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St. Joseph’s Hospital - Phoenix Medical Staff Residents and Medical Students Supervision Policy POLICY: It is the policy of St. Joseph’s Hospital - Phoenix to specify the mechanisms by which residents, medical and allied health students are supervised by members of the Medical Staff. The management of each patient’s care is the responsibility of a member of the medical staff with those clinical privileges granted. This policy is intended to guide the activities of admitting/attending physicians, residents, medical students, allied health practitioners and hospital personnel in insuring that in-hospital patient care activities in which residents and students participate are appropriately supervised and documented during the course of their rotations based in the hospital. This supervision should begin with the initial contact with the attending physician and the patient, continue through the daily contact with the patient, and with the attending physician, and be completed when all the documentation of the hospital stay is collected for the permanent medical record. All practitioners/students are required to dress appropriately and display proper identification badges at all times. DEFINITIONS: Resident: A resident is a medical doctor (M.D. or D.O.) in a formal residency training program approved by the Accreditation Council for Graduate Medical Education (ACGME). An “intern” is a first year resident. Chief Resident: Chief residents are designated residents with particular leadership responsibilities. Chief residents may be within their formal training period (“internal chief resident”). They may also be designated during a post formal residency year. Both types of chief residents are approved by the Academic Affairs Department, and are under the same supervision requirements as residents. Junior Faculty / Instructor: A chief resident who has completed residency training and is fully eligible for membership on the medical staff in his / her clinical department may apply for privileges as a faculty member upon the approval of the Program Director and Department of Academic Affairs. The junior faculty member will be subject to the same credentialing and qualification requirements and supervisory process as all newly credentialed members of the medical staff. Their responsibilities as chief resident will be governed by the job description, Medical Staff Bylaws, and Clinical Department Rules and Regulations. Rotating Residents: Resident physicians enrolled in approved ACGME training programs at other hospitals and medical schools may be permitted to train at St. Joseph’s Hospital and its associated training programs only if an institutional agreement is in force between St. Joseph’s Academic Affairs Department and the sponsoring hospital and medical school, the resident has been approved by the Academic Affairs Department, and the resident as well as the sponsoring program agree that the rotating resident is under the same supervision requirements as St. Joseph’s residents. Page 1 of 4 Printed: 05/04/17 D:\769855352.doc 12:36 PM Fellow: A fellow is a physician in a specialized training program following formal completion of initial residency training. Fellows may be in an ACGME approved fellowship training program, or a non-approved fellowship training program. Both types of fellowship programs are sponsored and officially designated by St. Joseph’s Department of Academic Affairs. All fellows are approved by the Academic Affairs Department, and are under the same supervision requirements as residents. Medical or Allied Health Student: A medical student or allied health practitioner student is a student (medical, physician assistant, advanced practice registered nurse) in an approved training program that has an education affiliation agreement with St. Joseph’s Hospital - Phoenix. PROCEDURE: A. Resident: 1. Appointment: Residents shall not hold medical staff appointment and shall not be entitled to the rights, privileges, and responsibilities of appointment to the Medical Staff. Residents are appointed by the Academic Affairs Department through the Medical Education Committee. 2. Licensure: Residents are not formally licensed, but are granted a State of Arizona Training Permit through the Department of Academic Affairs. If a resident possesses a full unrestricted Arizona Medical License, this may substitute for the training permit requirement, but the duties, roles and responsibilities of the licensed resident remain only in the scope of their supervised training program, and not as an independent licensed medical practitioner. Should a resident become licensed, that resident is under the same supervision requirements as residents with a Training Permit. 3. Clinical Care: Residents shall not be granted specific medical staff clinical privileges. Activities performed by residents shall be under the supervision of a medical staff member. Clinical activities shall be limited to those of the clinical privileges granted to the supervising attending physician and agreed upon by the hospital, resident training program and the sponsoring medical staff member. In an emergency or disaster, residents may act as necessary until the appropriate supervising physician is present. The job description, provided by the training program, shall be specific about what the resident can do according to medical specialty; year(s) in training; level of experience and degree of independence. The Academic Affairs Department shall maintain a list of all residents currently working at the facility, including rotating residents. 4. General Responsibilities of Residents: Residents may admit and render patient care in all hospital services under the supervision of medical staff physicians including: a. initial and ongoing assessment of patient’s medical, physical, and psychosocial status; b. perform history and physical; c. develop assessment and treatment plan; d. perform patient care management rounds; e. record progress notes; f. order tests, examinations, medications, and therapies; including restraints by hospital protocol; g. arrange for discharge and after care; h. write/dictate admission notes, progress notes, procedure notes, and discharge summaries; Page 2 of 4 Revised: MEC 10/27/03; BOARD 10/30/03 Reviewed: 5/4/2017 D:\769855352.doc Printed: 5/4/2017 i. j. provide patient education and counseling covering health status, test results, disease processes, and discharge planning; and assist in surgery. Note: All resident care is supervised and the attending physician is ultimately responsible for care of the patient. Co-signature is as required by hospital policy. The proximity and timing of the supervision, as well as the specific tasks delegated to the resident physician depend on a number of factors, including: a. attending physician has been granted same privileges b. the level of training (i.e., year in residency) of the resident, c. the skill and experience of the resident with the particular care situation, d. the familiarity of the supervising physician with the resident’s abilities, and e. the acuity of the situation and the degree of risk to the patient. 5. Quality of Care: The quality of care of residents shall be monitored through the medical staff committee structure and reported to the Medical Executive Committee, Department of Academic Affairs and its Residency Training Programs, Medical Staff and SJHMC Board. 6. Oversight: The Director of Academic Affairs is responsible for on-site coordination of the St. Joseph’s residency programs, including all residents, chief residents, fellows, rotating residents and medical students. The Director reports regularly, but at least annually, to the Medical Executive Committee regarding the safety and quality of patient care provided by the residents. Concerns or problems that may arise regarding a resident shall be reported to the Academic Affairs Medical Director for resolution. If satisfactory resolution is not obtained the issue may be taken to the Medical Executive Committee. 7. Identification: Residents shall identify themselves as a resident and shall wear name tags identifying them as such. 8. Participation: Residents may be invited to attend medical staff or hospital committees as non-voting members. The Chief of Staff will appoint residents to medical staff committees upon the recommendation of the Department of Academic Affairs. B. Medical or Allied Health Student: 1. Medical students and allied health students (physician assistant, certified nurse practitioner) shall not hold medical staff appointment and shall not be entitled to the rights, privileges, and responsibilities of appointment to the medical staff. 2. Students shall not be granted specific clinical privileges. Activities performed by students shall be under the supervision of a medical staff member. Co-signature is required on all medical record entries written by medical students. Clinical activities shall be limited to those of the clinical privileges granted to the supervising medical staff member and agreed upon by the hospital, preceptor program and the sponsoring medical staff member. 3. The supervising physician is directly responsible for the actions of the student. 4. Students may do History & Physical examinations at the supervising physician’s discretion. 5. Students are not allowed to examine or treat Emergency Department patients without the physical presence of the supervising physician or a designated physician within the hospital. Page 3 of 4 Revised: MEC 10/27/03; BOARD 10/30/03 Reviewed: 5/4/2017 D:\769855352.doc Printed: 5/4/2017 6. Students shall identify themselves to patients as a medical student under the supervision of the attending physician. Students shall wear a name badge identifying them as such. C. Chain of Command: All residents shall be given a copy of the Resident “Chain of Command Policy” of the Department of Academic Affairs and acknowledge in writing that they have reviewed it annually. D. External Regulations: This resident supervision policy does not supercede relevant portions of the State of Arizona Medical Practice Act (Arizona Revised Statutes), federal CMS regulations on resident supervision, or individual training program requirements of the ACGME, or other recognized authorities. E. Annual Review: This policy shall be reviewed annually for internal and external compliance with all mandated regulations as well as quality patient care for St. Joseph’s patient population. REFERENCES: SJH Medical Staff Bylaws, Rules and Regulations AMB/ State of Arizona Medical Practice Act Statutes ACGME Requirements Joint Commission Standards CMS Resident Supervision Regulations Medical Education Chain of Command Policy Page 4 of 4 Revised: MEC 10/27/03; BOARD 10/30/03 Reviewed: 5/4/2017 D:\769855352.doc Printed: 5/4/2017