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Medical Staff Policy Manual_03-11

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					                                               MEDICAL STAFF POLICY MANUAL
                                           FOR MUNROE REGIONAL MEDICAL CENTER

                    MEDICAL STAFF POLICY MANUAL
SECTION 1       Medical Staff Administrative Policies
    Chapter 1   Medical Staff Membership & Privileges
    Chapter 2   Medical Staff Officers and Chiefs
    Chapter 3   Medical Staff Committees
    Chapter 4   Medical Staff Reimbursements

SECTION 2       Patient Care
    Chapter 1   Admission through Discharge
    Chapter 2   Consultations
    Chapter 3   Laboratory

SECTION 3       Departmental Policies
    Chapter 1   Anesthesia Department
    Chapter 2   Emergency Medicine Department
    Chapter 3   Family Practice Department
    Chapter 4   Medicine Department
    Chapter 5   Obstetrics and Gynecology Department
    Chapter 6   Pediatrics Department
    Chapter 7   Radiology Department
    Chapter 8   Surgery Department

SECTION 4       Mid-Level and Allied Health Professionals

SECTION 5       Ancillary Hospital Department Plans
    Chapter 1   Hospital Utilization
    Chapter 2   Infection Control
    Chapter 3   Pharmacy
    Chapter 4   Medical Records
Policy      CHAPTER         Old No.     TITLE

1 #1.01.16 MEDICAL STAFF    NEW         APPLICANT WITH LESS
           MEMBERSHIP &                 THAN MINIMUM INPATIENTS
           PRIVILEGES                   - FPPE




1 #1.03.08 MEDICAL STAFF    BOARD       CHILDREN IN PHYSICIAN’S
           MEMBERSHIP &     APPROVED    LOUNGE
           PRIVILEGES       02/23/09;
                            06/21/07;
                            11/28/98




1           MEDICAL STAFF   1.03.151    CONFIDENTIALITY OF
#1.03.151   MEMBERSHIP &                RECORDS
            PRIVILEGES
1 #1.03.18 MEDICAL STAFF    1.03.18    CRITERIA TO "GO BARE/
           MEMBERSHIP &                SELF-INSURE" FLORIDA
           PRIVILEGES                  STATUTE 458.320(5)(g)




1           MEDICAL STAFF   1.03.181   CREDENTIALING "FAST
#1.03.181   MEMBERSHIP &               TRACK" PROCESS
            PRIVILEGES




1           MEDICAL STAFF   NEW        CREDENTIALING FOR
#1.03.182   MEMBERSHIP &               HOSPITAL EDUCATORS
            PRIVILEGES



1 #1.04.09 MEDICAL STAFF    1.04.09    DISRUPTIVE BEHAVIOR
           MEMBERSHIP &                POLICY
           PRIVILEGES
1 #1.05.13 MEDICAL STAFF   BOARD       EMERGENCY DEPARTMENT
           MEMBERSHIP &    APPROVED,   TEMPORARY PRIVILEGES
           PRIVILEGES      02/25/08    FOR NON-APPLICANTS.




1 #1.05.17 MEDICAL STAFF   1.05.17     EQUIPMENT REQUESTS
           MEMBERSHIP &
           PRIVILEGES




1 #1.09.13 MEDICAL STAFF   1.09.13     IMPAIRMENT POLICY
           MEMBERSHIP &
           PRIVILEGES




1 #1.20.05 MEDICAL STAFF   1.20.05     TEMPORARY PRIVILEGES
           MEMBERSHIP &                FOR NON-APPLICANTS.
           PRIVILEGES




1 #1.22.05 MEDICAL STAFF   1.22.05     VERIFICATION OF
           MEMBERSHIP &                MEDICATION PRESCRIBING/
           PRIVILEGES                  ORDERING AUTHORITY
1           MEDICAL STAFF   NEW         VERIFICATION OF LICENSE
#1.22.051   MEMBERSHIP &                AND DEA CERTIFICATES
            PRIVILEGES




1 #2.04.05 MEDICAL STAFF    1.04.05     DEPARTMENT VICE-CHIEF
           OFFICERS &                   POLICY
           CHIEFS




1           MEDICAL STAFF   1.16.181    PRESIDENT COMPENSATION
#2.16.181   OFFICERS &
            CHIEFS




1 #3.03.15 MEDICAL STAFF    1.03.15     CONFIDENTIALITY OF
           COMMITTEES                   MINUTES




1 #3.03.15 MEDICAL STAFF    BOARD       COMMITTEE REMOVAL
           COMMITTEES       APPROVED,
                            01/28/08




1 #3.16.18 MEDICAL STAFF    1.16.18     PRESENTATIONS AT FULL
           COMMITTEES                   MEDICAL STAFF MEETINGS
1           MEDICAL STAFF BOARD        EA REIMBURSEMENT FOR
#4.05.012   REIMBURSEMENT APPROVED,    PULMONOLOGISTS
            S             08/25/2008




1           MEDICAL STAFF 1.16.08      PHYSICIAN COURTESY
#4.16.081   REIMBURSEMENT
            S




2 #1.01.03 ADMISSION THRU 7.01.03      ACCEPTANCE OF VERBAL
           DISCHARGE                   ORDERS:




2 #1.01.04 ADMISSION THRU 5.01.04      ADMISSION BY STAFF
           DISCHARGE                   MEMBERS ONLY
2           ADMISSION THRU BOARD       ADMISSION OF PREGNANT
#1.01.041   DISCHARGE      APPROVED,   PATIENTS
                           9/29/08




2           ADMISSION THRU 7.01.04     ADVANCED DIRECTIVES
#1.01.042   DISCHARGE




2 #1.01.22 ADMISSION THRU 4.01.22      AVAILABLE BED
           DISCHARGE




2 #1.03.01 ADMISSION THRU 7.03.01      CANCELLATION OF ORDERS:
           DISCHARGE




2 #1.04.01 ADMISSION THRU 3.04.01      DAILY VISITS OF PATIENTS
           DISCHARGE                   BY ATTENDING
                                       PRACTITIONERS




2 #1.04.05 ADMISSION THRU 3.04.05      DEATH PRONOUNCED BY
           DISCHARGE                   ATTENDING PRACTITIONER
2 #1.10.21 ADMISSION THRU 4.10.21          JUSTIFICATION FOR
           DISCHARGE                       EMERGENCY ADMISSIONS




2 #1.15.21 ADMISSION THRU 6.15.21 (altered) OUT-PATIENT SURGERY
           DISCHARGE




2           ADMISSION THRU 4.16.011(altered) PATIENTS WITH NO
#1.16.011   DISCHARGE                        ATTENDING PHYSICIAN




2 #1.16.08 ADMISSION THRU 3.16.08          PHYSICAL EXAMINATION
           DISCHARGE                       REQUIREMENT OF FEMALE
                                           PATIENTS




2           ADMISSION THRU 2.16.08         PHYSICIAN MUST NAME
#1.16.081   DISCHARGE                      RELIEF




2           ADMISSION THRU 4.16.08         PHYSICIAN ACCEPTANCE OF
#1.16.082   DISCHARGE                      PATIENT




2 #1.16.18 ADMISSION THRU 5.16.18          PROVISIONAL DIAGNOSIS
           DISCHARGE                       REQUIRED
2           ADMISSION THRU 5.16.181   PROTECTION OF POTENTIAL
#1.16.181   DISCHARGE                 SUICIDE PATIENTS AND
                                      PATIENTS SUFFERING FROM
                                      INTENTIONAL CHEMICAL
                                      OVERDOSE



2           ADMISSION THRU 5.16.182   PROTECTION OF PATIENT
#1.16.182   DISCHARGE                 AND OTHERS




2 #1.18.05 ADMISSION THRU 5.18.05     RESPONSIBILITY FOR
           DISCHARGE                  PATIENT ADMISSIONS




2 #1.18.21 ADMISSION THRU 4.18.21     RULES FOR TRAUMA
           DISCHARGE                  ADMISSION




2 #1.20.18 ADMISSION THRU 2.20.18     TRANSFER OF PATIENT TO
           DISCHARGE                  ANOTHER STAFF MEMBER
2           ADMISSION THRU 2.20.18        TRANSFER OF PATIENT TO
#1.20.181   DISCHARGE                     SURGEON




2 #1.21.18 HOSPITAL         NEW (Hosp     URINARY CATHETER
           UTILIZATION      Section U
                            Number    )


2 #2.03.15 CONSULTATIONS 2.03.151         CONSULTANTS CALLING
                                          CONSULTANTS




2           CONSULTATIONS 2.03.152        CONSULTATION
#2.03.151                                 REQUIREMENTS:




2 #2.05.13 CONSULTATIONS 2.05.132         EMERGENCY
                                          CONSULTATIONS
2 #3.01.12 LABORATORY   6.01.121       ALL TISSUES TO
                                       PATHOLOGY




2 #3.02.05 LABORATORY   6.02.05        BETA SUB UNIT TESTING
                                       AND/OR CHART
                                       DOCUMENTATION




2 #3.15.18 LABORATORY   BOARD              ORGAN/ TISSUE DONATION
                        APPROVED
                        (HOSPITAL
                        POLICY)
                        03/31/08
                        (Previous policy
                        of 4/11/91 on list
                        as deleted)
3 #2.03.15 EMERGENCY    4.03.15        COMMUNITY PHYSICIANS
           MEDICINE                    STATEMENT OF
           DEPARTMENT                  ARRANGEMENT




3 #2.05.13 EMERGENCY    4.05.13        EMERGENCY ON-CALL
           MEDICINE                    PHYSICIAN FOLLOW UP
           DEPARTMENT                  CARE
3           EMERGENCY    4.05.131(altered) EMERGENCY DEPARTMENT
#2.05.131   MEDICINE                       ON-CALL
            DEPARTMENT




3           EMERGENCY    4.05.132 (altered) EMERGENCY ON-CALL
#2.05.132   MEDICINE                        PHYSICIAN RESPONSIBILITY
            DEPARTMENT




3 #2.08.01 EMERGENCY     BOARD          HAND CALL REQUIREMENT
           MEDICINE      APPROVED
           DEPARTMENT    4/24/06




3 #2.08.15 EMERGENCY     4.08.15        HOSPITALIST EMERGENCY
           MEDICINE                     DEPARTMENT ON-CALL
           DEPARTMENT
3 #2.13.05 EMERGENCY    NEW         MEDICINE ED UNASSIGNED
           MEDICINE                 DISCHARGE CALL
           DEPARTMENT               ROTATION




3 #2.13.05 EMERGENCY    BOARD       MEDICINE DEPARTMENT ON-
           MEDICINE     APPROVED,   CALL
           DEPARTMENT   10/27/08




3 #2.14.15 EMERGENCY    4.14.15     NOTIFICATION BEFORE OB/
           MEDICINE                 GYN PATIENTS LEAVE
           DEPARTMENT               EMERGENCY DEPARTMENT




3 #2.15.14 EMERGENCY    1.15.14     ON CALL ASSIGNMENTS
           MEDICINE
           DEPARTMENT




3 #2.16.05 EMERGENCY    4.16.05     PEDIATRIC CALL
           MEDICINE                 RESPONSIBILITY
           DEPARTMENT




3 #2.16.15 EMERGENCY    4.16.15     POLICY ON EMERGENCY
           MEDICINE                 DEPARTMENT TEMPORARY
           DEPARTMENT               PRIVILEGES FOR NON-
                                    APPLICANTS
3 #2.19.20 EMERGENCY     4.19.20            STABLE NON-EMERGENT
           MEDICINE                         SURGICAL CONSULTS
           DEPARTMENT




3           EMERGENCY    4.19.201           STABLE PEDIATRIC
#2.19.201   MEDICINE                        SURGERY PATIENTS
            DEPARTMENT




3 #2.23.01 EMERGENCY     4.23.01(altered)   WALK-IN OB/GYN
           MEDICINE                         EMERGENCY DEPARTMENT
           DEPARTMENT                       PATIENTS




3 #5.21.19 OB & GYN      6.21.19            USE OF VIDEOTAPING
           DEPARTMENT                       EQUIPMENT IN THE
                                            OPERATING DELIVERY
                                            SUITE




3 #8.05.13 SURGERY       6.05.13            EMERGENCY WRITTEN
           DEPARTMENT                       CONSENT REQUIRED




3 #8.07.21 SURGERY       NEW                GUIDELINES FOR ASSIGNING
           DEPARTMENT                       SCHEDULED “FLIP ROOM”
                                            BLOCK TIMES
4 #1.01.12 MLP & AHP    8.01.12   ALLIED HEALTH
                                  PROFESSIONAL, LPN'S,
                                  LIMITATIONS REGARDING
                                  PHYSICAL EXAMS AND
                                  DOCUMENTATION.


4           MLP & AHP   8.01.12   ARNP, ATTENDANCE AT C-
#1.01.121                         SECTIONS




4 #1.04.15 MLP & AHP    7.04.15   DOCUMENTATION BY
                                  PHYSICIAN SPONSORED
                                  RN’S (ROUNDING NURSES)




4 #1.08.09 MLP & AHP    8.08.09   HISTORIES AND PHYSICALS
                                  BY REGISTERED NURSES




4 #1.13.09 MLP & AHP    NEW       MID-LEVEL PRACTITIONERS
                                  WITHOUT SPONSORSHIP
4 #1.15.16 MLP & AHP     6.15.16   OPERATING ROOM FIRST
                                   ASSISTANTS




4 #1.16.08 MLP & AHP     8.16.08   PHYSICIAN ALLIED HEALTH
                                   PROFESSIONAL AND
                                   STUDENTS




4 #1.19.21 MLP & AHP     NEW       SUPERVISED STUDENT
                                   CLINICAL ROTATIONS FOR
                                   MID-LEVEL PRACTITIONERS




5 #1.03.01 HOSPITAL      1.03.01   CASE REVIEW
           UTILIZATION


5 #1.09.14 HOSPITAL      NEW       INFORMATION PROTECTION
           UTILIZATION             DISCIPLINARY MEASURES




5 #1.16.01 HOSPITAL      NEW       PATIENT CARE
           UTILIZATION             COMMUNICATIONS
                                   CONTACT POLICY
                                   (PerfectServe)
5 #3.05.13 PHARMACY   1.05.13    EMERGENCY OR
                                 COMPASSIONATE USE OF
                                 INVESTIGATIONAL DRUGS/
                                 DEVICES



5 #3.09.22 PHARMACY   3.09.22    IV CONSCIOUS SEDATION
                                 POLICY




5 #3.15.18 PHARMACY   7.15.181   ORDERING FORMULARY
                                 AND NON-FORMULARY
                                 DRUGS




5 #4.01.02 MEDICAL    5.01.02    ABUSE OR NEGLECT -
           RECORDS               ALLEGED OR SUSPECTED:




5 #4.01.07 MEDICAL    7.01.07    AGAINST MEDICAL ADVICE
           RECORDS               (AMA):
5 #4.01.13 MEDICAL    6.01.13       AMBULATORY CARE,
           RECORDS                  OUTPATIENT
                                    REQUIREMENTS




5 #4.01.14 MEDICAL    6.01.14       ANESTHESIA RECORD
           RECORDS                  REQUIREMENTS:




5 #4.03.08 MEDICAL    7.03.08       CHART SIGNATURE
           RECORDS                  REQUIREMENTS




5           MEDICAL   7.03.153 (altered) CONSENT FOR TREATMENT:
#4.03.153   RECORDS
5 #4.04.05 MEDICAL    7.04.05        DEATH/ DISCHARGE
           RECORDS                   SUMMARY REQUIREMENTS:




5           MEDICAL   2.04.051(altered) DENTAL SERVICES
#4.04.051   RECORDS                     REQUIREMENTS:
5 #4.04.09 MEDICAL    7.04.09    DIAGNOSTIC RADIOLOGY
           RECORDS               SERVICES REQUIREMENTS:




5           MEDICAL   7.04.091   DIETETIC SERVICES
#4.04.091   RECORDS              REQUIREMENTS:




5 #4.04.15 MEDICAL    3.04.15    DOCUMENTED NEED FOR
           RECORDS               STAY




5 #4.05.13 MEDICAL    7.05.13    EMERGENCY DEPARTMENT
           RECORDS               REQUIREMENTS:
5 #4.06.18 MEDICAL   7.06.18       FREE ACCESS OF RECORDS
           RECORDS                 FOR BONA FIDE STUDY




5 #4.07.05 MEDICAL   7.07.05       GENERAL DOCUMENTATION
           RECORDS                 REQUIREMENTS




5 #4.08.09 MEDICAL   7.08.09 (altered) HISTORY AND PHYSICAL
           RECORDS                     REQUIREMENTS:
5           MEDICAL   7.08.091      HISTORY AND PHYSICALS
#4.08.091   RECORDS                 FOR SURGICAL AND OB




5 #4.13.05 MEDICAL    3.13.05 (altered) MEDICAL RECORD
           RECORDS                      COMPLETION




5           MEDICAL   6.15.161      OPERATIVE REPORT
#4.15.161   RECORDS                 REQUIREMENTS:




5 #4.15.18 MEDICAL    7.15.18       ORDERS REQUIREMENTS:
           RECORDS
5 #4.16.01 MEDICAL    7.16.01(altered)   PAIN MANAGEMENT
           RECORDS                       REQUIREMENTS:




5           MEDICAL   7.16.011           PATHOLOGY AND CLINICAL
#4.16.011   RECORDS                      LABORATORY SERVICES




5 #4.16.15 MEDICAL    2.16.15            PODIATRIC PATIENTS
           RECORDS                       REQUIREMENTS:




5 #4.16.18 MEDICAL    6.16.18            PREOPERATIVE
           RECORDS                       DOCUMENTATION:




5 #4.18.05 MEDICAL    7.18.05            RECORDS ARE HOSPITAL
           RECORDS                       PROPERTY
5 #4.19.05 MEDICAL   7.19.05       SERIES OUTPATIENT
           RECORDS                 SERVICES REQUIREMENTS:




5 #4.19.16 MEDICAL   7.19.16       SPECIAL TREATMENT
           RECORDS                 PROCEDURES




5 #4.19.20 MEDICAL   7.18.15 (altered) STANDING ORDERS
           RECORDS
POLICY

If an applicant has less than the required minimum numbers of inpatient at the time of initial
approval it is recommended by this policy to institute a Focused Professional Practice Evaluation
(FPPE). It has been approved that if the appointment is approved it should be with the set up of a
FPPE that requires this practitioner to have thirty (30) admissions within the first 12 months.
Each of these admissions will be reviewed by a peer. Peers eligible to conduct reviews will be
Medical Staff members of an approved Specialty and that are not practice associates.
(08/30/2010)



Children will not be permitted in the Library/ Computer section of the Physician’s Lounge. It is
expected that Medical Staff will follow Hospital policy and privacy practices not allowing their
visiting children in patient care areas. Children are not permitted to attend physician rounds.
Children that are of an appropriate age or under supervision may remain in the Physician’s lounge
area. Children’s behavior is the direct responsibility of the physician. (02/23/2009)




Physician files may be released to:
1. A duly constituted Committee of the Medical Staff at any regular or special meeting;
2. The Chief of the Physician's clinical Department;
3. An elected officer of the Medical Staff;
4. Any regular or special meeting of the Board of Directors of Munroe Regional Health System,
Inc. d/b/a Munroe Regional Medical Center;
5. An elected officer of the Board of Directors;
6. The Chief Executive Officer or his designee member of the Hospital management team.
Exception; the Physician may see only that portion of his personal file which he himself supplied
to the Medial Staff office.

Section and/or Committee minutes may be released to:
1. An elected officer of the Medical Staff acting in an official capacity;
2. The Chairman or a member of that Committee;
3. An officer of the Board of Directors;
4. The Chief Executive Officer or his designee member
of the Hospital management team;
5. Any regular or special meeting of the Executive Committee;
6. Any regular or special meeting of the Board of Directors.
The subject documents are the property of
Munroe Regional Medical Center and the Medical Staff
and may not be removed from the Hospital premises for any purpose.

Any request received for the above information from outside agencies,
by subpoena or by any person or agency other than those noted above,
 shall be referred to the Vice-President Medical Affairs. Such requests
 require prior authorization from the President of the Medical Staff or
the Chief Executive Officer or their designee. 12/4/86
A physician meeting the criteria will be eligible to fulfill professional liability requirements to
practice at Munroe Regional Medical Center by “going bare/self-insuring” as defined by Florida
Statute 458.320(5)(g). The Medical Executive Committee of the Medical Staff of Munroe
Regional will review the physician request and make a recommendation to the Hospital Board.
Application and recommendation from the MEC will be forwarded to the Hospital Board of
Munroe Regional Health System. (03/2005)
**REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.



All Physician and Mid Level Practitioners will submit a fully completed application with all
appropriate documentation to the Medical Staff personnel for full processing. If the applicant has
successfully completed required training with an excellent record, has no malpractice actions
within the past ten (10) years, , has no investigations or licensure actions, has no prior disciplinary
actions, has an unrestricted license, and all favorable evaluations the application will be presented
for expedited review. At the time that all criteria have been met and documented appropriately,
the application will be forwarded to the Chief of that Department, or designee for review and
personal interview. After completion of a successful personal interview and a positive
recommendation from the Department Chief, Chairman of the Credentials Committee, President
of the Medical Staff, and Chief Executive Officer (or designee to each signatory) and completed
Medical Staff orientation temporary admitting and clinical privileges may be granted in
accordance with Article II Part G: Procedure For Temporary Clinical Privileges of the
Bylaws: Policy on Appointment, Reappointment, and Clinical Privileges,
pending a final staff approval decision by the Board after recommendation
from the Medical Executive Committee. Authorization has been given to use the Fast Track
approval process for applicants that are requesting to return to the Medical Staff if they
have not had any disqualifying credentialing elements since they left the Medical Staff.
Their history and previous credentialing does not disqualify them since it has been reviewed
and considered during the processing of their past appointment.(Revised 8/30/2010)



Practitioners that are working at the Hospital only in the capacity of Educator do not need to be
credentialed. There are no clinical privileges appointed to these practitioners. The contract or
employment for the Educators is handled by Human Resources Department. (08/30/2010)



It is the policy of this Hospital that all individuals within its facilities be treated courteously,
respectfully, and with dignity. To that end, the Hospital requires all individuals, employees,
physicians and other independent practitioners to conduct themselves in a professional and
cooperative manner in the Hospital.
**REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.
Approved recommended policy regarding Emergency Temporary Privileges for Non-Applicants
(02/25/2008)




Medical Executive Committee will preview request for equipment of $50,000 or more before the
request would be forwarded to the Hospital Board.




The responsibility for investigating impaired (alleged or proven) physicians and/or mid level
practitioners (MLP) that are credentialed by the Medical Staff at Munroe Regional Medical
Center (MRMC) shall be transferred to the Physician Recovery Network (PRN). The Physician
Recovery Network is a Committee of the Florida Medical Association having authority, through
an understanding with the Florida Board of Medicine, to investigate, monitor and integrate
Physicians who are impaired by substance abuse, psychological or physical illness. MLPs will be
reported to the appropriate professional organized equivalent to the PRN or, alternatively, to their
respective Board.
This policy is intended only to regulate management of impaired staff and shall neither supersede
nor limit, without prior written waiver of an affected practitioner, the operation of the Medical
Staff bylaws nor limit the Board in its final authority to make a disposition.
**REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.



A practitioner may be granted temporary privileges pursuant to the Policy on Appointment,
Reappointment and Clinical Privileges of the Medical Center; to be activated upon an individual
patient care need.(1/26/09)      **REFER TO FILE DOCUMENT FOR FULL PROCEDURE
OF POLICY.



A mechanism shall be established to determine that individuals who prescribe/order medications
are legally authorized to do so. All Physicians on the Medical Staff must demonstrate licensure to
practice medicine in the State of Florida. It is acknowledged that Physicians licensed to practice
medicine are empowered to prescribe medication as part of their scope of practice.
**REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.
It is required that the license and DEA of every appointed practitioner be primary source verified
at the time of initial appointment, reappointment and when a new certificate is issued by the
agency. This verification can take the place of the certification in the credentials files. It is not
required to have the practitioner supply a copy of the certificate if the primary source verification
has been completed and filed.
Practitioner’s that have applied for licenses, but the license is not able to be verified will
automatically relinquish their privileges. Similar to the Bylaws requirement regarding delinquent
proof of insurance coverage, it “shall result in immediate automatic relinquishment of a member’s
clinical privileges. If within 60 days of the relinquishment” the verification is not available the
practitioner “shall not be considered for reinstatement and shall be considered to have voluntarily
resigned.” (08/30/2010)


The Departments of Emergency Medicine, Medicine and Surgery have been found to be
departments with a large number of members and/ or complicated departments to manage. It has
been established that these Chiefs are permitted to appoint Vice-Chiefs to assist with the
management of these departments.(10/26/09) **REFER TO FILE DOCUMENT FOR FULL
PROCEDURE OF POLICY.


Medical Staff and Munroe Regional Medical Center match funds up to $10,000 total to
compensate the Medical Staff President annually. This money shall be raised by charging dues to
the Medical Staff at reappointment time every two years.




In order to protect the confidentiality of peer review information contained in the minutes of each
Section/Subsection/Committee, such minutes will not be distributed to the medical Staff via
attachment to the groups' agendas. A copy of the minutes will be sent to the Chief/Chairman prior
to each meeting. Physicians' names or Hospital identification numbers will not be recorded in the
minutes but each will be assigned an alphabetical code at random with a key code attached to the
original minutes. 3/9/89

Approved the removal of Surgical Case/ Blood Utilization Review, Infection Control, and
Physician Health Committees. (1/28/2008)




Presentations by philanthropic organizations shall be restricted from Full Medical Staff business
meetings. 12/18/90
Approval to including Pulmonologists reimbursement (EA/ other) through the Intensivist
Program. (8/25/2008)




Physician courtesy of $5,000 will be a medical credit per year. Established for the use on medical
services provided by Munroe Regional Medical Center. 9/9/2004




A verbal order shall be considered to be valid if dictated to staff authorized to accept verbal
orders as follows:

1. Registered Nurse (including Graduate Nurse designation)
2. Licensed Practical Nurse
3. Emergency Medical Technician
4. Paramedic
5. Physician Assistant
6. Pharmacist - when relating to a medication order
7. Dietician - when relating to a nutritional order
8. Medical Technologist - when relating to a laboratory test order
9. Respiratory Therapist - when relating to a respiratory treatment order
10. EKG and EEG Technician - when relating to procedures in their area
11. Physical, Occupational and Speech Pathology Therapists - when relating to treatment in their
specialty
12. Radiology, Nuclear and Ultrasound Technician - when relating to procedures in their area.
The individual receiving each verbal order will document the name and credential of the
individual(s) who gave and received the verbal order.

A patient may be admitted to the Hospital only by an Active, Associate, or Affiliate member of
the Medical Staff. The official admitting policies of the Hospital shall govern all Practitioners.
 All pregnant patients that are admitted for an Obstetrical (OB) problem will be admitted by
OB/GYN physicians. “Gynecologist on call will care for patients with gestational age 12 weeks
or less. Obstetrics on call will care for those patients with gestational age greater than 12 weeks.”
(See policy 4.23.01) All pregnant patients that are admitted for Medical issues unrelated to the
pregnancy will be admitted by Medicine physicians. If there is a question about the problems’
cause than Medicine will take the admissions during the first trimester and OB will take the
admissions during the second and third trimester. During either circumstance the opposite group
promises to be available for consults. Medicine physicians that are uncomfortable with admitting
pregnant patients with medical issues as primary complaint can have the Hospitalists admit these
patients. (9/29/2008)



On admission, each patient is offered information by the Hospital on Advance Directives/Living
wills/Withdrawal or Withholding of Life Support Systems. If a patient decides to limit treatment
and the physician is in agreement, an order shall be written delineating limitations of the
interventions and a progress note shall be written to reflect the communication with the patient. If
the physician is uncomfortable with such decision to withdraw or withhold life support, the
physician shall likewise document this concern and shall arrange transfer or consultation to
another physician that would be acceptable to the patient. (3/30/98)



In any 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 Department to ascertain whether
there is an available bed.




All previous orders are canceled when a patients goes to surgery or is transferred from SICU and
CCU for general care.




Every patient is to be visited at least once in every 24 hours period by the Attending Practitioner
or their appropraite privileged Physician designee. In any case where this does not happen, the
Chief of the Service of the Attending Practitioner should be notified immediately.




In the event of a Hospital death, the deceased shall be pronounced dead by the Attending
Practitioner or his desgnee (the Registered Nurse) within a reasonable time. Policies with respect
to release of dead bodies shall conform to local law. The body shall not be released until a proper
authorization is signed by the next of kin desingating the funeral home of their choice.
Practitioners admitting emergency cases shall be prepared to justify to the Executive Committee
of the Medical Staff and the Administration of the Hospital the said emergency admission as a
bonafide 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


Surgery in which no admission to the Hospital is anticipated shall be classified as out-patient
surgery; Laboratory evaluates as determined by anesthesia.




When a patient is to be admitted on an emergency basis and does not have a private Practitioner, a
member of the Active or Associate Staff on call for the Department will be assigned to the patient,
on a rotational basis where possible.




To meet the psychosocial needs of female patients during sensitive physical examinations (
including but not limited to pelvic, rectal, and breast exams). This policy will demonstrate to
Munroe’s patients a sensitivity to their privacy needs and protect Munroe from patient complaints
of this nature. All medical providers will request that another hospital associate be present during
sensitive physical examinations of female patients. (Required for Labor & Delivery) (03/26/07)
**REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.




Each member of the Medical Staff who is not available to attend their patient shall name an
appropriately privileged member of the Medical Staff who may be called to attend his patients in
an emergency or until he arrives. In case of failure to name such associate, the Chief Executive
Officer of the Hospital, President of the Medical Staff, or Chief of the Department concerned
shall have the authority to call any member of the Active Staff in such events.


If a physician accepts a patient at admission through the Emergency Department by phone or in
person, then that patient shall remain in that physician's service even in the event that this
acceptance was a mistake.




Except in an emergency, no patient shall be admitted to the Hospital until a 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.
For the protection of patients, the Medical and Nursing Staffs, and the Hospital, certain principles
are to be met in the care of the potentially suicidal patient and patients suffering from intentional
chemical overdoses. Any patient known or suspected to be suicidal in intent shall be referred, if
possible, to another institution where suitable facilities are available. When transfer is not
possible and patient meets the Medical Center's admission criteria, the patient may be admitted to
the Hospital and temporary measures will be provided as appropriate.


The Admitting Practitioner shall be held responsible for giving such information as may be
necessary to assure the protection of other patients who might be endangered, from any cause
whatsoever, as a result of the admission of his patient.




It shall be the responsibility of all members of the Active and Associate Medical Staff with
admitting privileges to be available for patients needing admission or provide a designee in their
absence.




1. A patient with a single system injury is admitted to the attending on call for the surgical
specialty that cares for that injury.
e.g.    General surgeon- abdominal trauma
         Neurosurgeon- neurological trauma (operative and non-operative)
         Cardiac surgeon- isolated blunt chest trauma
         - penetrating chest trauma between the clavicles and the nipples
         Plastic surgeon- degloving injuries
         - severe road rash
        Orthopedic surgeon- extremity trauma deeper than subcutaneous tissue
2. A patient with two systems injured is admitted to the attending on call for the surgical specialty
that would care for the more significant injury with a consult to an attending that would care for
the less significant injury.
3. A patient with more than two systems injured is admitted to general surgeon on call with
consults to the appropriate specialist. After twenty-four (24) hours the admitting general surgeon
will initiate transfer to the service of the most significant injury. (03/24/2006)
The ED Physician will determine the appropriate admitting attending based on the above rules
and the patient’s documented injuries. If any questions arise, the Emergency Department Chief
may provide direction to the ED physician.


Whenever it becomes appropriate for the primary responsibility for the care of a patient to be
transferred from one Staff member to another, this transfer shall be accomplished only when the
transferring Staff member has placed an order of transfer on the order sheet of the patient record
and the receiving Staff member has made a written acknowledgment or verbal order of his
acceptance on the order sheet of the patient's record.
When a patient requires an operation that is not included in the privileges of the Attending
Practitioner, the patient must be transferred to the care of a designated qualified Surgeon. The
transfer shall be accomplished by an Order of Transfer by the Attending Practitioner on the
patient record. The Surgeon to whom the patient is transferred shall acknowledge his acceptance
of the patient on the patient record. It is also required that the Surgeon indicate on the record the
patient has been examined by him prior to surgery and list the diagnosis and contemplated
surgery. This information shall be on the patient's record before the patient is taken to surgery,
except in an emergency. Upon sufficient recovery of the patient following surgery, the care of the
patient may be transferred back to the original Practitioner. Transfer Orders shall be the same as
listed above.


To provide guidelines for the prevention of catheter associated UTIs through development of
specific criteria for placement and continuation of catheters. **REFER TO FILE DOCUMENT
FOR FULL PROCEDURE OF POLICY. (01/13/2011)

                                                                                                        To provide guidelin
Consultants on a case should obtain authorization from the attending physician before calling in
another consultant.




1. First consult must be done by a physician.
2. All consults are to be requested by a physician.
3. A consultation shall include exam, complete assessment and plan. Documentation of the
following is required:
    A. evidence of review of the patient's medical record by the consultant;
    B. pertinent findings after examination of the patient;
    C. the consultant's opinion; and
    D. the consultant's recommendations.
2. If the consultation is requested in conjunction with a surgical procedure, the report shall be
completed prior to the procedure.
3. Consultations may be handwritten if legible.
4. Consultations shall be documented within 24 hours of the request unless otherwise stipulated by
the requesting Physician. (1/25/2010)

Emergency consultation requests should be made directly from the Attending Physician to the
Physician Consultant. (3/28/86; 04/10/86)
All specimens not specifically exempted must be sent to the Pathology Department for
examination. Irrespective of exemptions, microscopic examination will be performed whenever
the Attending Physician requests it or at the discretion of the Pathologist when such an
examination is indicated by the gross findings or clinical history. A pathology report will be
generated for any specimen submitted to the Pathology Department. This authenticated report
shall be made a part of the patient's medical record.
**REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.

Preoperatively, Beta Sub Unit testing is to be performed on all females of child bearing potential.
Alternatively, documentation must be placed in the record that the possibility of a concurrent
pregnancy and possible complications have been discussed with the patient prior to the procedure.
(12/3/85)



Hospital Policy on Organ/ Tissue Donation




When a patient presents to the Emergency Department as a current patient of a community
physician that does not have privileges at Munroe Regional, that patient can be considered an
"assigned patient" only if that community physician has an active statement of arrangement with a
member of the Medical Staff to take all of his/her patients. This statement of arrangement must
be signed by both physicians and be on record in the Emergency Department at Munroe Regional.


The on-call Physician treating an Emergency Department patient shall be responsible for the
follow up care of that patient, within the realm of the Physician's on-call specialty and/or
competence for a 30 day period from the date of the patient's discharge from the Hospital. It shall
be considered that the patient has severed the relationship with the Physician if the patient signs
out against medical advice and the Attending Physician will no longer be responsible for the
follow up care of that patient. 6/4/87
The Medical Staff, through its Bylaws, authorizes the Medical Executive Committee (MEC) to
determine the services, departments, Medical Staff categories, and individuals who will serve
Emergency Department call. Emergency Department call requirements are based on the
Hospital's patient care needs, not on economic issues. This policy facilitates the Hospital's
compliance with the 1992 COBRA legislation, which requires licensed facilities to be able to care
for all patients who present to its facilities. It is the MEC's responsibility to determine the
specialties that must be represented on the emergency call list. The MEC will work with each
Department Chair to determine who will represent each specialty. Each Department will
determine the length of service required by its members to meet the on-call obligations of that
service. The Chief of each Department will be responsible for a call roster to be submitted to the
Emergency Department by the beginning of each month for each specialty and subspecialty as
defined by the Executive Committee. The practitioner on-call is responsible for being available to
handle emergency admissions or have a suitable designee available. It is
required that staff practitioners participate on active Emergency Department
rotation for a minimum of twenty years. Individual Clinical Departments may,
by a majority vote of practitioners in that department, increase or decrease
this requirement to fit the particular needs of the department as approved
by MEC. The proceedings of the department meeting should reflect any
such decision.


This call is a requirement and obligation of all members of the Medical Staff - regardless of
category - with the exception of Honorary and Active-Community staff members. Failure of any
Medical Staff member to meet the obligation of emergency coverage is cause for disciplinary
action according to the corrective action portion of the Bylaws. The practitioner on call is
responsible for being available to handle emergency admissions or have a suitable designee
available. The MEC may make exceptions for physicians who are hospital-based or who are not
in active patient care. The MEC may determine that certain non-physician providers, such as
Nurse Midwife, may take backup call for Obstetrics.


Elimination of ED Hand on-call; providing there is a consulting service should an issue arise.
(4/24/2006)




Hospitalists will be responsible, on a rotating basis, for the Medicine Section Emergency
Department on-call. New attendings can also be included on ED call at their request.
Medicine Call rotation for Medical Staff practitioner's with offices will be open to three (3) days
per month. These practitioner's that request to take Medicine ED unassigned call will apply to
take part in rotation for the available three (3) days each month. Quality reviews will continue to
be a part of the initial application and continued participation. Also available to the Medicine
practitioner's is the opportunity to be placed on a separate daily rotation list. The physician
assigned to a day will receive the patients discharged from the Emergency Dept. as well as the
follow-up care on unassigned inpatients admitted through the Emergency Dept. on that day.
(03/29/2010 NOTIFICATION)




Any Internal Medicine Physician can take Emergency on-call. Days of on-call will be in
proportion to the number of members in the group. Practitioners can only re-assign days of call
within their own group. Medical Executive Committee can re-assign call based on quality
measures. (10/16/08)




All OB/ GYN physicians will be notified prior to their patients being discharged from the
Emergency Department. This will include incidents of demise.




New practitioners appointed to the Medical Staff shall be given a choice of on-call schedule
assignments directly related to their specialty and clinical privileges.




 All new physicians with Pediatric privileges and those physicians currently taking Pediatric
emergency call are responsible for being on the Pediatric emergency on-call schedule. These
physicians will also be internally responsible for after hours pediatric care for their own patients,
this responsibility will not fall to the on-call Pediatric physician. (05/19/2008)



A practitioner may be granted emergency temporary privileges pursuant to the Policy on
Appointment, Reappointment and Clinical Privileges of the Medical Center; to be activated upon
Emergency Department Call expectation. (2/25/08) **REFER TO FILE DOCUMENT FOR
FULL PROCEDURE OF POLICY.
Surgery Section: Stable non-emergent surgical consults (typically stable appendicitis) after 5a.m.
and before 7a.m. will be held for the new incoming call person to be called, unless immediate
attention is required. (5/21/07)




Surgery Section physicians will attend to stable pediatric patients of six (6) years and more. If the
patient over six (6) years of age is unstable or if there is any reason of medical concern a transfer
may still be requested, after assessment of the patient in the Emergency Department. (05/21/07)




All walk-in OB/GYN patients will be triaged by the Emergency Department staff. Problems
detected that are unrelated to labor will be assessed by the ED Physician, if the problem identified
in triage is related to labor or obstetrical care and does not display indication of infectious disease.
The patients with gestational age of 23 weeks or more will be referred to Labor and Delivery to be
assessed by the Nursing staff. The Obstetrical Physicians will be available for consultation as
required. Gestational age of less than 23 weeks will remain in the Emergency Department for
treatment. The screening evaluation will be done either in the ED or Labor & Delivery depending
on the result of triage. Gynecologist on call will care for patients with gestational age 12 weeks or
less. Obstetrics on call will care for those patients with gestational age greater than 12 weeks.
(Revised 12/11/2007)


A patient's right to privacy is to be protected and the most optimal working environment for the
Physician and surgical team is to be provided. Video cameras will not be permitted in the
operating suite during Cesarean Section deliveries. Video cameras will be permitted at vaginal
deliveries if there is no objection by the Physician(s) attending the delivery. Still pictures will be
permitted with the authorization of the patient and Physicians involved at either type delivery. No
exceptions are to be made. 7/9/92 Videotaping will not be allowed during the actual delivery,
whether vaginal or by Cesarean.


In emergencies involving a minor or unconscious patient in which consent for surgery cannot be
immediately obtained from parents, guardian or next of kin, circumstances shall be fully explained
on the patient's record. A consultation in such instances is required before the emergency
operative procedure is undertaken, if time permits.



“Flip Rooms” are a second staffed operating room for a single surgeon that is available to keep
the surgeon fully engaged in performing surgical procedures. The costs of staffing a second room
are substantial (estimated at $60. per minute) and the availability of scheduled “Flip Rooms”
needs to be limited and based on guidelines. (12/13/2010)
 **REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.
Allied Health Professionals, licensed as LPN’s, can do physical exams and documentation only
while their sponsoring Doctor is on that patient care floor. (12/12/05)




An appropriately credentialed ARNP, under the supervision of the Pediatrician/Neonatologist, can
attend all C-Sections in lieu of the Pediatrician/Neonatologist. (12/12/05)




Rounding nurses provides substantial efficiencies for physician documentation. However, clear
guidance on the type and extent of documentation must be established to ensure that staff are
practicing within the scope of their profession. The documentation also needs to make clear the
extent of work performed by the physician. **REFER TO FILE DOCUMENT FOR FULL
PROCEDURE OF POLICY.


Registered Nurses working as Physician's Nurse Assistants may take patient histories and record
them but may not perform nor dictate physicals. 6/13/91




All Mid-Level Practitioners will provide services only under the supervision of a member of the
Medical Staff.
Bylaws dictate: “Practitioners employed by physician members of the medical staff must submit a
statement by their employer or cosigned by a member of the medical staff concurring with the
request for permission to provide services. The statement must confirm that the physician does
contract with the practitioner and will, at all times, be responsible to supervise the practice of the
practitioner, and, if unavailable, will designate another member of the medical staff to assume
such responsibility. If the practitioner is employed by a group of physicians, at least one member
of the group must submit or cosign such a statement which includes the names of all physicians
employing the practitioner. If the appointment or privileges of the supervising physician are
suspended or terminated, the practitioner’s privileges will also be suspended or terminated.”
Practitioner’s that no longer have a sponsor are not permitted to work at Munroe Regional. As an
alternative to requesting a leave of absence or implementing an administrative
termination when a Mid-Level Practitioner does not have any physician sponsor, a sixty (60)
day relinquishment will be initiated. Similar to the Bylaws requirement regarding delinquent
proof of insurance coverage, it “shall result in immediate automatic relinquishment of a
member’s clinical privileges. If within 60 days of the relinquishment” the practitioner has not
submitted the necessary paperwork for a sponsor, the practitioner “shall not be considered for
reinstatement and shall be considered
to have voluntarily resigned.” (12/13/2010)
Cases that require Surgical Assistants: A) A First Assistant will be present in all cases in which
the presence of an assistant will materially facilitate the procedure by providing exposure,
hemostasis and other technical functions which help the Surgeon carry out a safe operation. The
First Assistant may be a Physician, a Dentist with surgical privileges, an R.N., L.P.N., P.A., or a
C.S.T. qualified by training or experience to work in this capacity. In those cases which are of
sufficient magnitude to require a First Assistant, the Scrub Nurse or Scrub Technician may not
double as a First Assistant. B)In the event these rules do not seem properly implemented by the
Attending Surgeon, the Charge Nurse will be responsible to report same to the proper authority.
**REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.



All entries in the chart must be countersigned by the sponsoring Physician.




Munroe Regional Medical Center will accept students for clinical rotation only if the student
program has been reviewed and approved. With the approval of the student program, a candidate
may submit appropriate documentation, as may be applicable, to the Medical Staff Services
Department for application. Formal approval must be received from the sponsoring educational
institution and an Active category member of the Munroe Regional Medical Staff must agree to
directly supervise all activities of the individual accepting full responsibility for his/her activities
in the hospital setting. Final approval must be granted by the Medical Executive Committee and
Governing Board. (10/26/2009)
**REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.

The Attending Physician is to be notified of any case review after evaluation by the Section Chief
and if further investigation is recommended. (9/4/86; rev.9/23/97)


Protected health information (PHI) is confidential and protected from access, use, or
disclosure except to authorized individuals requiring access to such information.
Attempting to obtain or use, actually obtaining or using, or assisting others to obtain or
use PHI, when unauthorized or improper, will result in counseling and/or disciplinary
action up to and including termination (for our associates) or removal from our medical
staff (for medical staff physicians). **REFER TO FILE DOCUMENT FOR FULL
PROCEDURE OF POLICY. (6/28/2010)

To provide physicians, nurses and other hospital staff members at Munroe Regional Medical
Center (MRMC), with an accurate and reliable physician contact process.
All MRMC staff members will use PerfectServe to contact physicians, or other staff members on-
call, for all patient care communications. (09/09/2010) **REFER TO FILE DOCUMENT FOR
FULL PROCEDURE OF POLICY.
The Pharmacy and Therapeutics Committee Chair or, in their absence, the Medical Staff President
shall be authorized to give permission for the emergency or compassionate use of Investigational
Review Board approved drugs/devices. 4/9/92




The purpose of this policy is to provide guidelines for monitoring and management of patients
during and after sedation for diagnostic and therapeutic procedures. This procedure will be
performed by those credentialed with appropriate expertise and knowledge specific to I.V.
conscious sedation (IVCS).
**REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.


Physicians will be required to prescribe drugs within various formulary categories established to
support efficiency and cost containment strategies at Munroe Regional Medical Center.
A)Formulary recommendations will be developed by the Pharmacy and Therapeutics Committee
for approval by the Executive Committee of the Medical Staff. B) Approved formulary drugs will
be dispensed by the Pharmacy as ordered. C)If a drug is ordered that is not on the current
formulary, such drug will not be stocked in the Pharmacy for dispensing. The ordering Physician
must obtain the approval of the Chairman of the Pharmacy and Therapeutics Committee for an
exception to have a non-formulary drug available through the Pharmacy. D)If a drug is ordered
that is currently under study or has not yet been considered for formulary development, the
Pharmacy will dispense the drug as ordered until such formulary is developed and/or finalized.
5/14/92




The medical record shall include:A) the consent of the patient or legal guardian specific to the
examination to be performed; B) documentation of the collection, retention and safeguarding of
evidentiary material released by the patient; C) the documentation of the notification of the
proper authorities; and D) the documentation of what information was released to the proper
authorities.


Should a patient leave the Hospital against the advice of the Attending Physician or without
proper discharge, a notation of the incident shall be made in the medical record and shall indicate
the patient left AMA.
1. When surgical and/or anesthesia services are provided to ambulatory patients (who are not
admitted), the medical record shall include:
    A. patient identification;
    B. drug allergies and medications;
    C. relevant history of the illness or injury and of physical findings;
    D. diagnostic and therapeutic orders;
    E. clinical observations including the results of treatment;
    F. reports of procedures and tests and their results;
    G. diagnosis or impression;
    H. patient disposition;
    I. referrals to practitioners or providers of other services; and
   J. communications to and from external practitioners or other services.
2. The techniques and findings of every operative procedure performed shall be included in the
medical record immediately following surgery and authenticated by the person who performed the
procedure.
3. A written final progress note may be used instead of a written or dictated discharge summary.



The Anesthesiologist or Nurse Anesthetist shall maintain a complete anesthesia record to include:
A) a pre-anesthesia evaluation and assessment; B) a reassessment immediately before the
induction of anesthesia; C) a post-operative status assessment on admission to and discharge from
the post-anesthesia recovery area according to discharge criteria; and D) patient assessment
during anesthesia. Anesthesia forms must be completed by the end of the procedure or prior to
the patient's discharge from the post-anesthesia recovery area.

The Practitioner performing a procedure (H&P, etc.) must be the one to dictate and sign the
record. Physician's Nurse Assistants, if credentialed to do so, may dictate a discharge summary
for the sponsoring Physician's countersignature but must also sign his/her dictation. 2/8/90




A specific consent for treatment shall be signed by, or on behalf of, every patient who will receive
a special treatment, including blood transfusion, or surgical procedure. These consent forms will
be provided by the Hospital. The physician is expected to ensure that the patient understands the
nature of the treatment and risks inherent in the procedure. The discussion with the patient shall
be documented in the medical record and clearly indicate that the patient was informed and
understands the proposed procedure and risks as evidenced by physician signature on consent
prior to procedure. (03/31/2008)
1. A discharge summary shall be dictated or handwritten for an Inpatient, Outpatient Observation,
or ASC patient immediately after discharge or death of the patient and shall include:
    A. the reason for hospitalization;
    B. significant findings;
    C. procedures performed;
    D. treatments rendered;
    E. condition of the patient on discharge; and
    F. instructions to the patient and/or family (if any).
2. A Discharge Clinical Resume (Summary) shall be dictated to all medical records on patients
hospitalized over 48 hours and deaths under 48 hours with the following exceptions: normal
obstetrical deliveries, normal newborn infants. For these, a final summation-type progress note
shall be sufficient to justify the diagnoses and warrant the treatment and end result. The
Practitioner shall include in this discharge summary the appropriate instructions with regard to
diet and exercise, if restrictions exist, and any medication prescribed. All summaries shall be
authenticated by the responsible Practitioner. The responsible Practitioner must request in writing
privilege for his staff to dictate the discharge summary and
provide verification of responsibility and authorization for all entries to
be made.
3. In the case of patients with problems of a minor nature who require less
than a 48-hour period of hospitalization, in the case of normal newborn
infants,and uncomplicated obstetric deliveries, a final written progress
note may be included in the medical record instead of a dictated
discharge summary. It shall include the patient's condition at discharge,
discharge instructions, and follow-up care required.
4. If a patient dies during hospitalization, a death summary must be
dictated.




Responsibility for care of a dental patient shall be defined as:
1. The Dentist shall complete:
    A. a detailed dental history justifying the Hospital admission;
    B. a detailed description of the examination of the oral cavity and a    preoperative dental
diagnosis;
    C. an operative report describing the findings and techniques used.     In cases of extraction of
teeth, the Dentist shall clearly state the number of teeth and fragments removed.
    D. a daily progress note pertinent to the oral condition; and
    E. a dental discharge summary.
2. The Attending Physician shall complete:
    A. a medical history pertinent to the patient's general health;
    B. a physical assessment to determine the patient's condition prior to anesthesia and surgery;
    C. the care of any medical problem that may be present at the time of admission or that may
arise during the hospitalization.
1. The medical record of a patient who has received Diagnostic Imaging Services shall include:
   A. a report of any Radiologic consultation;
   B. interpretations of diagnostic imaging studies; and/or
   C. interpretations of therapeutic invasive procedures.
2. Only practitioners with delineated clinical privileges to interpret diagnostic studies and/or
perform therapeutic invasive procedures shall authenticate reports of these studies and
procedures.



Only at the request of the physician, the qualified dietitian shall document appropriate nutritional
information in the medical record.




The Attending Practitioner is required to document the need for continued hospitalization after
specific periods of stay, as outlined in the Utilization Review Plan of the Hospital, have been
exceeded.




1. A medical record shall be maintained on every patient receiving emergency care. The E.D.
record shall be incorporated into the patient's permanent medical record, if the patient is admitted
from the Emergency Department.
2. The medical record shall include:
   A. as complete an identification as possible with an alias name assignment for patients who
cannot be properly identified;
   B. the time of the patient's arrival, means of arrival and means of transportation;
   C. pertinent history of the illness or injury and physical findings;
   D. details of the first aid or emergency care given to the patient prior to arrival in the
Emergency Department;
   E. diagnostic and therapeutic orders;
   F. clinical observations;
   G. reports of procedures, tests and results;
   H. diagnostic impressions;
   I. treatment given;
   J. conclusion at the termination of the evaluation/treatment, including the final disposition, the
patient's condition on discharge or transfer;
   K. instructions given to the patient and/or family relative to follow-up care; and
   L. a notation if the patient left against medical advice.
**REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.
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 periods which they
attended such patients in the Hospital.



1. All medical records shall contain sufficient information to allow the practitioner responsible
for the patient to:
   A. provide continuing care to the patient;
   B. determine later what the patient's condition was at a specific time;
   C. review the diagnostic and therapeutic procedures performed and;
   D. review the patient's response to treatment.
2. There shall be sufficient information in the medical record to allow a consultant to render an
opinion after an examination of the patient and a review of the medical record.
3. There shall be sufficient information in the medical record to allow another physician to assume
the care of the patient at any time.
4. The medical record shall be detailed and organized enough to allow for the retrieval of
pertinent information required for utilization review and quality assessment and improvement
activities.
5. All entries in the medical record shall be dated and authenticated following any applicable State
regulations. Authentication shall be by signature, initials
or computer key.


History & Physical assessment shall include:
A. chief complaint
B. history of present illness
C. past medical history
D. relevant family/social history
E. review of body systems
F. physical examination
G. pertinent laboratory and diagnostic reports
H. admission diagnosis/impression
I. treatment plan or planned course of action

1. MEDICAL SERVICE ADMISSION
2. SURGICAL SERVICE ADMISSION
3. READMISSION WITHIN 30 DAYS
4. OBSTETRICAL SERVICE
5. NEWBORN
6. AMBULATORY CARE SERVICE (Observation or Ambulatory Surgery Patients)
**REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.
Short Stay Admission A)Short stay surgical patients' medical records must contain a history and
physical at least pertinent to the preoperative and postoperative conditions of the patient. B)Short
stay medical patients' records must contain a pertinent history and physical. C)Medical records of
patients receiving local anesthesia must contain a detailed description of the surgical site, pre-
operative diagnosis, pre-existing conditions, allergies, etc. Out Patient Surgery A)Medical
records of patients receiving general anesthesia must contain a history and physical at least
pertinent to the pre-operative and post-operative conditions of the patient. B)Medical records of
patients having operations performed under local anesthesia must contain an appropriate history
of the illness or injury, a detailed description of proposed surgical site, previous illnesses,
hospitalizations, pre-existing conditions, medications, and allergies. Obstetrical Record A)In
the event an OB patient is admitted under the Improved Pregnancy Outcome Project (IPOP) and
whose medical care is directed by a Nurse Midwife as provided
for under this project, the signature of the directing OB/GYN Physician
placed on the face sheet will signify review of the record and completion for
filing. All other signature requirements will be met with the signature of the
Nurse Midwife.

To provide a complete and accurate medical record to:
1. facilitate the continuity of patient care by the health care provider during and after care;
2. provide an adequate database for reviewing the quality and appropriateness of patient care; and
3. assure that MRMC has an effective communication tool to serve the many users of medical
information.
**REFER TO FILE DOCUMENT FOR FULL PROCEDURE OF POLICY.




1. Immediately after completion of the procedure, an operative report shall be dictated or
handwritten by the primary surgeon.
2. The operative report shall include:
    A. name of primary surgeon and assistants;
    B. a description of the findings;
    C. procedure performed;
    D. the specimen(s) removed;
    E. the pre- and post-operative diagnoses;
3. In addition to the dictated operative report, a handwritten post-operative progress note shall be
written and include the information listed under post-operative progress note requirements.

1. All orders for treatment shall be written clearly, legibly, and completely. Orders which are
illegibly or improperly written will not be carried out until rewritten or understood by the staff.
2. All verbal orders shall be authenticated by the physician or designee for completion of the
chart.
3. Written orders shall be authenticated at time of writing.
4. All orders written/taken by an Allied Health Professional shall be authenticated by their
supervising Physician.
All Pain Management medical records shall include documentation of: A)diagnosis;
B)examinations; C)treatment given; D)any referral(s) made to other care providers and to
community agencies and any required reporting to the proper authorities; E)immunization status
of children and adolescents; and F)allergies



1. All reports of examination and testing performed shall be dated and authenticated.
2. Any report that is sent to the medical record shall include:
   A. the date and time of reporting;
   B. the condition of any unsatisfactory specimen; and
   C. the individual responsible for performing or completing the procedure is identified.
3. Whenever an autopsy is performed on a patient, whether it is performed within or outside the
Hospital, the gross and microscopic reports shall be made a part of the medical record and shall
include:
   A. A complete dictated report if and when it is received.


Responsibility for care of a podiatric patient shall be defined as:
1. The Podiatrist shall complete:
   A. a detailed podiatric history justifying the Hospital admission;
   B. a detailed description of the proposed surgical site and a pre-operative diagnosis;
   C. an operative report describing the findings and techniques used.
   D. a daily progress note pertinent to the surgical site(s); and
   E. a Podiatric discharge summary.

2. The Attending Physician shall complete:
    A. a medical history pertinent to the patient's general health;
    B. a physical assessment to determine the patient's condition prior to anesthesia and surgery;
and
    C. the care of any medical problem that may be present at the time of admission or that may
arise during the hospitalization.



Except in severe emergencies, the preoperative diagnosis, history and physical, and required
laboratory tests shall be recorded on the medical record prior to any surgical procedure. If not
recorded, the procedure shall be cancelled. In a severe emergency, the surgeon shall write a
comprehensive note regarding the patient's condition prior to induction of anesthesia and start of
surgery.


Records may be removed from the Hospital's jurisdiction and safekeeping only in accordance with
Subpoena, court order, 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
readmission of a patient, all previous records shall be available for the use of the Attending
Practitioner. This shall apply whether the patient be 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.
1. For patients receiving series ambulatory services, the medical record shall include:
   A. known significant medical diagnoses and conditions;
   B. known significant surgical and invasive procedures;
   C. known adverse allergic reactions;
   D. medications known to be prescribed for and/or used by the patient; and
   E. the initial medical history and physical examination.
2. This information shall be reviewed and updated as necessary with pertinent new information
entered at the time of each visit.


Documentation is required in the medical record for special treatment procedures that require
special justification - Restraint or Seclusion: A)A time-limited order from a Physician is to be
signed within 24 hours after the initial use of restraint or seclusion. The time limit should not
exceed 24 hours. In emergency situations, orders must be obtained within 4 hours of placing
restraints. B)Documentation that the patient has been assessed, that the needs of the patients are
attended to at least every 2 hours, especially in regard to meals, bathing, and use of the toilet.
Other special treatment procedures for children and adolescents. A)Evidence of consultation
with a qualified child Psychiatrist /Psychologist.




A Practitioner's standing orders, when applicable to a given patient, shall be reproduced in detail
on the order sheet of the patient's record, dated, and signed by the Practitioner.
To provide guidelines for the prevention of catheter associated UTIs through development of specific criteria for placem
ent of specific criteria for placement and continuation of catheters.

				
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