I will commit to providing a safe environment for patients.
How do I apply the standard of “Safe”?
 I will adhere to all policies regarding safe patient practices.
 I will communicate all patient issues to maximize patient safety.
 I will respond to patient needs and requests.
Timely
I will commit to providing timely care while addressing and anticipating patient needs.
How do I apply the standard of “Timely”?
 Regardless of my role, I will respond to call lights immediately.
 I will provide current information to patients and their families as appropriate.
 I will keep patients informed whenever there is a delay.
 I will respond to patients needs with a sense of urgency.

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Commitment to Appearance
As an employee of Garden City Hospital my commitment to appearance will encompass personal, facility
and environmental.
Personal
I will commit to my personal appearance being the first impression our customers have of our
hospital. My first consideration will be the customer’s expectation of how I should present myself.
How do I apply the standard of “Personal Appearance”?
 I will always dress professionally and adhere to the dress code policy.
 I will always practice good personal hygiene and assure my appearance meets
organizational policy.
 I will wear my identification badge correctly and at all times.
 I will greet everyone with a smile and a positive attitude.
Facility and Environment
I will commit to making sure that our building and surroundings are kept clean and safe.
How do I apply the standard of “Facility and Environmental Appearance”?
 I will take responsibility for the building; treat it as if it is my home.
 I will report needed repairs or problems to the appropriate department.
 I will pick it up, even if I did not drop it.
 I will clean it up, even if I did not spill it.
 I will straighten it up, even if I did not make it messy.

Good Neighbor

I will commit to helping Garden City Hospital be a good neighbor and corporate citizen

How do I apply the standard of being a “Good Neighbor”?
 I will respect my neighbor’s home and property in regard to smoking, parking, noise and car
lights

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Commitment to Attitude

As an employee of Garden City Hospital my attitude must be positive, respectful, professional, and friendly.
Positive
I will be pleasant, upbeat and optimistic.
How do I apply the standard of “Positive”?
 I will take pride in my work.
 I will build confidence in others
 I will support change in the organization through my words and actions
Respectful
I will be considerate of people and my environment
How do I apply the standard of “Respect”?
 I will be courteous to those with other cultures and beliefs
 I will protect the privacy of others
 I will take personal pride in my environment
 I will a demonstrate confidence in others. I will make sure my words portray employees,
leaders and the medical staff in a positive way.
Professional
I will act in a manner that is consistent with my profession
How do I apply the standard of “Professionalism”?
 I will conduct myself in an efficient, cost effective and business like manner.
 I will take ownership of other peoples needs in the place I work.
 I will welcome opportunities to learn and improve.
Friendly
I will be gracious and welcoming.
How do I apply the standard of “Friendly”?
 I will be proactive and anticipate the needs of our customers.
 I will show people to their destination and assure a positive handoff.
 I will greet others with a smile; in person and on the phone.
 I will be polite.

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Commitment to Communication
As an employee of Garden City Hospital my commitment to others is to communicate respectfully, promptly
and professionally.
Respectful
I will convey a sense of importance to others.
How do I apply the communication standard of “Respect”?
 I will listen carefully. I will allow the other person the opportunity to have a dialogue.
 I will make eye contact. All people have a need to be acknowledged.
 I will be honest. My reputation is really all I have. People follow and trust someone they
believe is truthful.
Promptness
I will promptly communicate with others.
I will convey a sense of urgency to the other person putting the needs of others ahead of my own.
How do I apply the communication standard of “Promptness”?
 I will respond promptly by putting others first.
 I will remember that timely sharing of information is essential and at times critical to the well
being of others.
 I will use good phone etiquette
Professionalism
I will be professional in all my interactions with others.
I will convey a sense of confidence and experience to the other person.
How do I apply the communication standard of “Professionalism”?
 I will do my job to the best of my ability. I will go that “extra mile” to make the difference
 I will courteously identify myself by wearing my name tag so others can easily read it. On
the telephone I will clearly identify myself and ask how I can help.
 I will be a patient advocate. I will ask for what I need to do the best job possible. I will use
appropriate channels to convey my needs.
 I will be a hospital advocate. I will make sure my words portray the organization in a
positive way.

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Commitment to Co-Workers
As an employee of Garden City Hospital my commitment to co-workers will encompass respect and
friendliness and mentoring.
Respect
I will be respectful of all members of the Garden City Hospital team.
How do I apply the standard of “Respect”?
 I will treat co-workers with honesty, courtesy and work with them as a team.
 I will treat co-workers as equals; we each bring value to the team.
 I will work to resolve differences and act professionally.
 I will value everyone’s privacy and refrain from idle gossip.
Friendliness
I will be friendly with all members of the Garden City Hospital team.
How do I apply the standard of “Friendliness?”
 I will gladly offer assistance and support.
 I will be welcoming and courteous.
 I will express my appreciation for others.
 I will be loyal to my co-workers and the Garden City Hospital organization

Mentoring

I will welcome and support new staff members.
How do I apply the standard of “Mentoring?”
 I will educate and mentor co-workers.
 I will be aware of the impact of my actions upon other team members

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General Information and Requirements
Attire while on duty
All house staff are expected to promote the Hospital’s image by maintaining a professional appearance.
Clothing should be clean, neat and conforming to professional standards for men and women. Men are
expected to wear slacks, shirt and tie. Women are expected to wear slacks, skirts or dresses; blouses that
are low-cut or have a bare midriff are not permitted. Jeans, shorts and sandals are not permitted. Lab coats
are to be worn in patient care areas and are to be clean. See also “Lab Coats and Scrubs” below.

Disaster and emergency codes and drills
Garden City Hospital uses the following overhead announcements:
“Code Red” for fire alert
“Code Yellow” for disaster (may be internal or external)
“Code Black” for tornado
“Code Blue” for cardiopulmonary arrest

In the event of a “code yellow”: House staff who are on the hospital campus will report to the Manpower Pool
in the auditorium when the disaster is called; the exceptions being if they are in the OR or involved with a
critical patient, in which case they will report to the manpower pool as soon as possible. House staff who are
not on campus but on pager call (General Surgery, Neurosurgery, Orthopedic Surgery) will call in to the
Emergency Department to see if they are needed.

House staff may be deployed to any area as needed by the Incident Commander and/or Manpower Pool
supervisor. House staff that have other duties still need to check in with the manpower pool but may be
released to address those duties.

Educational stipends
House staff are granted an educational stipend through the Department of Medical Education with each
contract year. The amount of the stipend is stipulated in the house staff contract. The stipend may be used
to offset expenses such as professional association dues; licensure fees; books, journals or other
educational materials; examination fees; conferences and meetings; etc.

To request reimbursement, submit proof of expenses to the Medical Education office. The Hospital’s finance
department requires that original receipts are submitted to document expenses; credit card statements or
cancelled checks can be used as well. Order forms, reservation confirmations and the like are not
considered acceptable documentation. Any questions as to whether an item qualifies for reimbursement or
how to obtain reimbursement should be directed to the Department of Medical Education. There is no need
to obtain program director signatures on submitted receipts.

Reimbursement checks may take up to four to six weeks for processing. The Medical Education office will
contact house staff when checks arrive.

The Medical Education Department will track stipend balances throughout the year. Educational stipend
funds not used do not roll over into the subsequent year of training. However, for large expenditures, house
staff may request to borrow against the subsequent year’s stipend. Such requests must be made directly to
the Vice President of Medical Education.

Stipends may be utilized toward purchases of computers and other electronic devices, but these purchases
are subject to tax under federal law. See the policy section for more information.

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Employee Assistance Program (EAP)
The Hospital has contracted with an employee assistance program to provide a mechanism by which employees
and their immediate families can obtain counseling and assistance in dealing with physical, emotional or mental
illness; financial, marital, family and legal issues; and alcohol and/or chemical dependency. The specially trained
E.A.P. staff is available 24 hours a day, seven (7) days a week. Literature on the program is available in Human
Resources. The E.A.P. offers an initial confidential assistance session at no cost to employees or their
immediate family. If further help is required, the cost may be covered totally or partially by your health care
benefit plan. Participation in the E.A.P. does not excuse employees from complying with normal Hospital
policies or from meeting job requirements during or after receiving E.A.P. help. Participation in the E.A.P.
does not waive Garden City Hospital’s right to take disciplinary action.

If you or a member of your immediate family needs help, you may call the E.A.P. hotline at 1-800-854-1446.
Online access is also available at www.lifebalance.net, user I.D. and password information may be obtained
from the Human Resources department.

Employee benefits
As employees of Garden City Hospital, interns, residents and fellows are eligible to receive benefits as
described in their contracts, including health insurance, professional liability insurance, and others.
Representatives from the Human Resources department will assist new house staff in selection of benefits
and are available to answer questions as needed. The Human Resources Department is located on the
second floor of the Office Centre East Building (on Hospital campus near Inkster Road entrance) and may be
reached at extension 4277.

Employee benefits may be changed if you experience a qualifying change in status, such as marriage,
divorce, birth or adoption of a child, etc. It is your responsibility to notify Human Resources of any such
change within 30 days using the Employee Action Form. These forms are available in near the Cafeteria
and in Human Resources.

Employee physical examination
New house staff will undergo a physical examination and routine laboratory testing. All house staff will
undergo periodic tuberculosis screening (PPD skin test and/or chest xray) in accordance with the Hospital’s
Infection Control and Employee Health policies.

Fire safety
As employees of Garden City Hospital, all house staff should be aware of the following fire safety
information:

To report a fire: Call 3333

If you identify a fire, remember RACE:
Rescue: get patients, visitors, staff to safety
Alarm: pull alarm and/or call 3333
Contain: close doors, etc.
Extinguish: use fire extinguisher if you can

To use a fire extinguisher, remember PASS:
Pull: Pull pin
Aim: Aim hose at base of fire
Squeeze: Squeeze handle
Sweep: Sweep spray across fire

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Hours of duty
Hours of duty are determined by the GME program and by the clinical rotation. House staff are to check with
the attending physician or senior resident at the start of the rotation as to expected hours. As professionals,
house staff are expected to show up for all assigned shifts promptly.

If you are unable to come to work due to illness or emergency, you must contact the Department of
Medical Education at (734) 458-4486 and must also notify the attending physician or resident on your
assigned rotation.

If the illness or emergency keeps you from completing a scheduled call shift, it is your responsibility
to arrange for a colleague to cover the call.

All house staff will be responsible for knowing and adhering to Garden City Hospital’s policy on duty hours
restrictions and reporting (see Duty Hours Policy elsewhere in this Manual).

Human Resources Department
Human Resources is a customer service-oriented department dedicated to the mission and vision of Garden City
Hospital as well as its affiliates. Primary to that goal is maintaining an adequate work force by hiring and
retaining the best possible individuals. We are committed to the highest standards of customer service,
employee relations, compensation and benefit administration, and recordkeeping/processing. Every aspect of
our function shall be delivered with compassion, empathy and propriety.

As an equal opportunity employer, we shall treat every individual equally, without regard to race, color, religion,
sex, age, national origin, disability, marital status, height, weight, or other unlawful or unethical criteria.

Human Resource Department is located in the Office Centre East on the northeast corner of the GCH Campus.
Hours: Monday–Friday - 8:00 a.m.–4:30 p.m. Contact numbers are provided below.

Main number 458-4277
Recruiter (Allied Health)/HR Generalist 458-4270
Recruiter (Nursing)/HR Generalist 458-4279
Compensation / Worker’s Comp/401k/Pension 458-4293
Benefits Specialist 458-4289
Benefits Assistant 458-4399
Employee Welfare/Recruitment Rep. 458-4283

Identification badges
All house staff will be provided with a Garden City Hospital photo identification badge. This badge must be
worn at all times in patient care areas. Badges are also required for electronic access to the house staff on-
call facilities, certain patient care areas and after-hours entrance to the Hospital, and for payment in the
Hospital cafeteria. Contact Human Resources to obtain a replacement badge; there is a $5.00 fee.

Immunizations and tuberculosis screening
All house staff may receive influenza vaccination annually; those who decline the vaccination need to
complete a declination form. Proof of immunity to hepatitis B, varicella, measles and mumps must be
documented. Immunizations are available free of charge if necessary. In compliance with OSHA
requirements, all house staff must be screened for tuberculosis as part of the pre-employment physical
process. Mandatory screening is required thereafter at least annually and is provided by the Employee
Health Department.

Job Safety
The key to prevention of injuries is the willingness of each employee to help us maintain a safe work
environment. Each employee must accept his/her responsibility to prevent accidents. Report any unsafe
equipment or call the Environmental Services Department for removal of any items on floors or stairways that
may cause a person to slip or fall.

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In the event that an employee (including house staff) sustains an injury while on duty, he/she is expected to
report to the Emergency Department for evaluation. An Employee Occurrence Report is to be completed. This
includes needlestick/sharps injuries. An additional form is required for such injuries; see forms section.

Jury duty
Garden City Hospital encourages and supports employees in the pursuit of their civic duty. In keeping with that
belief, employees may be granted time off for jury duty, but not to exceed the term of the jury. Time off for jury
duty may result in extension of the internship or residency program depending on the duration. The Hospital
reserves the right to ask to have the employee excused from jury duty, or to have jury duty rescheduled, and the
employee must assist the Hospital in this effort if requested.

Lab coats and scrubs
House staff are furnished with personalized lab coats through a uniform supply service. Soiled coats are to
be deposited in the receptacles located in the House Staff Lounge. Clean coats are delivered to the House
Staff Lounge once a week. All coats are to be considered as property of Garden City Hospital and are to be
retained by the hospital at the completion of training.

Scrubs are available in the house staff lounge and in the surgery department. Scrubs are the property of
Garden City Hospital and are to be returned after use. Scrubs should not be worn to or from work; rather,
one should change into scrubs at the hospital and remove them prior to leaving. This is to be strictly
observed when the intern, resident or fellow will be entering into a sterile operating or procedure room.

Lectures and conferences
Garden City Hospital schedules daily educational programs, including Morning Case Review, Tumor Board,
Journal Clubs and other lectures. The Academic Calendar is available for download on the Medical
Education website at www.gchmeded.org. Special events, Statewide Campus System Educational Days
and other items of note are featured on the online Calendar on the website.

Morning and noon lectures
These lectures represent the cornerstone of the didactic programming for OGME-1 house staff and
medical students. Lecture attendance is expected, unless urgent patient care needs arise.
Participation in scheduled conferences is to be documented in logs and will be reviewed during
quarterly meetings with the Vice President of Medical Education. OGME-1’s will be assigned to
present at Monday Case Report and to give a presentation on a topic of their choosing during the
academic year.

Tumor Board
Tumor Board is held twice monthly, August through May. House staff are assigned cases to prepare
and present; usually the Chief Surgery Resident is responsible for case assignment. Assignments
are posted in the House Staff Lounge. Attendance is required for OGME-1’s and others as
determined by their residency program.

OGME-1 Meetings/Medical Education Town Hall Meetings
There will be a monthly meeting for all OGME-1 house staff to meet with the VP Medical Education.
Medical Education Town Hall Meetings will also be scheduled periodically; all house staff are invited
to attend. The meetings will provide a forum to discuss issues relevant to Garden City Hospital in
general and Medical Education in particular. House staff may bring forward issues of concern.

SCS Educational Days
Residents who are OGME-2 and up are expected to attend Statewide Campus System (SCS)
Educational Days scheduled for their specialty. For OGME-1 house staff, attendance at SCS
conferences is dependent upon the individual specialty program as well as current assigned rotation.
Specific guidelines will be provided, including whether pre-registration through the SCS website will
be required. Conference dates and locations will be noted in the GCH Academic Calendar online at
www.gchmeded.org and are also available through the SCS website at www.com.msu.edu/scs.

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It is expected that house staff will attend 70% of the SCS events for their specialty. To view the SCS
attendance policy, click here:

Library
The Harry A. Simmons Medical Library at Garden City Hospital is located in the Medical Education Center on
the lower level of the Hospital. The library is staffed Monday through Friday from 8:00 am to 4:30 pm and is
closed on weekends and holidays. Students and house staff may access the library 24 hours a day. After
hours, the Library may be entered through the Journal Club Room using a GCH photo ID badge.

Library resources are also available in the Resources section of the Medical Education website; this includes
electronic databases, requests for literature searches and summaries of library holdings. House staff may
also check with the library staff about purchasing books at discounted rates.

A photocopier is available in the library during staffed hours for photocopying of library materials. Multiple
copies of articles or handouts can be made in the Hospital’s Mail Room and Copy Center; provide original
materials to the Department of Medical Education and allow for 1-2 days for processing. House staff are
encouraged to utilize the GCH Online Journal Club for posting articles; instructions are available on the
website or from Library staff.

UpToDate is available on the Journal Club Room computer, which is available 24 hours a day. The
computer Learning Lab is available during staffed library hours only.

Meals and cafeteria facilities
The Hospital cafeteria is located on the lower level. Hours of operation are as follows:

 Monday through Friday:
o Breakfast: 6:45 am to 10:00 am
o Lunch: 10:45 am to 2:00 pm (hot food until 1:30 pm)
o Dinner: 4:45 pm to 7:00 pm
 Weekends and Holidays
o Breakfast: 8:15 am – 10:00 am
o Lunch: 10:45 am – 1:30 pm
o Dinner: 4:45 pm – 6:45 pm

The Garden Café is located off the Main Lobby on the first floor. It is open daily 7:00 am to 7:00 pm. House
staff cannot charge items at the Garden Café.

Interns, residents and fellows have a meal credit of $300 per month for use in the cafeteria. Food may be
charged to each physician’s account by swiping the photo ID badge. Amounts in excess of that monthly
allotment will be charged to the physician. House staff working nights may purchase food prior to cafeteria
closing or in the FastTrack convenience area on the first floor.

House staff are welcome to bring meal trays may from the cafeteria to the Classrooms for morning and noon
conferences.

On-call facilities
House staff on-call facilities, including lounge, locker room, restrooms and showers, and sleeping quarters,
are available in the Medical Education Center.

On-call schedule
OGME-1 house staff will be scheduled to provide day and night house float coverage. This schedule will be
developed and published by the Medical Education office. If any changes to assigned call shifts are
required, it is that person’s responsibility to notify
a) The Medical Education office
b) The hospital operator
c) The assigned units

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Specialty call schedules are typically developed by the chief resident. Copies of the monthly call schedule
must be provided to the Medical Education office. Any changes to the original schedule must be
communicated as described above.

Pager system
Garden City Hospital provides an alphanumeric display pager to all house staff. The pager may be accessed
directly by dialing the pager number or by dialing 2800 from inside the Hospital. Display pages can be sent
via Microsoft Outlook accounts within the hospital or through American Messaging online.

To activate the Rapid Response Team or to call a Code Blue, dial 3333.

Pager display “1111” indicates Rapid Response Team. It will be followed by the three-digit room number.
The designated physician should go to that room; however, house staff involved in the care of that patient
should respond as well. (See also RRT policy elsewhere in this manual).

Pager display “8888” indicates code blue, followed by the two-digit number indicating the area of the hospital
(see table below). Labels with these zones are provided in Medical Education and may be placed onto the
pagers for quick reference.

Two digit code Hospital area Two digit code Hospital area
00 DDR (Drs. Dining Room 16 Ambulatory Surgery
01 1 East 17 Operating Room
02 1 South (Rehab) 18 Recovery Room
03 Labor/Delivery 19 ER/OPD
04 Nursery 20 Imaging Services
05 Post Partum 21 Physical Therapy
06 Peds 22 Stress Lab/Nuclear
07 23:59 Observation 23 Lobby/Admitting
08 2 East 24 Auditorium
09 2 North 25 Cafeteria
10 2 Center 26 Administration
11 2 South 27 Lab
12 Critical Care Center 28 Cardiac Rehab
13 3 West 29 Cardiac Cath Lab
14 3 Center/Ortho MOB Classrooms
30
15 3 East Radiation Therapy

Batteries for pagers are available in the Medical Education office. For problems with pagers, please see staff
in the Mailroom and Copy Center, located on the lower level of the Medical Office Building (MOB).

Parking
Parking on the Hospital campus is at a premium. All house staff will receive a parking sticker which is to be
displayed on front window of their vehicle. A designated house staff parking area is located at the southeast
corner of the main parking lot, accessible off Elmwood Street. Parking is also available at the Harrison
Building which is located one-half (1/2) mile from the Hospital. Shuttle service is available between the Hospital
and the Harrison lot between the hours of 5:30 a.m. and 8:00 p.m., Monday through Friday, excluding Holidays.

Parking in the physician lot near the Emergency Department is prohibited on weekdays but permitted at night
and on weekends; see table below.

House staff may park in the following areas at the defined times:
Area Permitted times Restrictions
House Staff Parking Area Any time 24-7 None
(southeast corner of main lot)
Harrison Building lot Any time 24-7 Call security after hours for shuttle access

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Other employee parking Weeknights between 6:30 No parking during weekdays from 6:30 am to
areas on campus pm and 6:30 am 6:30 pm
Weekends

Physician Lot west of ER Weeknights between 6:30 No parking during weekdays from 6:30 am to
pm and 6:30 am 6:30 pm *
Weekends

Physician MOB Lot (north No house staff permitted at any time
side of campus)
Visitor parking No house staff permitted at any time

* Due to the limited availability of parking for attending physicians, any intern/resident/fellow who parks in the
physician lot during weekdays will be ticketed by Security and may lose his/her access card.

Paychecks
Paychecks are distributed through the Department of Medical Education every other Thursday. Paychecks
not claimed by Friday will be sent via US mail. House staff are encouraged to utilize direct deposit; forms to
initiate this are available through Human Resources and the Hospital intranet.

Security Services
Garden City Hospital Security Officers are assigned to 24-hour parking lot surveillance; are responsible for
policy enforcement and assist with incident/accident investigation and reporting. Security Officers will
provide, upon request, off-hour shuttle service to the Harrison lot for those employees requiring
transportation to their vehicles beyond the regular shuttle hours and escort service to or from the employee’s
vehicle within the parking lot 24 hours daily to ensure safety.

As an additional service, limited assistance is provided with vehicle jump-starts, tire inflation, lockouts and
frozen locks. In the event Security can not directly provide a needed service, arrangements will be made by
Security to obtain additional assistance. These services are not available to those employees electing to
park on city streets. Employee vehicles must be registered with the Security Department and have a valid
employee parking permit displayed.

Smoke-free campus
Effective July 1, 2007, Garden City Hospital joined other hospitals in creating a smoke-free campus. This
means that smoking and use of tobacco products is prohibited throughout the campus. As employees,
house staff are to abide by this policy. Also prohibited is smoking during a shift such that clothing or
uniforms smells of smoke upon return. For patients who are smokers, resources will be available, including
nicotine replacement products. Patients are not permitted to smoke outside the facility.

Time off/vacation
According to AOA standards, no more than twenty (20) business days (Monday through Friday) may be
taken off for any purpose in an academic year. Time off in excess of the above WILL result in an extension of
the training period and will be handled on a case-by-case basis.

OGME-1 house staff will be scheduled for house coverage during the winter break; this counts as one week
(five business days) of vacation. OGME-1 house staff may also take up to two weeks (10 days) additional
vacation time subject to the approval of the supervising physician and the VPME. Vacation may not be taken
during house float or ICU rotations. Vacation policies for OGME-2 and up are set by the Residency Program
but may not exceed AOA standards.

Discretionary time off must be requested in advance by submitting the Time Off Request Form to the
Department of Medical Education. This form requires the signature of the supervising attending physician
and/or program director and designation of a fellow house officer to cover duties during the absence. It is the
individual’s responsibility to arrange for coverage of any scheduled call shifts during a requested vacation;
the Department of Medical Education and the Hospital switchboard must be notified of such changes.

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Extended absences due to health issues, maternity leave, personal matters, etc. require completion of Leave
of Absence request forms and other paperwork. Contact the Department of Medical Education in advance to
ensure all paperwork is completed appropriately. The Human Resources department will assist with
questions regarding salary continuation and/or disability coverage during a leave of absence.

Wireless internet (WiFi)
Wireless internet service is provided throughout the hospital for use with PDA’s and laptop computers.
Employees, patients and visitors may access this service free of charge.

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Medical records documentation

H&P’s (History and physical examinations)
All patients admitted to Garden City Hospital must have a documented history and physical examination
(H&P). The Hospital is bound to meet standards set by the Healthcare Facilities Accreditation Program
(HFAP) of the AOA and by the Centers for Medicare and Medicaid (CMS).

H&P Standards:
 An H&P is to be completed as soon as possible but within 24 hours of admission.
 An admission note will be written if the H&P is not completed at the time of admission.
 The H&P may be completed up to seven days prior to admission, as for patients undergoing surgery.
 An “interim” H&P may be performed on patients who had a complete H&P performed on a prior
admission to this hospital within thirty (30) days. The interim H&P must reference the prior H&P, and
must include an interim history and a new complete physical examination. It is not acceptable to merely
provide a photocopy of a prior H&P or a note to “see prior H&P” without additional documentation.
 The attending physician must review and sign the H&P, and may add additional information or make
corrections.

What you MUST include:
 H&P’s must include the patient’s “point of origin”, e.g. where the patient was prior to admission or
presentation to the Emergency Department. Examples are:
 Home
 ECF (extended care facility)
 Rehab unit
 Direct admit from physician office
 Transfer from other institution
 Etc.
 H&P’s must include a complete physical examination.
 This includes examination of the genitalia and rectum. If these or any other portion of the physical
examination is not performed, the reason must be clearly documented on the H&P form. It is not
sufficient to say “refused” or “deferred” (see more guidelines below).
 The physical examination also includes an osteopathic structural examination (OSE), to be
documented on the H&P form. Instruction on completing the OSE will be provided and assessed
as part of the orientation program for incoming house staff.
 H&P’s must include documentation of “pre-existing conditions”, which are those conditions that are
present on admission. They may be chronic or acute. This includes
 Chronic medical diagnoses (e.g. diabetes)
 Newly diagnosed abnormalities (e.g. hyperglycemia on ER labs)
 Evidence of infections (e.g. abnormal urinalysis suggesting UTI)
 Presence of any skin breakdown or decubiti

Guidelines for completion of the Review of Systems portion of the H&P form are as follows:
 Negative findings (absence of the symptom or condition) are to be designated by CROSSING OUT the
prompt.
 Positive findings (presence of symptom or condition) are to be designated by CIRCLING the prompt.
 Positive findings are to then be described in the space provided.
 As not all prompts are necessarily relevant for all cases, prompts that are neither circled nor crossed out
will be interpreted as not asked.
 Additional symptoms or conditions, e.g. those for which no prompt is given but are relevant to the patient,
may be described in the space provide. These may be either positive findings or negative findings and
should be so described.

Guidelines for completion of the Physical Examination portion of the H&P form are as follows:
 Positive findings (presence of finding) are to be designated by CIRCLING the prompt
 Positive findings are to then be described in the space provided.

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 Since each area is being examined for any deviation from normal, prompts that are neither circled nor
crossed out will be interpreted as negative or absent.
 Additional findings, e.g. those for which no prompt is given but are relevant to the patient, may be
described in the space provide. These may be either positive findings or negative findings and should be
so described.
 Examinations that are not performed or are deferred need to be documented as to the reason why.
Pelvic and rectal examinations are considered part of a complete H&P, and are a critical component of
the evaluation of certain patients (e.g. those with abdominal pain). If, from a clinical standpoint, these
examinations may be reasonably deferred, the notation in the chart should provide detail, such as “Pelvic
examination deferred. Done by OBGYN last month, normal per patient” or “Rectal exam done by GS
resident. See consult.”

Orders
Orders are to be WRITTEN LEGIBLY, with the proper amount of information necessary for others to interpret
and carry out correctly (i.e., dosage, route of administration, frequency, etc.). Make sure that the proper
patient is identified on the order form.

Orders may not be added to an order form already fully or partially completed by another physician or
provider. A new order sheet must be utilized.

ALL ORDERS MUST BE SIGNED, DATED AND TIMED AND INCLUDE A BEEPER NUMBER AND
PRINTED NAME.

Telephone and Verbal Orders
Significant changes in patient status warrant a trip to the bedside to evaluate the patient and to chart
findings. Telephone orders given in response to change in status or significant diagnostic results are to be
followed up by a progress note addressing the situation as soon as possible. House staff may give
telephone orders, which may only be taken by licensed professionals (i.e. RN, RPh, PT, PA, CRNA) or by
certified or registered staff (RT, OT, ST, RD).

Telephone orders must be countersigned by the issuing physician. House staff should therefore keep track
of such orders given during their shift, and then round on those charts to sign the orders at the end of the
shift. Orders not signed on the floor will be flagged in the Health Information Management department and
house staff will be responsible for reporting to Medical Records to sign those orders.

The use of verbal orders (e.g. directing an order to a nurse rather than writing it in the chart) is to be limited
to emergency situations and not simply for convenience.

In-house transfers
Admissions to the Inpatient Rehabilitation unit or inpatient hospice are considered discharges form acute
care and admission to another facility. A new chart is generated and new orders written. Likewise, if a
patient goes back to acute care, it is a discharge from Rehab and a new chart is generated.

Abbreviations
Garden City Hospital has a list of accepted abbreviations (see Hospital Policies section of this Manual).
Additionally, certain abbreviations are prohibited when writing orders (see table below).

DO NOT USE
Abbreviation Intended Meaning or Explanation Why This is a Problem Do this Instead

U unit May look like a zero Write out “unit”
May look like the
IU international unit Write out “int’l unit”
number 10
QD or qd daily May be interpreted as Write out “daily” or

- 25 -
wrong interval “qday”
Write out “every other
QOD or qod every other day
day”
X.0 trailing zeros following decimal 5.0 may be read as Do not use trailing
(e.g. 5.0 mg) points 50 zeroes
_.X lack of a leading zero before Be sure to use a
.5 may be read as 5
(e.g. .5 mg) decimal points leading zero
morphine sulfate or magnesium
MS
sulfate
morphine sulfate or magnesium May be interpreted as
MSO4 Write out name of drug
sulfate wrong drug
MgSO4 magnesium sulfate

Progress Notes
Progress notes are to be written in the medical records of assigned patients on a daily basis, and more often
if the patient’s condition so dictates. The header of the notes should reflect the assigned service and level
of training of the house staff authoring the note; e.g. “General Surgery Resident” or “IM Intern”. Notes
completed during rounds with the attending physician should document the attending physician’s presence;
e.g. “Seen with Dr. Smith.” All progress notes are to be dated, timed, and signed, and are to include a
printed name and pager number.

Progress notes should typically follow the “SOAP” format:
S = Subjective: symptoms, reported history
O = Objective: vital signs, physical examination, lab and diagnostic results
A = Assessment: diagnoses, condition (stable/better/worse), interpretation
P = Plan: therapeutics, further diagnostics, discharge planning

If you are called to evaluate a change in patient status, it is critically important that your findings are
documented in the progress notes. The resident and/or attending physician must be contacted in the event
there have been significant changes in patient condition. It may also be appropriate to notify consulting
physicians, particularly if the change in status is related to the reason the consultant has been asked to
participate. All communication with the attending and/or resident must be documented. The use of the
abbreviation “D/W” for is strongly discouraged, as it is not clear whether it indicates “discuss with” or
“discussed with”. Suggested alternatives are “Will discuss with Dr. Smith” or “Discussed with Dr. Smith.”

Documentation for Rapid Response Team (RRT)
A Rapid Response Team documentation form will be utilized for evaluations carried out by members of the
RRT. This form will document the reason(s) for activation of the team, the assessments made and
interventions carried out, and the disposition of the patient (stabilized, transferred, coded, expired).

Documentation for Code Blue’s
When ACLS (“code blue”) protocols are activated, a blue form is completed by nursing staff to document the
course of the code. The house staff physician who runs the code blue is responsible for reviewing this form
for completeness and accuracy. In addition, he/she is to complete an entry in the progress note section of
the medical record, noting
 reason for and time of arrival to patient’s room
 brief, pertinent description of patient’s initial status and resuscitative efforts underway
 reference to ACLS protocol as per code sheet
 procedures performed during the code (dictate a procedure note for each as well)
 notification of family, attending physician, and, if applicable, medical examiner

Following the code, the house staff physician running the code blue or his/her designee must
complete the pink “Code Blue Peer Review” form. A form will also be completed by one of the nursing

- 26 -
staff involved in the code. Both forms will be given to the clinical nurse manager on that unit and forwarded
to the Quality Management department.

Discharge summaries
Discharge summaries are required for all patients who are hospitalized for 24 hours or more. The discharge
summary shall include:
 Date of admission
 Reason for admission with chief complaint, principal and secondary diagnoses
 Brief summary of the hospital course with significant diagnostic findings
 Pertinent laboratory tests, interventions, procedures, operations, consultations, and complications
 Date and time of discharge
 Discharge disposition (to home, ECF, hospice, home nursing, etc.)
 Discharge instructions, including diet, activity, and follow-up visit (approximate time and with whom)
 Discharge medications: provide a complete list including doses and intervals, as well as any changes
to medication regimen from admission.

Correcting errors
If an error in documentation is made, it should be corrected as follows:
 Draw a single line through the error in ink, making sure that the entry is still legible. Entries should
never be erased, made illegible, or covered up with liquid correction fluid.
 The correction should be dated, timed and signed or initialed by the individual making the correction.
 A note should be placed near the correction stating why the entry was changed, e.g. “error”, “wrong
patient”, “wrong chart”.

Completion of assigned charts
It is the responsibility of house staff to complete assigned charts in a timely fashion. Refer to the Medical
Education Department Policy Section of the Manual for the current Policy on Completion of Medical Records.

iDOC
iDOC is an electronic medical record archive and retrieval system deployed in 2008. Charts of discharged
patients are converted into electronic format through a combination of scanning of paper documents (e.g.
H&P form, progress notes, orders) and upload of electronic documents (e.g. transcribed reports). Medical
records may then be accessed through a secure internet connection 24-7. House staff will utilize iDOC to
access records of prior hospital encounters and to complete assigned records. Training on iDOC will be
available during New House Staff Orientation and through the Health Information Management department.

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- 28 -
Department of
Medical Education
Policies

- 29 -
GARDEN CITY HOSPITAL
DEPARTMENT OF MEDICAL EDUCATION
Policies and Procedures

POLICY: DUTY HOURS

PURPOSE: To provide an institutional policy and procedure relative to duty hours for interns,
residents and fellows (“trainee”), as required by the American Osteopathic
Association (AOA), and to establish a process for reporting and monitoring of duty
hours.

REFERENCE: AOA Basic Document for Postdoctoral Training Programs (AOA BOT 2/2006)

EFFECTIVE: July 1, 2006

PEC APPROVAL: June 5, 2006

1. The trainee shall not be assigned to work physically on duty in excess of 80 hours per week averaged
over a 4-week period, inclusive of in-house night call.

2. The trainee shall not work in excess of 24 consecutive hours inclusive of morning and noon educational
programs. Allowances for inpatient and outpatient continuity, transfer of care, educational debriefing and
formal didactic activities may occur, but may not exceed 6 hours. Residents may not assume
responsibility for a new patient after working 24 hours.

3. The trainee shall have on alternate weeks 48-hour periods off, or at least one 24-hour period off each
week.

4. Upon conclusion of a 24-hour duty shift, trainees shall have a minimum of 12 hours off before being
required to be on duty again. Upon completing a lesser hour duty period, adequate time for rest and
personal activity must be provided.

5. All off-duty time must be totally free from assignment to clinical or educational activity.

6. Rotations in which trainee is assigned to Emergency Department duty shall ensure that trainees work no
longer than 12 hour shifts.

7. It is the policy of Garden City Hospital that patient care responsibility is not precluded by the work hour
policy. In cases where a trainee is engaged in patient responsibility which cannot be interrupted,
additional coverage should be provided as soon as possible to relieve the resident involved.

8. The trainee may not be assigned to call more often than every third night averaged over any consecutive
four-week period.

9. Any professional clinical activity (“moonlighting”) performed outside of an official residency program may
only be conducted with as defined in Garden City Hospital Department of Medical Education policy. All
approved hours are included in the total allowed work hours under AOA policy and will monitored by the
Physician Education Committee. This policy must be published in the institution’s house staff manual.
Failure to report and receive approval by the program may be grounds for terminating a resident’s
contract. All moonlighting will be inclusive of the 80 hour per week maximum work limit and must be
reported.

10. The trainee will be required to submit a House Staff Duty Hours Report Form (sample attached) to the
Department of Medical Education on a regular basis. Duty hour forms will be reviewed by Medical
Education staff.

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11. The Physician Education Committee will review duty hour compliance on a quarterly basis and will be
advised of duty hour violations if and when they become known.

12. The Department of Medical Education will provide a written report on duty hour compliance to the
Educational Standards Committee of the Statewide Campus System as per AOA requirements.

13. Trainees who wish to report duty hour noncompliance may do so without reprisal by contacting any or all
of the following:

a. Vice President of Medical Education at Garden City Hospital
b. Compliance Officer at Garden City Hospital
c. Assistant Dean at Statewide Campus System
d. AOA confidential e-mail address (postdoc@osteopathic.org)
e. The AOA Postdoctoral Program Violation Hotline (877) 325-8197.

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HOUSE STAFF DUTY HOURS REPORT FORM
Name ____________________________ OGME- ____ Residency program _______________ Quarter: _____

Part 1: For the next two-week period, report the total number of hours worked by date. Work hours include: assigned rotations,
in-house call, outpatient clinic and required educational conferences, as well as any outside professional activities (“moonlighting”).
WEEK ONE: WEEK TWO:
FILL IN NUMBER HOURS FILL IN NUMBER HOURS
DATE WORKED DATE WORKED
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
TOTAL # Hours TOTAL # Hours
Week One Week Two

Part 2: Answer the following questions for the most recent quarter (3 months):
Yes No
1 Have you been assigned to in-house call?
If so, have you been consistently able to leave post-call (such that the
1a
duration of your shift is no longer than 30 consecutive hours)?
2 Have you been assigned to take call from home?
2a If so, have you had to come into the hospital while on call?
2b If so, have you included hours spent in the hospital in your work hours total?

3 Have you been assigned to shifts in the Emergency Department?
3a If so, has the duration of your shifts been 12 hours or less?
Have you done any outside professional activities (“moonlighting”) during the
4
current quarter?
If so, have your total work hours (including moonlighting) totaled 80 hours or less per
4a
week averaged across four weeks?
Do you feel that your work hours have resulted in significant sleep deprivation
5
and/or impaired your ability to function in a clinical setting?

If you checked any shaded boxes, please explain on the reverse

Part 3: I attest the following is an accurate account of my worked hours during this time period.

Signature ________________________________________ Date ____________________

RETURN COMPLETED FORM TO MEDICAL EDUCATION

MEDICAL EDUCATION OFFICE USE ONLY
 WITHIN AOA AND GCH POLICIES REVIEWED BY __________ DATE _________

 EXCEPTION: Attach follow-up documentation REVIEWED BY PEC:

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GARDEN CITY HOSPITAL
DEPARTMENT OF MEDICAL EDUCATION
Policies and Procedures

POLICY: OUTSIDE PROFESSIONAL ACTIVITIES (“MOONLIGHTING”)

PURPOSE: To establish conditions under which outside professional activities (“moonlighting”)
are permitted and to define the process for requesting, approving and reporting
those activities.

REFERENCE: Garden City Hospital Medical Education Policy/Procedure: Outside Professional
Activities (“Moonlighting”) for Residents

EFFECTIVE: Immediately

PEC APPROVAL: June 5, 2006

1. It is understood that Residents (OGME-2+) shall devote themselves conscientiously to the
performance of their full-time professional efforts as defined by Garden City Hospital (GCH)
policies, Medical Education Policies/Procedures, and program specific requirements. Required
residency program obligations take precedence over all outside professional activities.
Residents shall not engage in outside professional activities (“moonlighting”) unless all of the
following conditions are met:

a. The Resident completes the “Moonlighting Request” form (see attached example). This form
provides written notice of the nature, duration, and affiliation of outside professional activities.
Completion and approval of the “Moonlighting Request” form by the Resident’s Program
Director and the GCH Medical Education Office must be received prior to engaging in any
outside professional activities (“moonlighting”).

b. The Resident must provide the Program Director and the Vice President of Medical Education
with a written statement in a form acceptable to GCH that the Resident shall fully indemnify the
Hospital against any claim, damage, expense, or liability resulting from engaging in outside
professional activities (“moonlighting”); and

c. The Resident must have a State of Michigan Medical License (i.e. “Full” Physician License, not
an “Educational Limited” License) and agrees that outside professional activities performed do
not adversely reflect on GCH’s reputation or functions; and

d. The Resident must be a United States Citizen or have a permanent Visa. Individuals who have
either a J-1 or H-1B Visa are not allowed by the ECFMG and Immigration and Naturalization
Service to participate in any outside professional activities.

e. It is further understood that in engaging in outside professional activities (“moonlighting”), the
Resident will not be covered by GCH Professional Liability Insurance. The Resident
understands that if he/she possesses a valid Michigan Educational Limited License to practice,
the rendering of professional services may only occur at the institution that is designated in the
license (i.e. GCH). Permission to engage in outside professional activities (“moonlighting”) is not
be construed as constituting acceptance or ratification by GCH of responsibility for the
Resident’s conduct while engaging in such outside professional activities (“moonlighting”).

f. It is understood that performing outside professional activities (“moonlighting”), in addition to the
Resident’s GCH residency position that create a conflict of interest; are performed during the
same working hours or result in impaired efficiency, absenteeism, or tardiness; or performing
work for another employer without prior authorization will subject the Resident involved to
disciplinary action up to and including discharge.

- 33 -
g. The resident must include time spent in all outside professional activities (“moonlighting”) in
his/her duty hour totals. Duty hour totals and reporting of duty hours must be in compliance with
GCH Department of Medical Education policy on duty hours. Approval for outside professional
activities (“moonlighting”) must take into account the resident’s duty hours. Failure to report
outside professional activities (“moonlighting”) hours or exceeding duty hour limits will result in
actions including withdrawal of approval and/or restriction on future moonlighting.

2. Individual Residency Programs may have additional requirements. It is the responsibility of the
Resident to consult with their individual Residency Program Director for these additional
requirements and to abide by them.

3. House staff are not permitted to engage in outside professional activities (“moonlighting”) during
OGME-1.

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GARDEN CITY HOSPITAL MEDICAL EDUCATION
“MOONLIGHTING” REQUEST FORM

Name: ______________________ Residency Program: ____________ Year: OGME-_____

Outside Professional Activity (“Moonlighting”) Description

Nature of employment: __________________________________________________________

__________________________________________________________

Requested date(s): __________________________________________________________

Estimated hours: __________________________________________________________

Name of Employer/Contact Person: ______________________________________________________

Contact telephone: __________________________________________________________

Liability/Malpractice Insurance Coverage (Include contractors, policy number, and expiration date)

__________________________________________________________

NOTE: You must provide written proof of insurance coverage.

Acknowledgement:
This request is made within the guidelines of the GCH Medical Education Policy and Procedure,
“Outside Professional Activities (‘Moonlighting’) For Residents”. I have read and understand the
GCH Policy/Procedure for “Outside Professional Activities (‘Moonlighting’) For Residents”. I agree to
comply with this Policy. I am aware that any violation of the “Outside Professional Activities
(‘Moonlighting’) For Residents” Policy will result in disciplinary action up to and including discharge
from GCH.

I hereby authorize the representatives of the GCH Medical Education Department to, at their
discretion, contact the moonlighting services as indicated above and any others who may have
information regarding my employment, hours, duties, and supervision and release from liability all
representatives of the Medical Education Program Directors, the Medical Education Office, and GCH
for their acts performed in good faith and without malice in connection with evaluating my request for
moonlighting privileges. In addition, I release from any liability all individuals and organizations that
provide information pertaining to my outside professional activities (“moonlighting”) in good faith and
without malice concerning my request for moonlighting privileges.

Resident Signature Date

Residency Program Director Approval Date

VP Medical Education Approval Date

THIS FORM MUST INDICATE APPROVAL BY SIGNATURES OF ALL PARTIES PRIOR TO ANY
“MOONLIGHTING” ACTIVITIES.

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GARDEN CITY HOSPITAL
DEPARTMENT OF MEDICAL EDUCATION
Policies and Procedures

POLICY: APPOINTMENT, ADVANCEMENT AND DUE PROCESS

PURPOSE: To provide an institutional policy and procedure relative to the initial
appointment, reappointment and advancement of interns and residents
at Garden City Hospital, to define due process relative to recommendations of
adverse actions; and to provide for hearing of grievances.

REFERENCE: AOA Basic Document for Postdoctoral Training Programs (AOA BOT
2/2006)

EFFECTIVE: July 1, 2007

PEC REVIEW: February 5, 2007

Part 1: Selection and Appointment

1. OGME-1/Match
a. GCH will accept applications for OGME-1 through the Electronic Resident Application Service
(ERAS) or whatever system may be designated by the AOA.
b. GCH will participate in the Osteopathic Internship Match sponsored by AOA and administered by
the National Matching Service (NMS), and will abide by the guidelines of both AOA and NMS.
c. The selection of candidates for linked programs will be carried out by the Residency RPD (RPD)
for that specialty and/or his/her designee(s). Recommendations for candidates will be submitted
to the VPME (VPME) for inclusion on the rank order match list.
d. The selection of candidates for unlinked traditional rotating internship positions will be carried out
by the VPME and/or his/her designee(s).
e. Matched candidates will receive a contract for OGME-1 postdoctoral training from the VPME
within the time frames required by AOA and NMS.
f. Candidates who apply during the post-match period (“scramble”) will be reviewed by the RPD
and DME. Selected candidates will be offered a contract for OGME-1 training.
g. If an OGME-1 candidate breaches the match agreement or contract, the VPME will notify the
AOA.

2. Applicants for Residency Positions (OGME-2 or higher)
a. Applicants for residency and sub-specialty residency (fellowship) positions will submit the
following documents: application form (GCH or ERAS), curriculum vitae, copy of osteopathic
medical school diploma or final transcript, COMLEX transcript, letters of recommendation,
including a letter from the RPD and/or Director of Medical Education of all current or prior
graduate medical education training programs.
b. The RPD will review applicants and recommend selected applicants to the VPME for
appointment.
c. A contract for the appropriate year of postdoctoral training will be provided to the applicant by the
VPME.

3. All candidates selected for appointment will be approved by the Physician Education Committee. A list
of appointees will be presented the Medical Executive Committee. Verification of appointments will be
made by the Department of Medical Education to the AOA, OPTI and specialty colleges as required.

- 36 -
4. All contracts will be for a period of one year (12 months). Any extension of a contract due to leave of
absence or for academic reasons will be made in accordance with AOA guidelines.

Part 2: Advancement and Reappointment
1. Continuation of a linked intern or resident in his/her graduate medical education program will be based
upon evaluation and progress.

2. Recommendations for advancement and reappointment will be made by the RPD to the VPME and will
be presented to the PEC. Contracts will be issued by the VPME to those interns and residents
recommended for reappointment.

3. If the RPD and/or VPME recommend against advancement in the program, the intern/resident will be
duly notified in writing within the time frame specified by AOA. The intern/resident will be entitled to due
process as defined below.

4. Verification of advancement and reappointment, or of non-continuation in the program, will be made by
the Department of Medical Education to AOA, the OPTI, and the specialty college as required.

Part 3: Program Completion
1. Recommendation for graduation for residents who have completed their training will be made by the
RPD to the VPME and will be presented to the PEC.
2. Certificates of completion of the residency program will be presented to the resident after the resident
has completed all program requirements and GCH has received all required documents from the
resident.

Part 4: Due Process
1. In the event that an Intern/Resident demonstrates poor performance, the RPD and/or VPME will address
the behaviors accordingly. A progressive process of corrective action may be undertaken depending on
the nature of the performance issue.

2. If poor performance issues persist or recur, the RPD and VPME will confer regarding appropriate
remedial and/or disciplinary action, including such actions as: suspension; probation; recommendation
to not reappoint; termination.

3. Suspension: Suspension may be imposed for cause by the RPD/VPME. When the interests of patient
care may be adversely affected, the RPD may impose such suspension, and shall immediately notify the
VPME of such activities.

4. Probation: An Intern/Resident may be placed on probation for academic or behavioral performance.
The probationary period shall provide for critical examination and evaluation to determine whether
certain criteria and expectations have been accomplished.
a. The VPME shall notify the Intern/Resident, in writing, regarding the imposition of the
probationary status; and this notification shall include, but not be limited to, a reasonable
statement in detail describing the problem(s), length of probationary status, performance change
expectations, and possible alternative outcomes.
b. Within 30 days of Intern/Resident receipt of this probationary status notice, the VPME will meet
with the Intern/Resident for counseling and appropriate guidance after consultation with the RPD
and/or Department Chairperson.
c. The RPD shall evaluate (in writing) the Intern/Resident at not less than 30-day intervals from the
date of notice of probationary status. These evaluations must be signed by the RPD and
reviewed and discussed by the RPD with the Intern/Resident. The Intern/Resident shall also
sign the evaluation; refusal to do so shall be noted by the RPD, setting forth the reasons for
refusal if stated by the Intern/Resident.
d. Each such evaluation will be sent to the VPME, who shall meet with the RPD and/or
Intern/Resident as deemed appropriate.

- 37 -
e. If performance has not met the expectations as stated in the notice of probation at the end of the
probationary period, or if during the period the RPD determines that it is unlikely that the
Intern/Resident will successfully complete probation, the RPD may recommend termination.
f. The circumstances relating to probationary status situations will be reviewed with the House
Staff Training Committee.

5. Termination: Termination will be recommended by a RPD only for cause. Prior to the recommendation
for termination of any Intern/Resident, the RPD shall consult the VPME.

a. The VPME will provide the Intern/Resident with written notice of recommendation for termination
by personal delivery or by registered/certified mail (return receipt requested).
b. This notice will include:
i. A statement providing a reasonable summary of the reason(s) for the termination.
ii. Notice of the right to a hearing under the provisions of this policy as to the
recommendation for termination, including information concerning the procedure for, and
the time limits related to, such hearing.
iii. Notice to the Intern/Resident that termination, if final, may be reported to the Michigan
Division of Professional Regulation and/or the Board of Osteopathic Review. An
explanatory statement may also be submitted to the American Osteopathic Association.

6. Hearing Procedures: If an Intern/Resident is notified of an adverse action including probation,
termination, or non-advancement, he/she shall be entitled to request a hearing. Such a request must be
made within five days after a notice of recommendation of the adverse action has been delivered or
mailed to the Intern/Resident.

a. The written request will specify the reasons the Intern/Resident believes his/her case warrants
review and special consideration. Failure to make a timely request for a hearing will constitute a
waiver of the right to a hearing by the Intern/Resident.
b. If the request for a hearing is timely, the VPME will arrange a hearing before a committee
composed of the VPME (who shall serve as Chairman), two Garden City Hospital Medical Staff
Members, two Garden City Hospital House Staff members, and the Chairperson of the House
Staff Training Committee. The VPME shall not serve on the committee if he/she originated the
recommendation to suspend or terminate, or if he/she desires to be, or is to be, called as a
witness at the hearing. In such event or in the absence of the VPME or inability to serve, the
VPME shall appoint a Medical Staff member to the committee, which shall select a Chairman.
The committee will conduct a hearing as soon as possible.
c. The committee will provide the Intern/Resident with an opportunity to present on his/her behalf.
The sole function of the committee shall be to ascertain whether or not (a) there was any
reasonable basis to recommend the adverse action and that such action was not arbitrary or
capricious, and (b) the provision of this policy and procedure statement were, in substance,
adhered to. It shall not be the function of the committee to recommend alternative action.
d. At the hearing, attorneys shall not be present. However, the Intern/Resident may select any
member of the Garden City Hospital Medical/House Staff to assist in presenting the case of the
Intern/Resident.
e. Prior to the hearing, the Intern/Resident and the Hospital will exchange pertinent information
concerning their respective presentations, including a list of witnesses. Prior to the hearing, the
Intern/Resident will be given copies of, or be permitted to review, documents that will be
submitted in support of the adverse action recommendation.
f. The RPD, or designee, will present the case of the department, and may present witnesses and
submit documentary material.
g. The Intern/Resident may present witnesses and documentary material for consideration by the
committee.
h. While cross-examination will not be permitted, rebuttal statements by either side on evidence
presented by the other side may be made.
i. The committee will be permitted to ask pertinent clarifying questions.
j. The committee will render a written decision which shall be forwarded to the Intern/Resident and
the RPD within 14 days after completion of the hearing. Based upon the decision of the

- 38 -
committee, the RPD may reconsider the proposed disciplinary action. If the recommendation for
the adverse action is unchanged, this recommendation and the decision of the committee shall
be considered final and will be reported to the Physician Education Committee and to other
parties as indicated, such as AOA or State of Michigan.
k. The stipend and benefits of the Intern/Resident will continue during the period of the hearing
process until the hearing committee makes its written report. The exception would be that the
stipend and benefits will cease at the end of the current appointment period, should the hearing
process continue beyond that period.

Part 5: Review of Grievances

1. Interns and residents are encouraged to attempt to address grievances and resolve issues by working
with individuals involved and/or discussing the matter with the RPD, VPME and/or other appropriate
representatives of Garden City Hospital.

2. Any issue that remains unresolved following discussion(s) between the Intern/Resident and the
respective RPD and/or Hospital Medical Staff members, the RPD and/or the Intern/Resident may refer
the unresolved issue to the VPME.

3. In the event that any issue still remains unresolved, following A. above, the matter may be referred to a
"Grievance Committee," which shall be composed of the RPD, the VPME, the House Staff Training
Committee Chairman, one department staff member, and one House Staff Training Committee non-
department member. The "Grievance Committee" will attempt to reconcile the matter.

4. The circumstances relating to any unresolved issue may also be referred to the House Staff Training
Committee by any RPD and/or any Intern/Resident at any time.

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GARDEN CITY HOSPITAL
DEPARTMENT OF MEDICAL EDUCATION
Policies and Procedures

POLICY: Completion of Medical Records

PURPOSE: To ensure timely completion of the medical record for patients seen at Garden City
Hospital by interns and residents.

EFFECTIVE: Immediately

PEC REVIEW: May 7, 2007

Introduction
The Department of Medical Education and the Medical Staff of Garden City Hospital recognize that the
prompt completion of medical records is a responsibility of each practitioner and is an important component
of quality patient care. For interns and residents, timely completion of assigned charts is considered a core
competency measurement This policy is in effect to encourage efficient medical records completion, with
the goal that all records are completed within 30 days of patient discharge.

1. Assignment of medical records
a. GCH interns and residents (hereafter referred to as “residents”) may be assigned to complete
portions of the medical record and are expected to do so in a timely fashion. This includes, but
is not limited to, the following types of entries:
i. History and physical examination
ii. Operative report
iii. Discharge summary
b. Records may be assigned by the attending physician to the resident, or by Medical Records
staff, utilizing available guidelines.
c. If a resident believes he/she has been assigned a medical record in error, it is his/her
responsibility to address that with the attending physician and/or Medical Records staff.

2. Expectations for completion of medical records

a. It is the responsibility of the resident to check with the Health Information Management
Department for any assigned medical records. Residents are strongly encouraged to schedule
time each week to check for and complete assigned charts.
b. The Health Information Management Department will provide a list of pending records by
resident to the Medical Education department. This list will be posted in the House Staff Lounge.
c. The following actions will be taken by the Department of Medical Education for each resident
based on chart age assigned to him/her. These actions apply to residents that are in-house.
i. Charts 0-14 days: No action
ii. Charts 15-30 days: Display page reminder
iii. Charts 31 or more days: Written notification of delinquent records will be sent to
resident, with copy sent to resident’s program director and placed in resident’s file.
d. Expectations during and prior to out-rotations are detailed below.
e. A warning will not be issued if the resident has made a good-faith effort to complete assigned
charts and the charts are not available in the Health Information Management Department and if
verified in writing by the Medical Records staff.

3. Corrective action:

a. A corrective action sequence will be initiated when a resident receives his/her third warning in a
six-month period.

b. A corrective action for delinquent medical records shall be issued in writing to the resident. The
residency program director will be advised of the corrective action.

- 40 -
i. If the resident can be excused from clinical duties, he/she will immediately complete the
assigned charts.
ii. Depending on the number of charts, one day of administrative leave of absence may be
arranged by the program director and/or DME.
iii. Time lost from clinical duties may require assignment of a make-up day, to be scheduled
within (30) thirty days by the resident and program director.
iv. Administrative leave of absence time shall be utilized exclusively for resolution of
medical records deficiencies. Residents are expected to return to clinical duties upon
completion of this task.
v. Documentation of corrective action will be performed in keeping with GCH Administrative
Policy 2-112.

c. Residents who receive three corrective actions for any cause within an eighteen-month period
may be subject to probation.

d. Residents who receive four corrective actions within an eighteen-month period may be subject to
dismissal from their residency program.

4. Out-Rotations

a. Prior to leaving for a scheduled out-rotation, a resident shall complete assigned charts as
determined by the Health Information Management Department (MR).

b. MR will provide the DME with confirmation of that the resident completed his/her charts.

c. A resident on a rotation outside the state of Michigan will not receive a warning if charts appear
on his/her list during the rotation.

d. A resident on a local out-rotation (e.g. within two hours drive of GCH) is responsible for checking
with MR and for completing assigned charts as they would during an in-house rotation.

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GARDEN CITY HOSPITAL
DEPARTMENT OF MEDICAL EDUCATION
Policies and Procedures

POLICY: PROGRAM CLOSURE OR REDUCTION

PURPOSE: To describe the protocol to be followed in the event of closure or reduction in
positions of any of the graduate medical education programs at Garden City Hospital

REFERENCE: AOA Basic Documents for OPTI and Postdoctoral Training Programs (AOA BOT
2/2006)

EFFECTIVE: Immediately

PEC APPROVAL: July 10, 2006

1. As required by the American Osteopathic Association, it is the policy of Garden City Hospital that
the steps outlined below will be taken in the event of
a. the closure of an approved graduate medical education (GME) program, e.g. internship,
residency or fellowship
b. the reduction of positions in an approved graduate medical education (GME) program, e.g.
internship, residency or fellowship that impacts trainees prior to program completion

2. Garden City Hospital shall immediately notify the AOA, the OPTI (Statewide Campus System of
MSUCOM) and its trainees of a program closure or reduction in positions which would impact
trainees prior to program completion.

3. Every attempt will be made to permit interns, residents or fellows currently enrolled in that program to
complete their training prior to the reduction or closure.

4. In the event that program closure or reduction would displace an intern, resident or fellow from
his/her training program, Garden City Hospital will immediately contact the OPTI (Statewide Campus
System of MSUCOM) to seek assistance in placing the trainee in another AOA-approved program
within the OPTI.

5. Severance pay shall be provided for two months when institutional program closure or reduction
decisions prevent the interns/residents from program completion in that or another geographically
proximate program arranged by the institution and/or the OPTI

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GARDEN CITY HOSPITAL
. DEPARTMENT OF MEDICAL EDUCATION
Policies and Procedures

POLICY: VERIFICATION OF TRAINING

PURPOSE: To define a process for the release of information related to verification of
postgraduate training for interns, residents, and fellows.

REFERENCE: None

EFFECTIVE: Immediately

PEC APPROVAL: June 5, 2006

4. As a training institution, Garden City Hospital (“GCH”) has the responsibility to respond to requests for
verification of postgraduate training for physicians who have participated in the Hospital’s internship,
residency and/or fellowship programs (“trainee”).

5. All requests for verification of training must be submitted in writing and must be accompanied by a
release form signed by the trainee, authorizing GCH to release information about the trainee’s
postgraduate training. GCH will not accept telephone or email requests for release of information.

6. If a verification letter is requested, the Department of Medical Education will provide a letter with the
following information:
a. Accreditation of the training program by the American Osteopathic Association
b. Dates of training at GCH; program name(s); whether the program(s) was (were) successfully
completed; and whether a certificate(s) of completion was issued.

7. Forms for verification of training will be completed by the Department of Medical Education based on
review of the trainee’s academic file. Requests as to whether the trainee is considered competent in or
should be granted credentials for specific procedures will be deferred to the residency program director.

8. Copies of all requests and releases, as well as completed forms and verification letters, will be kept in
the trainee’s academic file.

- 43 -
GARDEN CITY HOSPITAL
DEPARTMENT OF MEDICAL EDUCATION
Policies and Procedures

POLICY: HOUSE STAFF LEAVE OF ABSENCE

PURPOSE: To define the process for interns, residents and fellows regarding leaves of absence
during the period of their training.

REFERENCE: AOA Basic Document for Postdoctoral Training Programs (AOA BOT 2/2006)
Garden City Hospital Leaves of Absence Policy

EFFECTIVE: Immediately

9. This policy and procedure applies to interns, residents and fellows (“house staff”) who are absent from
work for fore than seven (7) calendar days, due to illness, injury, or personal reasons as defined under
the Family Medical Leave Act, must notify Garden City Hospital by completing a “Request for Leave of
Absence” form.

10. The “Request for Leave of Absence” form should be submitted thirty (30) days in advance of the
anticipated start date of the leave of absence, of as soon as the leave start date is known. Forms may be
obtained from the Department of Medical Education or the Department of Human Resources. In the
event of an unforeseeable leave, the Department of Medical Education is to be notified as soon as
possible and will submit the form on behalf of the house officer.

11. During a leave of absence, the intern/resident/fellow shall not engage in any outside professional
activities (“moonlighting”).

12. As a salaried employee, the intern/resident/fellow will be compensated at regular pay rate for the first
nd
twenty-one (21) calendar days of a leave of absence. From the twenty-second (22 ) calendar day and
up until a maximum of twelve (12) weeks, the intern/resident/fellow is eligible to request short-term
disability benefits, which provide compensation at sixty-five percent (65%) of regular salary, up to a
maximum of $600 per week.

13. Per the standards of the American Osteopathic Association, no more than 20 business days of leave
may be granted for any purpose, without extending the program. If an intern or resident is given a leave
of absence for reasons of maternity, physical or mental disabilities and returns to duty, he/she may
continue the training to completion. The OPTI, Specialty College and AOA’s Division of Postdoctoral
Training must be notified in writing of the extension. Any absences from the training program in excess of
the allowed vacation and academic time must be made up.

14. If the internship/residency/fellowship training year is extended, the intern/resident/fellow will continue
under the employ of Garden City Hospital, with the same salary and benefits as stipulated in his/her
contract for that academic year. The contract will be amended to reflect the extended dates of training
for that academic year.

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HOUSE STAFF TIME OFF REQUEST FORM
1. Completed forms are to be forwarded to the Medical Education Office 2 WEEKS PRIOR to the scheduled absence or
activity and require the signature of the Vice President, Medical Education.

2. FOR VACATION REQUESTS: requires signature of intern/resident covering service; signature of Program Director (for
residents and fellows) or attending physician for the rotation during which the time off is requested (for interns).

3. FOR CONFERENCES/SEMINARS: for any off-site educational activity that would take the intern/resident/fellow off their
assigned rotation, excluding Statewide Campus System Education Days. Requires signature of intern/resident covering
service; signature of Program Director (for residents and fellows) or the attending physician for the rotation during which the
time off is requested (for interns). Copy of conference agenda or brochure must be attached to this form.

NAME ______________________________________________ DATE _________________________

 VACATION REQUEST
DATES REQUESTED: ________________________________ NUMBER OF DAYS: __________

PHYSICIAN COVERING _____________________________________________

 CONFERENCE/SEMINAR REQUEST
EVENT ____________________________________ DATES REQUESTED ___________________

SPONSORING ORGANIZATION __________________________ BROCHURE ATTACHED

PHYSICIAN COVERING _____________________________________________________________

SIGNATURES

INTERN/RESIDENT/FELLOW ________________________________________________________ DATE _____________

PHYSICIAN COVERING SIGNATURE __________________________________________________ DATE _____________

PROGRAM DIRECTOR (Residents/Fellows) ______________________________________________ DATE _____________

ATTENDING PHYSICIAN FOR ROTATION (Interns) ________________________________________ DATE _____________

APPROVAL

VICE PRESIDENT, MEDICAL EDUCATION _______________________________________________ DATE _____________

- 45 -
OUT-ROTATION PROCEDURES AND FORMS

RESIDENTS: READ ALL GUIDELINES CAREFULLY!
COPIES OF ALL FORMS ARE INCLUDED IN THIS PACKET!

1. The following procedures apply to all rotations that take place outside of Garden City Hospital. This
includes both assigned rotations and electives, and both hospital and non-hospital settings (e.g.
clinics, physician offices).

2. For elective rotations (e.g. those that are not part of the resident’s regular rotation assignment), it is the
resident’s responsibility to confirm availability of the requested rotation prior to submitting the required
paperwork to Medical Education.

3. Requests must be submitted for all rotations to the Medical Education no fewer than 8 WEEKS PRIOR to
the scheduled start date of the rotation. This is to allow proper processing of paperwork in our office as
well as that of the host institution.

4. For out-of-state rotations, it is the resident’s responsibility to ascertain if licensure in that state is required
and, if so, to obtain it prior to the start of the rotation. A copy of the out-state license must be given to
Medical Education.

5. The form must be signed by the Residency Program Director and the Vice President, Medical Education.

6. Prior to the out-rotation, the resident must complete assigned charts and submit a Medical Records
Completion Verification form to Medical Education. If the out-rotation is within a two-hour drive of
Garden City Hospital, the resident is responsible to check with Medical Records during the out-rotation
and complete assigned charts in a timely fashion.

7. During the out-rotation, vacation time is permitted only if specifically agreed to in advance by the
supervising physician.

8. After the out-rotation, the resident is responsible for making sure the following documentation is
completed and forwarded to the Department of Medical Education. One evaluation form may be used to
evaluate the entire duration of the rotation.
 A House Staff Evaluation form (or equivalent) completed by the supervising physician
 A Rotation Evaluation Form completed by the resident
 Time Analysis Form completed by the resident

- 46 -
OUT-ROTATION REQUEST FORM
Complete all information. Please type or print legibly.

RESIDENT NAME ______________________________________________________________
ROTATION REQUESTED ______________________________________________________________
(Be specific, e.g. Trauma Surgery, Neonatal Intensive Care, Neurological MRI)

SITE OF ROTATION Institution Name ________________________________________________

Address __________________________________ State _____ ZIP _______

SUPERVISING PHYSICIAN Name _________________________________________________________

Specialty ___________________ Email ______________________________

CONTACT AT INSTITUTION Name/Position __________________________________________________

Telephone _____________________ Fax ____________________________

Email _________________________________________________________

DATES OF ROTATION Start date __________________ End date ___________________________

During this rotation, will you be involved in patient care at Garden City Hospital? Check all that apply.
 Will have on-call duties at Garden City Hospital
 Will attend Resident Clinic (with Garden City Hospital affiliated physician)
 Other patient care at Garden City Hospital – please specify: __________________________________
 No patient care at Garden City Hospital – rotation is exclusively at other institution
For out-of-state rotations: Will a license in that state be required? (You must verify with the institution)
 Rotation will accept my State of Michigan License
 Rotation requires that I obtain licensure in that state and I have done so.
Reason for request of this rotation: Please describe why this rotation is needed/requested,

_________________________________________________________________________________________________

RESIDENT SIGNATURE _________________________________ DATE SUBMITTED _________________

OFFICE USE ONLY
 APPROVED
 DENIED
PROGRAM DIRECTOR _______________________________________________________________ DATE _____________

VICE PRESIDENT, MEDICAL EDUCATION _______________________________________________ DATE _____________

- 47 -
MEDICAL RECORDS COMPLETION VERIFICATION FORM

Residents: You are to complete assigned charts prior to leaving for your out-rotation.
After you do, take this form to the Health Information Management Department
for their signature.

This should be completed no more than one week prior to the start of your rotation.

Resident: Please complete this portion.

RESIDENT _________________________________________________ (your name)

will be completing an out-rotation starting on _______________________ (insert date)

and will return to Garden City Hospital on __________________________(insert date)

Health Information Management Department: Please complete this portion
I verify that this resident has completed assigned charts to date.

Name __________________________________

Signature _______________________________

Date ___________________________________

Medical Records: Please keep a copy of this form for your records and return the
original to the Department of Medical Education. Thank you.

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OUT-ROTATION TIME ANALYSIS FORM

Complete all information. Please print legibly.

RESIDENT NAME ______________________________________________________________

DATES OF ROTATION Start date __________________ End date ___________________________

Check one of the following:

During this rotation,
 I had NO clinical duties at Garden City Hospital.  Return form to Medical Education
 I had call, clinic or other patient care duties at Garden City Hospital.  Complete information below

Instructions:
It is essential that Garden City Hospital have an accurate description of what portion of your clinical duties was here versus at the
out-rotation institution. For each week, please indicate ACTUAL time spent in various patient care duties at Garden City Hospital.
Attach additional sheets if the rotation was longer than 1 month. Return the completed form to Medical Education within 2 weeks of
the conclusion of your out-rotation.

Rotation week Number of clinic half- Hours on call at Garden City Hours in other clinical
number days at Garden City Hospital duties at Garden City
Hospital Hospital
1
2
3
4
5

I certify that the above represents an accurate description of my clinical duties at Garden City Hospital during this out-
rotation.

Signature ____________________________________________ Date ____________________________

OFFICE USE ONLY

 REVIEWED FOR FTE REPORT by ___________ date ____________ GCH CLAIM __________%

 RECONCILIATION REPORT GENERATED by ___________ date ____________
 RECONCILIATION RECEIVED FROM HOST INSTITUTION by ___________ date ____________

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GARDEN CITY HOSPITAL
DEPARTMENT OF MEDICAL EDUCATION
Policies and Procedures

POLICY: COMMUNITY EDUCATION AND SERVICE PROGRAM

PURPOSE: To provide avenues for GCH House Staff to participate in community education
during their residency training, for the benefit of the residents, the community, and
Garden City Hospital.

EFFECTIVE: 2008

PEC REVIEW: November 5, 2007

5. Garden City Hospital (GCH) will require that each resident participate in at least one community
education and/or service activity during the course of their training.

6. Potential activities which will fulfill this requirement include
a. GCH Community Education Programs
b. GCH Employee Wellness Fair
c. Presentation to local civic groups, schools, etc.
d. Other options as deemed appropriate by the Residency Program Director and/or Vice President
Medical Education

7. Participation in such events may be viewed as fulfilling Core Competency requirements in
a. Patient care
b. Communication
c. Professionalism
d. Systems-based practice

8. Participation in at least one event will be encouraged for residents graduating in 2008; thereafter, it will
be required. Traditional rotating interns completing only a one-year internship program at GCH are
welcome but not required to participate.

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Hospital Policies and Procedures

Hospital policies for employees

Confidentiality
It is the policy of Garden City Hospital to protect the premises, access to work locations, patient and employee
records, computer information, and cash or other items of monetary value. Employees who are assigned keys,
given special access, or assigned job responsibilities in connection with the safety, security, or confidentiality of
such records, material, equipment, or items of monetary or business value will be required to use sound
judgment and discretion in carrying out their duties, and will be held accountable for any wrongdoing or acts of
indiscretion.

Patients and staff members have an unquestionable right to expect all personal information about themselves,
their family, and financial circumstances be kept confidential. Information about Garden City Hospital, its
patients, medical staff, employees or suppliers, should not be divulged to anyone other than persons who have a
need to know, or are authorized to receive such information. When in doubt as to whether certain information is
or is not confidential, prudence dictates that no disclosure be provided without first clearly establishing that such
disclosure has been authorized by appropriate supervisory or management personnel. This basic policy of
caution and discretion in handling of confidential information extends to all electronic, written and oral
communication for both external and internal disclosure. This policy applies to all employees when on duty or off
duty.

Confidential information obtained as a result of employment with Garden City Hospital must not be used by an
employee for the purpose of furthering any private interest, or as a means of making personal gains. Use or
disclosure of such information can result in civil or criminal penalties both for the individuals involved and for
Garden City Hospital as this information is protected by law.

Employees should have a reasonable expectation of personal privacy in the workplace. However, for the
Hospital to conduct its business, desks, offices, lockers and other spaces assigned to individual employees
remain the property of the Hospital and are subject to search at the discretion of the Hospital.

Any violations of this policy will result in disciplinary action up to and including termination from employment.

HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires healthcare providers to
protect the integrity, confidentiality, availability and security of protected health information (PHI). Information
that contains patient identifying data may not be released, transmitted or communicated in any fashion
except where patient care of business needs necessitates such action and is directed with proper authority
and is permissible by law. Violation of HIPAA confidentiality and security regulations are serious matters and
may result in disciplinary action up to and including discharge.

Additional training on HIPAA will be provided to all house staff. Key reminders include:
 PHI includes information in written, verbal, and electronic formats.
 HIPAA does not preclude healthcare providers from sharing information on a patient’s status with their
families or others, but it does require that the patient consent to the sharing of information. This should be
documented in the medical record.
 Do not leave patient lists, dictations, diagnostic reports, logs, or other documents with PHI in public places.
All such documents must be disposed of in a locked bin (available throughout the hospital).
 It is permissible to make photocopies of medical records documents for educational use. If you are
distributing handouts, make sure to remove all patient identifiers by blacking (or whiting) out names, MRN,
etc. Once the copies are no longer needed, they MUST be disposed of in a locked bin (available
throughout the hospital).

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Computer, internet and email use
The computer system including the network and stand-alone computers, software, e-mail and any Internet or
Intranet access is the property of GCH. All computer documents, including e-mail, voicemail, and online
messages, are GCH documents. GCH reserves the right to monitor, access, print, and disclose computer
documents for any reason including to investigate suspected misconduct, locate needed information
pursuant to legal or governmental request, or to protect GCH’s interests. Employees are not permitted to
use or download GCH-owned software for personal use outside of GCH.

In an effort to avoid unnecessary system maintenance and viruses, the following activities are prohibited:
 Disconnecting/reconnecting computer lines and network cables
 Installation of any software or hardware on GCH’s computer network without prior authorization from the IT
department (Caretech)
 Charging or syncing handheld devices, including PDA’s, MP3 players, etc. on computers in clinical areas

Use of the internet is limited to business use only. Employees should not expect privacy with personal e-mail
messages sent or received. Like all messages sent and received, the content and volume of personal
messages may be monitored.

Restricted use includes but is not limited to the following:
 Users are NOT permitted to utilize e-mail to solicit personal business or activities, such as selling personal
items or soliciting for personal charities.
 Sending harassing or threatening e-mail to another user is prohibited. This includes, but is not limited to
obscene and offensive material or obscene or abusive language in connection with GCH’s computer
network.
 Using GCH’s computer network to harass other employees or members of the public, including derogatory
remarks, regarding race, color, religion, age, national origin, disability status or sex. Making derogatory or
defamatory remarks towards another person or remarks which could be construed as harassment,
including sexual harassment.
 Using GCH’s computer network to store or transmit unlawful material. Examples of unlawful material
include child pornography, libelous and defamatory material, including material that disparages the trade
of vendors, competitors, and copyrighted, trademarked, and other proprietary or confidential material
without proper authorization from the owner of the rights thereto.
 Using e-mail to distribute chain letters is prohibited.
 E-mailing patient protected health information (PHI) outside the firewall to another health provider or other
entity is prohibited, UNLESS permission has been granted by the HIPAA Security Officer.
 Removing, modifying, forwarding or destroying GCH files (e-mail or otherwise) is strictly prohibited.

Corporate compliance
All employees of Garden City Hospital and its affiliates are expected to be honest, ethical, professional and
dedicated to provide the highest level of service to our customers. The Compliance Plan and the Standards
of Conduct detail our beliefs and set the guidelines that must be followed in our day-to-day business
activities. Compliance is the responsibility of every member of the Garden City Hospital team. The
standards form the foundation of a successful and thriving work environment.

You should contact your Director or the Compliance Officer whenever you have a concern as to the legality
of any particular Hospital related business activity. If you have a serious concern and suspect or know that
illegal or fraudulent conduct is occurring, a hotline is available at (734) 458-4298 for you to report without fear
of retaliation or reprisal.

Fitness for duty
The Hospital has a vital interest in maintaining a safe and healthful environment for all of its employees,
patients and guests. Consequently, employees must be fit for duty, and must refrain from actions that
threaten fitness for duty. The Hospital may require, at its own expense, an employee to submit to such tests
and examinations, including alcohol testing and/or to be examined by a Hospital appointed physician, clinic,
psychologist, or other professional, to determine if the employee is fit for duty when such examinations/tests
are job-related and consistent with business necessity. In addition to the employee authorizing the Hospital’s
appointed physician, clinic, psychologist, or other professional, to conduct such tests and examinations, the

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employee shall sign such documents and medical release forms which are necessary in order to secure from
the employee’s physician, clinic, psychologist, or other professional, copies of all his/her pertinent medical
records. The Hospital may require, at its own expense, an employee to submit to a drug test at any time.
Refusal to submit to any of the foregoing examinations/tests may result in discipline, up to and including,
discharge.

Discrimination and harassment
Garden City Hospital will not tolerate unlawful discrimination or harassment by any of its employees, officers,
directors, vendors, contractors or others doing business with the Hospital. Unwelcome sexual advances,
requests for sexual favors or other verbal or physical conduct relating to any individual’s sex, race, color, national
origin, age, religion, height, weight, marital status or disability constitutes harassment when:

 Submission to the conduct is made either an explicit or implicit condition of employment;
 Submission to or rejection of the conduct is used as the basis for an employment decision affecting the
harassed employee; or
 The harassment substantially interferes with an employee’s work performance; creates an intimidating,
hostile, offensive or abusive work environment; or otherwise adversely affects an individual’s employment
opportunities.

Any employee or applicant who believes he or she has suffered discrimination or harassment shall report the
incident(s) to his or her supervisor, to the Vice President of Human Resources, or to any member of
management. Garden City Hospital guarantees that an employee reporting incident(s) of discrimination or
harassment will not suffer any form of reprisal.

In determining whether the alleged conduct constitutes discrimination or harassment, the totality of the
circumstances, the nature of the discrimination or harassment and the context in which the alleged incident(s)
occurred will be investigated. Garden City Hospital has the responsibility of investigating and resolving
complaints of discrimination and harassment. The results of an investigation and any action taken thereon will
be communicated to the complaining employee.

Garden City Hospital considers discrimination or harassment on the basis of religion, race, color, national origin,
age, sex, height, weight, marital status, or disability to be a major offense which may result in disciplinary action
against the offender, regardless of the offender’s position with Garden City Hospital.

Workplace violence policy
It is the policy of Garden City Hospital to provide all employees with a workplace free of personal threats and
intimidation. We are firmly committed to a policy of zero tolerance as it pertains to acts of violence, threats of
violence or other threatening and/or intimidating behavior. Such behavior includes, but is not limited to, the
following:
 Acts of physical violence in the workplace or involving the workplace.
 Casual or joking remarks (including remarks made in jest, horseplay) or any threat of violence. The
articulation of same will be presumed to constitute a statement of an employee’s intent to do physical harm
to another employee, person, customer, visitor, or Garden City Hospital.
 Any act of sabotage, or threat of an act of sabotage, against the property of Garden City Hospital, an
employee, customer or visitor.
 Any threat of violence or conduct which creates a hostile, abusive or intimidating work environment.

All employees have a good faith responsibility to assist the Hospital in providing a workplace free of violence,
threats and/or intimidation. It is the affirmative obligation of every employee to immediately report any
violation of this policy to his/her supervisor, or to any member of management. An employee reporting a
violation of this policy will not suffer any form of reprisal of any kind.

Garden City Hospital has the responsibility of investigating and resolving alleged threats or acts of violence.
Garden City Hospital reserves the right to take the appropriate legal action it deems necessary and to report
threats or acts of violence or sabotage to law enforcement authorities.

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Garden City Hospital reserves the right to discipline, up to and including discharge, any employee who
violates this policy.

Drug free workplace
It is the policy of Garden City Hospital and its affiliates to provide safe patient care according to prevailing
standards and to insure that all of its employees are able to function properly and are not impaired due to the
use of drugs or alcohol. The consumption, possession, distribution, sale, offering for sale or being under the
influence of intoxicants, narcotics or other legally controlled substances while on Hospital property at any
time is prohibited, unless the use has been prescribed and determined to be safe for use while performing
their job function by the employee’s personal physician. In the case of suspected impairment of a healthcare
provider, the Vice President of Medical Education and/or the Chief Medical Officer should be contacted.

Hospital Policies for patient care
Policies regarding hospital operations, patient care, documentation and other matters may be found in the
patient care areas and on the hospital intranet. House staff are encouraged to familiarize themselves with
these policies. Key policies and procedures will be reviewed as part of New House Staff Orientation and
discussed during didactic programs.

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OGME-1 Requirements
Hours of duty and scheduling

Overview
For OGME-1 house staff, hours of duty on most rotations are 7:00 am to 7:00 pm Monday through Friday.
Exceptions are Emergency Medicine, which produces a shift schedule each month; House Medicine Float-
Nights, which is described below. Individual services may require or patient care may dictate earlier arrival
and/or later departure. In the event that assigned duties are completed prior to 7:00 pm, OGME-1’s may
leave early provided that they first contact the day house officer to sign out. It is the discretion of the day
house officer to agree to cover until the end of shift. If there are patient care needs, such as patients
awaiting admission, OGME-1’s are expected to work collaboratively in the best interest of the patients. See
guidelines on assignment of H&P’s for more information.

Hours for the House Medicine Float-Days (“Day House”) rotation are from 7:00 am to 7:00 pm Monday
through Friday. Hours for the House Medicine Float-Nights (“Night House”) rotation are from 7:00 pm and to
7:00 am the following day. Night House shifts are scheduled Sunday night through Thursday night.

OGME-1 weekend call is assigned as follows: Weekend day shifts begin at 7:00 am and end at 7:00 pm
both Saturday and Sunday. Weekend nights shifts are from 7:00 pm Friday to 7:00 am Saturday and 7:00
pm Saturday to 7:00 am Sunday.

Rotation Objectives
Description and objectives for current OGME-1 rotations will be distributed to OGME-1 house staff prior to
the start of the academic year and/or made available online.

Lectures and Attendance
The GCH Academic Calendar is published monthly and shows scheduled didactic programs. A morning
conference is scheduled for each weekday at 7:15 am in Classrooms A/B. Noon conferences, meetings and
workshops are scheduled several times per week. OGME-1 house staff are expected to attend morning
and noon conferences. Attendance will be tracked and reported to the Physician Education
Committee and the residency program directors.

Block didactics, journal clubs, and other conferences are also held throughout the month; consult the
Academic Calendar for details. Education Day programs are sponsored by the Statewide Campus System.
A schedule of events is available on the SCS website at www.com.msu.edu/scs and on the Calendar on the
GCH Medical Education website at www.gchmeded.org. For more information, see the Lectures and
Conferences section of this Manual.

Evaluations
OGME-1 house staff will be responsible for submitting the following evaluations for each rotation:

Evaluation of your performance:
 House Staff Performance Evaluation: completed by the supervising attending physician or resident.
This may be done electronically via New Innovations or using the paper version of the form.

Evaluations you complete via New Innovations:
 House Staff Evaluation of Rotation: completed by you to evaluate the rotation.
 House Staff Evaluation of Faculty: completed by you to evaluate the attendings and/or residents with
whom you rotated.
 House Staff Self-Evaluation Form: completed by you to evaluate your own performance and learning
on the rotation.

Quarterly evaluations
All OGME-1 house staff will schedule quarterly meetings with the VPME to review academic progress, logs,
and evaluations completed to date. In addition, many OGME-1 house staff will have quarterly evaluations
with their residency program director.

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Logs
All OGME-1 house staff will complete logs of their patient care and academic activities for each rotation.
Some of the logs will follow the OGME-1’s specialty college requirements. Due to the internship
restructuring for 2008, this is relatively new information and may continue to evolve. An overview of log
requirements is described below

Specialty/Program OGME-1 requirements OGME-2 and beyond
Diagnostic Radiology Rotation log form for each rotation Logs required.

Emergency Medicine Rotation log form for each rotation Logs required. May be printed
through Emergisoft for in-house
rotations
Family Medicine Rotation log form for each rotation Continuity clinic patient log and
procedure logs, format to be
determined
General Surgery Rotation log form for each rotation Surgical logs to be entered via
May access the ACOS log system the ACOS log system
Internal Medicine Rotation log form for each rotation, Daily inpatient logs not required
plus continuity clinic and procedure Continuity clinic and procedure
logs per ACOI protocol logs per ACOI protocol are
required.
Neurological Surgery Rotation log form for each rotation Surgical logs to be entered via
May access the ACOS log system the ACOS log system
Neurology Rotation log form for each rotation Format to be determined

OBGYN Logs completed on eLogs system OGME-1 through -4

Orthopedic Surgery Rotation log form for each rotation Surgical logs to be entered via
the AOAO log system
Urological Surgery Rotation log form for each rotation Surgical logs to be entered via
May access the ACOS log system the ACOS log system
TRI (Rotating Internship) Rotation log form for each rotation n/a

The “Rotation Log Form” refers to the GCH Rotation Log Form which is available on the GCH Medical
Education Website at www.gchmeded.org – click on Resources and Links > GCH Downloads. A copy is also
available in the Forms section of this Manual.

Data may be entered onto the form in any of the following 3 ways.
1. Download to a desktop PC and enter data.
2. Download to a desktop PC and then upload to a PDA as a Word Document.
3. Print out as a paper document and enter data manually (handwritten).

When the form is complete, it is to be signed by the intern/resident and the supervising physician, then
turned in to Medical Education. Logs will be due within 2 weeks of the completion of each rotation. It is
suggested that house staff keep copies of logs for their personal records.

General Residency Guidelines
Each residency program will provide guidelines to its residents, to include a Residency Program Description
and Requirement Checklists. These will be distributed directly to the residents and/or made available online.

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