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									                                 FRANKLIN MEMORIAL HOSPITAL

                                          MEDICAL STAFF

                                       RULES & REGULATIONS

Revised by:
Medical Staff: April 4, 2011
FMH Board of Trustee: April 26, 2011
Proposed Changes to the FMH Medical Staff Rules & Regulations

                                              MEDICAL STAFF RULES & REGULATIONS

                                                             TABLE OF CONTENTS

A.       ADMISSION AND DISCHARGE OF PATIENTS ........................................................................................... 3

B.       MEDICAL RECORDS .................................................................................................................................... 5

C.       GENERAL CONDUCT OF CARE .................................................................................................................. 8

D.       GENERAL RULES REGARDING SURGICAL CARE ................................................................................... 11

E.       EMERGENCY SERVICES............................................................................................................................ 14

F.       INTENSIVE CARE UNIT .............................................................................................................................. 15

G.       CLINICAL SERVICE ..................................................................................................................................... 15

H.       HEALTH PROFESSION STUDENTS ........................................................................................................... 16

I        INTERN AND RESIDENT DOCTORS OF MEDICINE OR OSTEOPATHY.................................................. 16

J.       MOONLIGHTING RESIDENTS .................................................................................................................... 17

K.       EMERGENCY MEDICAL TECHNICIANS .................................................................................................... 18

Proposed Changes to the FMH Medical Staff Rules & Regulations
                                    MEDICAL STAFF RULES & REGULATIONS

         1.       The hospital shall accept all medical and surgical patients for admitting as per paragraph two
         2.       Only a member of the medical staff may admit a patient to the hospital, except for special situations
                  as outlined in the Bylaws. All practitioners shall be governed by the official admitting policy of the
         3.       A member of the medical staff shall be responsible for the medical care and treatment of each
                  patient in the hospital, for the prompt completeness and accuracy of the medical record, for
                  necessary special instructions, and for transmitting reports of the condition of the patient to the
                  referring practitioner and to relatives of the patient where permitted by state and federal law
                  (HIPPA). Whenever these responsibilities are transferred to another staff member of another
                  practice, a note covering the transfer of responsibility shall be entered on the order sheet of the
                  medical record.
         4.       Except in an emergency, no patient shall be admitted to the hospital until provisional diagnosis or
                  valid reason for admission has been stated. In the case of an emergency such statement shall be
                  recorded as soon as possible.
         5.       In an emergency case in which it appears the patient will have to be admitted to the hospital, the
                  practitioner shall when possible, first contact the admitting office to ascertain whether there is an
                  available bed.
         6.       Practitioners admitting emergency cases shall be prepared to justify to the executive committee of
                  the medical staff and the administration of the hospital that the said emergency admission was a
                  bona fide emergency. The history and physical examination must clearly justify the patient being
                  admitted on an emergency basis and these findings must be recorded on the patient's chart as
                  soon as possible after admission.
         7.       A patient needing admission on an emergency basis who does not have a practitioner on staff may
                  select any practitioner who agrees to so serve in the applicable service to attend to him. Where no
                  such selection is made, a member of the active or provisional staff on duty in that service will be
                  assigned to the patient, on a rotation basis, where possible. The chief of each service shall provide
                  a schedule for such assignments.
         8.       The chief admitting clerk will schedule patients for admission on the basis of the following order of
                  a) Emergency Admissions. Adequate documentation will be made within 48 hours of such an
Proposed Changes to the FMH Medical Staff Rules & Regulations
                  b) Pre-Operative Admissions. This includes all patients already scheduled for surgery. If it is not
                       possible to handle all such admissions, the chief of the surgical service may decide the
                       urgency of any specific admission.
                  c) Routine Admissions. This will include elective admissions involving all services.
         9.       Patient Transfers. Transfer priorities shall be as follows:
                  a) Emergency Room to appropriate patient bed
                  b) From obstetric patient care area (unit) to general care area, when medically indicated.
                  c) From intensive care unit to post coronary care or general care area.
                  d) From temporary placement in an inappropriate geographical or clinical service area to the
                        appropriate area for that patient. No patient will be transferred without such transfer being
                        approved by the responsible practitioner.
         10.      The admitting practitioner shall be held responsible for giving such information as may be
                  necessary to assure the protection of the patient from self harm and to assure the protection of
                  others whenever his/her patients might be a source of danger from any cause whatever.
         11       Admission to Intensive Care Units
                  If any question as to the validity of admission to or discharge from the intensive care unit should
                  arise, that decision is to be made through consultation with the chairman of ICU or his/her
         12       Utilization
                  a) The attending practitioner is required to document the need for continued hospitalization after
                        specific periods of stay as identified by the utilization reviewers of this hospital, and approved
                        by the executive committee of the medical staff. This document must contain:
                       1. An adequate written record of the reason for continued hospitalization.               A simple
                            reconfirmation of the patient's diagnosis is not sufficient.
                       2. Plans for post-hospital care.
                  b)    Upon request of the reviewers dealing with utilization, the attending practitioner must provide
                        written justification of the necessity for continued hospitalization of any patient. This report
                        must be submitted within one working day of receipt of such request.
                  c)    Failure of compliance with this policy will be brought to the attention of the executive
                        committee for action.
         13.      A patient shall be discharged only on a written order of the attending practitioner. Should a patient
                  leave the hospital against the advice of the attending practitioner or without proper discharge, a
                  notation of the incident shall be made in the patient’s medical record.

Proposed Changes to the FMH Medical Staff Rules & Regulations

A. Admission & Discharge of Patients
           14.     In the event of a hospital death, the deceased shall be pronounced dead by the attending
                   practitioner or his/her designee within a reasonable time. The body shall not be released until an
                   entry has been made and signed in the medical record of the deceased by a member of the
                   medical staff or a member of the AHP staff. Exceptions shall be made in those instances of
                   incontrovertible and irreversible terminal disease wherein the patient's course has been adequately
                   documented to within a few hours of death. Policies with respect to release of dead bodies shall
                   conform to state law.
           15.     It shall be the duty of all staff members to seek to determine if an autopsy is appropriate in any
                   case of unusual deaths and of medical-legal and educational interest, and informs the medical staff
                   (specifically the attending physician) of any autopsy that the hospital intends to perform..1 An
                   autopsy may be performed only with a written consent, signed in accordance with state law or as
                   authorized by the office of the Chief Medical Examiner in the case of a death coming within the
                   purview of that office. (Also see C. 12 for obligations regarding autopsies. All autopsies shall be
                   performed by the hospital pathologist or by a practitioner delegated this responsibility. Provisional
                   anatomic diagnoses shall be recorded on the medical record within two working days and the
                   complete protocol should be made part of the record within 3 months.2

           1.      The attending practitioner shall be responsible for the preparation of a complete and legible
                   medical record for each patient. Its contents shall be pertinent and current. This record shall
                   include identification data; complaint; personal history; family history; history of present illness;
                   physical examination; special reports such as consultations, clinical laboratory and radiology
                   services, and others; provisional diagnosis; medical or surgical treatment; operative report;
                   pathological findings; progress notes; final diagnosis; condition on discharge; summary or
                   discharge note (clinical resume); discharge instructions and follow-up plans; and autopsy report
                   when performed.
            2.     A complete admission history and physical examination shall be recorded within 24 hours of an
                   inpatient admission, for patients held for extended observation over 12 hours or for any patient on
                   whom an operating room procedure is performed. This report shall include all pertinent findings
                   resulting from an assessment of all the systems of the body. If a complete history has been

    College of American Pathologists, ANP.33100
Proposed Changes to the FMH Medical Staff Rules & Regulations
                    recorded and a physical examination performed within 30 days of the patient's admission to the
                    hospital, or prior to the observation period or operating room procedure, a reasonably durable,
                    legible copy of these reports may be used in the patient's hospital medical record in lieu of the
                    admission history and report of the physical examination, provided these reports were recorded by
                    a member of the medical staff or are countersigned consistent with the provisions in subsection 4,
                    below. In such instances, when the medical history and physical examination are completed within
                    30 days prior to registration or inpatient admission, an update documenting any changes in the
                    patient’s condition is completed within 24 hours after registration or inpatient admission, but prior to
                    surgery or a procedure requiring anesthesia services.3 The update must include all additions to the
                    history, any subsequent changes in the physical findings or patient condition, and any changes to
                    the patient assessment and care plans. The medical history and physical examination are
                    completed and documented by a physician, an oral maxillofacial surgeon, or other qualified
                    licensed individual in accordance with state law and hospital policy.4
           3.       When the history and physical examination or update are not recorded before an operation or any
                    potentially hazardous diagnostic procedure, the procedure shall be canceled, unless the attending
                    physician states in writing that such delay would be detrimental to the patient.
           4.       The attending physician shall countersign (authenticate) the history, physical examination and pre-
                    operative note when they have been recorded by an individual other than a member of the medical
                    staff. The attending physician is required to countersign only those portions of the history and
                    physical or preoperative note that he did not prepare.
            5.      Pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity
                    and transferability of care. Wherever possible, each of the patient's problems should be clearly
                    identified in the progress notes and correlated with specific orders as well as results of tests and
                    treatment. Progress notes shall be written daily on all patients unless they are awaiting nursing
                    home placement or are at SNF level.

    §482.22 (c)(5)(i) / MS.01.01.01
Proposed Changes to the FMH Medical Staff Rules & Regulations

         6.       A full operative report is entered into the medical record upon completion of any operation or
                  high-risk procedure. For the purposes of this section, entered means to be made available for
                  immediate review. The full operative report is entered prior to transferring the patient to the next
                  level of care unless the provider accompanies that patient to that level of care. The full operative
                  report is then entered at that level of care. If the full operative report cannot be entered at that
                  time, then a brief operative note is entered into the medical record. Both the full operative report
                  and a brief operative note contain the following minimal information; the name of the surgeon and
                  assistant, procedure performed procedure findings, estimated blood loss, specimens removed, and
                  postoperative diagnosis. The full operative report shall include a detailed account of the findings at
                  surgery as well as the details of the surgical technique and may be written or dictated. The full
                  operative narrative report is dictated or written within 24 hours of the procedure in cases where a
                  brief operative note was entered immediately following the procedure.

         7.       Consultations shall show evidence of a review of the patient's record by the consultant, pertinent
                  findings on examination of the patient, the consultant's opinion and recommendations. This report
                  shall within 24 hours be made a part of the patient's record, in order to be available to the physician
                  or other care providers to use in making assessments of the patient’s condition, to justify treatment
                  or continued hospitalization to support or revise the patients’ diagnosis, to support or revised the
                  plan of care, to describe the patients’ progress and to describe the patient’s response to
                  medications, treatments or services.
         8.       The current obstetrical record shall include a complete prenatal record. The prenatal record may
                  be a legible copy of the attending practitioner's office record transferred to the hospital before
                  admission, but an interval admission note must be written that includes pertinent additions to the
                  history and any subsequent changes in the physical findings.
         9.       All clinical entries in the patient's medical record shall be authenticated and bear the date, and time
                  of entry. Identification of the author may be by written signature, initials, computer key or other
         10.      Symbols and abbreviations may be used only when they have been approved by the medical staff.
                  An official record of approved abbreviations shall be kept on file in the record room.
         11.      A discharge summary (clinical resume) shall be written or dictated within 15 days of discharge on
                  all medical records of patients hospitalized. In all instances, the content of the medical record shall
                  be sufficient to justify the diagnosis and warrant the treatment and end results. All summaries shall
                  be authenticated by the responsible practitioner.

Proposed Changes to the FMH Medical Staff Rules & Regulations
         12.      Written consent of the patient is required for release of personally identifiable medical information
                  to persons not otherwise authorized by state or federal law (HIPPA) to receive this information.
         13.      Records may be removed from the hospital's jurisdiction and safekeeping only in accordance with
                  a court order, subpoena, or statute. All records are the property of the hospital and shall not
                  otherwise be taken away without permission of the chief executive officer. In case of re-admission
                  of a patient, all previous records shall be available for the use of the attending practitioner. This
                  shall apply whether the patient is attended by the same practitioner or by another. Unauthorized
                  removal of charts from the hospital is grounds for suspension of the practitioner for a period to be
                  determined by the executive committee of the medical staff.
         14.      Free access to all medical records of all patients shall be afforded to members of the medical staff
                  for bona fide study and research consistent with preserving the confidentiality of personal
                  information concerning the individual patients. All such projects shall be approved by the executive
                  committee of the medical staff before records can be studied. Subject to the discretion of the chief
                  executive officer, former members of the medical staff shall be permitted free access to information
                  from the medical records of their patients covering all periods during which they attended such
                  patients in the hospital.
         15.      A medical record shall not be permanently filed until it is completed by the responsible practitioner
                  or is ordered filed by the medical records committee.
         16.      A practitioner's routine standing orders, when applicable to a given patient, shall be reproduced in
                  detail on the order sheet of the patient's record, dated, timed and signed by the practitioner.
         17.      The patient's medical record shall be complete at time of discharge, including progress notes, final
                  diagnosis and dictated clinical resume. Where this is not possible because final laboratory or other
                  essential reports have not been received at the time of discharge, the patient's chart will be
                  available in a stated place in the medical record room for 15 days after discharge. After written and
                  verbal warning of failure to complete patient records within 30 days after discharge, a practitioner
                  will received an “administrative withdrawal of privileges” as defined in the Practitioner Suspension
                  for Failure to Complete Medical Records policy. Hospital privileges will be reinstated; one the
                  practitioner has notified the administrator on call that his/her records are complete.
         18.      Authentication of medical records may occur by means of personal signature, a signature stamp
                  used personally by the practitioner, or an electronic means of authentication appropriately
                  protected by password or electronic key system. If a signature stamp is utilized, the practitioner
                  whose signature the stamp represents shall place in the administrative offices of the hospital a
                  signed statement to the effect that they are the only person who has the stamp and used it. There
                  shall be no delegation to another individual. Any unauthorized uses of the stamp, a computer key

Proposed Changes to the FMH Medical Staff Rules & Regulations
                  or other code signature shall be referred to the Executive Committee and may be grounds for
                  discipline under the provisions of the medical staff bylaws.

            1. Except in an emergency, a general consent form, signed by or on behalf of each patient admitted to
                 the hospital, must be obtained at the time of admission. The admitting officer should notify the
                 attending practitioner whenever such consent has not been obtained. When so notified, it shall,
                 except in emergency situations, be the practitioner's obligation to obtain proper consent before the
                 patient is treated in the hospital.
            2. All orders for treatment shall be in writing, except for verbal orders given and implemented in
                 accordance with this section. Verbal orders are limited to urgent situations where immediate written
                 or electronic communication is not feasible. They shall be used only to meet the medical care
                 needs of the patient when the ordering practitioner is unable to write the order themselves. Verbal
                 orders are not to be used for the convenience of the ordering practitioner.

                  Verbal orders, when necessary, shall be dictated to:
                  a) a licensed nurse
                  b) a licensed pharmacist
                  c) a licensed respiratory therapist
                  d) another qualified person authorized to accept such orders consistent with state and federal law
                  All such verbal orders shall be
                  a) signed, dated and timed by the appropriate person when dictated
                  b) repeated back to the practitioner ordering (repeated and verified)

                  Authenticated by the responsible practitioner within 48 hours of giving the order.

                  If the responsible practitioner is not available to authenticate the order within 48 hours, such order
                  may be countersigned by the covering physician who attends the patient within the 48 hour period.
                  The covering physician countersigning the order assumes full responsibility for the order as being
                  complete, accurate and final.

                  Failure of the responsible practitioner to authenticate such order within 48 hours shall be referred
                  to the Medical Staff Executive Committee for appropriate action consistent with the Medical Staff

Proposed Changes to the FMH Medical Staff Rules & Regulations

         3.         The practitioner's orders must be written clearly, legibly and completely and in black ink.
         4.         Standing orders in general use will be reviewed annually at the respective medical service. A
                    physician may adopt standing orders for personal use and must review them each year.
         5.         All previous orders are canceled when patients go to surgery.
         6.         Automatic stop order shall exist for antibiotics and narcotics unless otherwise specified in the
                    physician orders. Before cancellation the nursing service shall consult the physician. A listing of
                    specific medications for which automatic stop orders are required shall be adopted as needed as
                    part of the Pharmacy & Therapeutics function and maintained by the pharmacy. The pharmacist
                    will notify the physician with a Stop Order when a medication must be renewed. The physician will
                    have 23 hours to renew, change or discontinue the order. If not renewed within 23 hours,
                    pharmacy will contact the physician directly indicating the order in question will be discontinued
                    unless the order is renewed.
         7.         Drugs and Medications
                    7-1        All drugs and medications administered to patients shall be those listed in the latest
                               edition of:     United States Pharmacopoeia, National Formulary, American Hospital
                               Formulary Service or A.M.A. Drug Evaluations. Such drugs may be administered as
                               ordered unless subject to written pharmacy and therapeutic policy.
                    7-2        Investigational drugs may be used in accordance with written pharmacy and therapeutic
                               policy, with the Statement of Principles Involved in the Use of Investigational Drugs in
                               Hospitals, and all regulations of the Federal Drug Administration.
         8.         Any qualified practitioner with clinical privileges in this hospital can be called for consultation within
                    his/her area of expertise.
         9.         The attending practitioner is primarily responsible for requesting consultation when indicated and
                          for calling in a qualified consultant.
                          a.   consultation shall be ordered when:
                               1. the attending physician deems it necessary
                               2. as required by services
                          b.   the requesting physician should indicate if he wishes consultant to renderopinion only,
                                   assume management of a specific problem, or accept patient in transfer.
              11.         If a nurse has any reason to doubt or question the care provided to any patient or believes that
                          appropriate consultation is needed and has not been obtained, she shall call this to the
                          attention of her superior who will contact the attending physician. If warranted the matter will
                          be referred to the chief of the service wherein the practitioner has clinical privileges. Where

Proposed Changes to the FMH Medical Staff Rules & Regulations
                     circumstances are such as to justify such action, the chief of the service may himself request a
            12.      Autopsies:
                     12-1 Indications
                      It is recommended that the physician responsible for a deceased patient’s care seek
                      permission to obtain an autopsy in the following circumstances:
                      a) Explain unknown and unanticipated medical complications.
                      b) Cause of death is not known with certainty on clinical grounds.
                      c) To help allay concerns of family and/or public; provide reassurance.
                      d) Unexpected or unexplained death occurring during or following any dental, medical, or
                           surgical diagnostic procedures, therapies.
                      e) In patients who have participated in clinical trials.
                      f)   Unexpected or unexplained deaths which are apparently natural and not subject to a
                           forensic medical jurisdiction.
                      g) Natural deaths which are subject to, but waived by a forensic medical jurisdiction, such as
                           DOA, deaths within 24 hours of admission, deaths in which the patient sustained or
                           apparently sustained an injury while hospitalized.
                      h) Deaths which resulted from high-risk infectious and contagious diseases.
                      i)   All obstetric, neonatal, pediatric deaths.
                      j)   Deaths at any age in which autopsy may disclose a known or suspected illness which also
                           may have a bearing on survivors or transplant recipients.
                      k) Deaths known or suspected to have resulted from environmental or occupational hazards.
                  12-2.    Permission
                           Permission for performance of an autopsy must be obtained from the deceased patient’s
                           next of kin or other legally appointed person by the attending physician or his/her
                           designee in all cases. Permission will be documented on forms available from the
                           Pathology Services. Permission may also be granted by authorities within the office of the
                           Chief Medical Examiner in cases coming within its jurisdiction.

                  12-3.    Notification
                           The Pathology Department will notify the attending physician of the time, date, and
                           location where the autopsy will be performed and invite the attending physician and other
                           interested practitioners to attend the autopsy.
                  12-4.    Presentation

Proposed Changes to the FMH Medical Staff Rules & Regulations
                            The clinical aspects and autopsy findings will be discussed at the appropriate Service
                            meetings on all cases in which an autopsy has been performed.
              13. Restraints:
                   Restraint standing orders will be followed as outlined in the State and Federal regulations and the
                   policies of Franklin Memorial Hospital.

         1.        Except in severe emergencies, the history and physical examination, the preoperative diagnosis
                   and clinically indicated laboratory tests must be recorded on the patient's medical record prior to
                   any surgical procedure. The history and physical examination shall have been recorded within 30
                   days before the surgical procedure is performed or within 24 hours after inpatient admission. If
                   performed within 30 days of admission, an update documenting any changes in the patient’s
                   condition must be completed within 24 hours after inpatient admission or prior to surgery. If not
                   recorded, the operation shall be canceled. In any emergency the practitioner shall make at least a
                   comprehensive note regarding the patient's condition prior to the induction of anesthesia and the
                   commencement of the surgical procedure.
         2.        A patient admitted for dental care is a dual responsibility involving the dentist and physician
                   member of the medical staff.
                   2-1 Dentist's Responsibilities
                            a. A detailed dental history justifying hospital admission.
                            b. A detailed description of the examination of the oral cavity and a preoperative
                            c. A complete operative report, describing the findings and technique. In cases of
                                 extraction of teeth the dentist shall clearly state the number of teeth and fragments
                                 removed. All tissue including teeth and fragments shall be sent to the hospital
                                 pathologist for examination.
                            d. Progress notes as are pertinent to the oral condition.
                            e. Clinical resume (or summary statement).
                            f.   The discharge of the patient shall be on written order of the dentist member of the
                                 medical staff.
                   2-2      Doctors of medicine or osteopathy' Responsibilities:
                            a. Medical history pertinent to the patient's general health.
                            b. A physical examination to determine the patient's condition prior to anesthesia and

Proposed Changes to the FMH Medical Staff Rules & Regulations
                           c. Supervision of the patient's general health status while hospitalized.
         3.       Written, signed, informed, surgical consent shall be obtained prior to the operative procedure
                  except in those situations wherein the patient's life is in jeopardy and suitable signatures cannot be
                  obtained due to the condition of the patient. Consent forms must have been signed within 60 days
                  prior to performance of surgery. In emergencies involving a minor or unconscious patient in which
                  consent for surgery cannot be immediately obtained from parents, guardian or next of kin or other
                  legally authorized person, the procedure may be performed but these circumstances should be
                  fully explained on the patient's medical record. A consultation in such instances may be desirable
                  before the emergency operative procedure is undertaken if time permits.
         4.     The anesthetist shall maintain a complete anesthesia record to include evidence of pre-anesthetic
                  evaluation and post-anesthetic evaluation and post-anesthetic follow-up of the patient's condition.
                  In the event that the anesthetist has performed a pre-anesthetic evaluation prior to the immediate
                  operative period, he/she must update and record the pre-anesthetic evaluation to include an
                  evaluation of the patient’s immediate pre-operative status.
         5.     A list of case types for which a surgical assistant is required shall be maintained and updated by
                  Surgical Services no less than every three years. The following practitioner categories shall be
                  allowed to function as surgical first assistants: doctors of medicine or osteopathy, physician
                  assistants, nurse practitioners, RN first assistants, CNM first assistants and Certified Surgical
                  Technician first assistants. No practitioner shall assist at surgery without being privileged to do so
                  under these Bylaws, Rules and Regulations.
         6.      Except in an emergency, in any surgical procedure with unusual hazard to life, there must be a
                  second surgeon who is qualified and credentialed by the medical staff present and scrubbed. A
                  listing shall be maintained of case types for which a second surgeon shall be required.
         7.     All tissues removed in the hospital, except those specifically excluded by written hospital policy,
                  removed at the operation shall be sent to the hospital pathologist or another licensed pathologist
                  who shall make such examination as he may consider necessary to arrive at a tissue diagnosis.
                  His/her authenticated report shall be made part of the patient's medical record.
         8.       Surgeons must be in the operating room and ready to commence operation at the time scheduled
                  and except in emergency situations, the operating room will be held no longer than 15 minutes
                  after scheduled time.
         9.       In general the more serious operations should have priority over elective cases to permit more
                  prolonged recovery room observation.

Proposed Changes to the FMH Medical Staff Rules & Regulations
         10.During such times as there may be a shortage of personnel due to vacations or illnesses, the scheduling
                  of minor cases requiring general anesthesia shall be at the discretion of the operating room
                  supervisor or his/her representative.
         11.    A sponge, instrument, and needle count is to be taken on all surgical procedures. The decision that
                  such count is not necessary will be the surgeon's and the count sheet of the patient shall make
                  note of that decision. On completion the count sheet of the patient shall become a permanent part
                  of the patient's record.
         12.     A roster shall be maintained of all practitioners, including surgical assistants, and their specific
                  surgical privileges.

         1.       The medical staff or other qualified and credentialed personnel shall provide 24 hour emergency
                  medical and surgical coverage for the emergency room. X-ray, laboratory, and anesthesia
                  services will be available at all hours necessary.
         2.       Twenty-four hour in-house emergency room coverage will be provided by full-time emergency
                  room doctors of medicine or osteopathy and their affiliated physician assistants or other qualified
                  and credentialed personnel.        These individuals are also required to respond to in-patient
                  emergencies pending arrival of the appropriate physician.
         3.       The routine outpatient form shall be completed and signed by the attending clinician.
         4.       This form shall include the history, significant physical and laboratory findings, diagnosis and
         5.       There shall be a plan for the case of mass casualties at the time of any major disaster, based upon
                  the hospital's capabilities in conjunction with other emergency facilities in the community. It shall
                  be developed by a committee which includes at least 1 member of the medical staff or AHP, the
                  Chief Nursing Officer or his/her designee, and a representative from hospital administration. When
                  approved by the medical staff and governing body, the plan shall be appended to this document.
         6.       All doctors of medicine or osteopathy shall be assigned to posts and it is their responsibility to
                  report to their assigned stations. The chief of medical staff and the chief executive officer or their
                  designees will work as a team to coordinate activities and directions. In case of evacuation of
                  patients from one section of the hospital to another or evacuation from hospital premises, the chief
                  of the medical staff or incident commander during the disaster will authorize the movement of
                  patients. All policies concerning direct patient care will be a joint responsibility of the service chiefs
                  and the Chief Executive officer of the hospital.

Proposed Changes to the FMH Medical Staff Rules & Regulations
         7.       The disaster plan should be rehearsed at least twice a year, preferably as part of a coordinated drill
                  in which other community emergency services participate. The drills, which should be realistic,
                  must involve the medical staff, as well as administrative, nursing and other hospital personnel. A
                  written report and evaluation of all drills shall be made.

         1.       An intensive care unit is a controlled area staffed by skilled personnel and modern emergency
                  equipment providing care of the highest quality for the acutely ill medical and surgical patients.
                  1-1      The purpose of the intensive care unit is:
                           a) To provide the best possible physical and emotional care for patients with acute
                                 myocardial infarction, arrhythmias, and other serious medical and surgical
                           b) To detect and attempt to correct danger signs that could lead to a cardiac or
                                 respiratory emergency by continuous skilled observation.
                           c) To provide definitive treatment for such emergencies.
                  1-2      Policies of the ICU
                           a) The unit director will be responsible for the conduct of the unit.
                           b) The attending physician shall at all times retain, in accordance with written ICU
                                 policies, responsibility for the medical management of his/her patient. In placing the
                                 patient in the unit, the physician indicates his/her wish for prompt resuscitative
                                 efforts. Consultation for seriously ill patients may be well advised.
                           c) The unit director will serve as liaison between the attending doctors of medicine or
                                 osteopathy and the unit nursing staff regarding priorities, policies and all other
                                 matters connected with the unit.
                  1-3      Criteria for admission to the unit include:
                           a) Those patients having suspected impending or acute myocardial infarctions.
                           b) Those patients having acute manifestations or other cardiac or life-threatening
                                 respiratory problems.

Proposed Changes to the FMH Medical Staff Rules & Regulations
                           c) Any conflicts concerning bed utilization will be resolved be the director or his/her

         1.       The Maternal & Child Health, Adult Medicine and Surgical Services shall adopt procedural
                  regulations to cover the areas of medical care, evacuation, and ongoing education.
         2.       Each service will formulate the criteria for the various medical and surgical privileges and will
                  constantly update these criteria.
         3.     Each service shall have at least six meetings each year.

         1.       Health profession students may from time to time be granted temporary clinical status at the
                  hospital for the purpose of furthering their education and of providing the intellectual stimulation of
                  teaching to the medical staff.
         2.       Applications for such temporary clinical status shall include a letter from the student’s professional
                  school attesting to his/her status as a student at the school, describing the student’s present
                  training and experience, and setting forth the school and the student’s expectations for their
                  experience at Franklin Memorial Hospital. All students shall be covered by malpractice insurance.
         3.       Students to whom temporary clinical status are granted shall be individually assigned to an
                  appropriate service and shall be responsible to the chief of that service and under the supervision
                  of a member of the medical staff. They shall not be members of the medical staff. At all times the
                  responsible member of the medical staff is responsible for the actions of the student.
         4.      Health Profession Students may interview patients, perform physical examinations, review medical
                 information, write histories, physical examinations, and other narrative notes in the medical record,
                 and perform procedures under the supervision of a member of the Medical Staff. All invasive
                 procedures must be performed under the direct supervision of a member of the Medical Staff.
         5.      All orders by students must include the name of the responsible member of the medical staff and
                 those orders must be signed by the same member of the medical staff before such orders are
                 carried out.
         6.      If the responsible practitioner is unavailable, a covering practitioner shall be designated in writing.


Proposed Changes to the FMH Medical Staff Rules & Regulations
         Intern and resident doctors of medicine or osteopathy may from time to time be granted temporary clinical
         status at the hospital for the purpose of furthering their education and providing the intellectual stimulation of
         teaching to the medical staff. Applications for such temporary clinical status shall include a letter from the
         physician’s training program hospital attesting to his/her status as a physician in training, describing the
         physician’s present training and experience, and setting forth the program and the physician’s expectations
         for their experience at Franklin Memorial Hospital. Intern and resident doctors of medicine or osteopathy to
         whom temporary clinical privileges may be granted shall be individually assigned to an appropriate service,
         shall be responsible to the chief of that service and under the supervision of a member of the medical staff.
         They shall not be members of the medical staff. At all times the responsible practitioner is responsible for
         the actions of the individual intern and/or resident. If the responsible practitioner is unavailable, a covering
         practitioner shall be designated in writing.

         From time to time, residents who are not yet eligible for Board Certification may be
         utilized at Franklin Memorial Hospital to assist Primary and Hospitalist doctors of medicine or osteopathy with practice
         coverage. The resident doctors of medicine or osteopathy are considered independent contractors and not considered
         employees of Franklin Memorial Hospital
         1. Qualifications
             The resident must:
             a)    Be independently licensed in the State of Maine (cannot moonlight on training license)
             b)    Be in their last year of residency.
             c)    Submit a letter from the director of the residency program attesting to the qualifications of the resident and
                   endorsing the activity of moonlighting
             d)    Be credentialed in accordance with Franklin Memorial Hospital Medical Staff Bylaws
         2. Overview of supervision
             The attending physician will meet with the resident and go over plans and obligations. The resident will act as the
             on-call physician and be the primary responder for the practice. The attending physician will be available
             continuously by either phone or in person during the residents’ shift.
         3   Specific rules for supervision
             a)    The resident will notify the attending of all admissions. The attending will visit and write a note within 48
                   hours of each admission
             b)    The resident will review discharge plans with the attending on all patients being discharged. The resident is
                   responsible for dictating the discharge summary and writing discharge orders.

Proposed Changes to the FMH Medical Staff Rules & Regulations
              c)   The resident will consult the attending on all transfers to the ICU or to another acute care facility.
              d)   The resident will consult with and co-manage with the attending on all ICU patients and all other seriously ill
                   or complex patients.
              e)   The attending will complete a written evaluation form as proscribed by the residents’ training program. A
                   copy of this will be retained in the residents’ file in the Office of Medical affairs and the original forwarded to
                   the residency program director.
              f)   The residents’ privileges will not exceed those of the attending physician
              g)   The resident under the direct supervision of an attending who holds the privilege to perform the procedure
                   may perform procedures.

         1.        Ambulance personnel are allowed to assist in the hospital if the following criteria are met:
                   a) the ambulance personnel must:
                             i. be a licensed E.M.T. - A or accredited by the state
                            iii. and have their credentials approved by the emergency room chief
                   b) while in the hospital, ambulance personnel wear appropriate clothing with identifying patches
                   c)   no more than three ambulance personnel be present in the emergency room at any time
                        without a patient whom they have transported.
                   d)   the ambulance personnel stay either in the emergency room itself or in the cafeteria unless
                        requested to go elsewhere by the emergency room nurse or a physician to attend a patient.


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