Download ThedaCare Medical Center-Waupaca Medical Staff Rules and

MEDICAL CENTER-WAUPACA
MEDICAL STAFF RULES AND REGULATIONS
THEDACARE MEDICAL CENTER-WAUPACA
MEDICAL STAFF RULES AND REGULATIONS
TABLE OF CONTENTS
A.
ADMISSION AND DISCHARGE ..........................................................................3
B.
EMERGENCY SERVICES ....................................................................................4
C.
MEDICAL RECORDS ...........................................................................................6
D.
GENERAL CONDUCT OF CARE .........................................................................9
E.
SURGICAL CARE .............................................................................................. 11
F.
OBSTETRICAL CARE ....................................................................................... 14
G.
NEWBORN CARE ............................................................................................. 15
H.
DISASTER PLAN ............................................................................................... 15
I.
MISCELLANEOUS............................................................................................. 15
J.
HOSPITAL CALL ............................................................................................... 15
THEDACARE MEDICAL CENTER-WAUPACA
MEDICAL STAFF RULES AND REGULATIONS
A.
ADMISSION AND DISCHARGE
1. Only practitioners who are appointees to the medical staff may admit patients to this hospital
as provided in the medical staff bylaws and procedural policies. Only individuals granted
clinical privileges may treat patients at this hospital. All practitioners with authority to admit
patients shall be governed by the admitting policy of the hospital. Podiatric and dental
patients admitted to the hospital must have a physician appointee to the medical staff to
perform an admitting history and physical for the patient who will also be responsible for any
medical care the patient requires while in the hospital.
2. The hospital shall accept patients for care and treatment except as follows:
a. Patients who are known to be suffering from drug abuse, alcoholism, and mental
illness shall not be admitted and arrangements should be made available for transfer
to another facility. Patients may however be admitted for AODA detoxification in
accordance with current certification.
3. A physician appointee to the medical staff shall be responsible for the medical care and
treatment of each patient in the hospital, for the prompt completion and accuracy of the
medical record, for necessary special instructions and for transmitting reports of the condition
of the patient, if appropriate, to the referring practitioner. Whenever these responsibilities are
transferred to another practitioner, the communication necessary to convey transfer of
responsibility for patient care shall be executed including direct communication between
practitioners so that there is the opportunity for the accepting practitioner to have questions
answered regarding patient status and care.
Accepting practitioners include primary care, on-call practitioners, hospitalists, specialists,
emergency room providers, and others that may be involved in the patient’s care. Direct
communication is the preferred method of hand-off of responsibilities to another practitioner.
Other acceptable methods of hand-off communication in this facility include but are not limited
to voice mail, e-mail, text message, and notes in the paper chart or electronic medical record
(EMR). Information that should be communicated through the hand-off process includes
diagnoses, current condition with recent changes in condition, other services involved,
guidelines implemented, treatment plan, anticipated changes in condition, and what concerns
are for the next interval of care. The practitioner transferring the patient’s care should allow
the accepting practitioner to ask and respond to clarifying questions either in person, by
phone or by e-mail communication. Hand-off communication needs to be up-to-date and
accurate to meet goals of patient safety.
4. Each patient shall be assigned to the service concerned in the treatment of the disease,
which necessitated admission. In the case of the patient requiring admission who has no
practitioner, he shall be assigned to the practitioner on-call for the service to which the illness
of the patient indicates assignment.
5. Except in the case of emergency admissions, 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. A copy of the emergency
service record shall accompany the patient to the nursing unit.
6. In any emergency case in which it appears the patient will have to be admitted to the hospital,
the practitioner or designee shall, when possible, first contact admitting or if closed, the
clinical supervisor or designee to ascertain if there is a bed available.
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7. Physicians must be able to justify emergency admissions based on criteria developed by the
medical staff or MEC. The history and physical must clearly justify the patient being admitted
on an emergency basis and these findings must be recorded on the patient's medical record
as soon as possible after admission. Violators of this rule shall be referred to the credentials
committee for appropriate action.
8. A patient to be admitted on an emergency basis shall be given the opportunity to select an
appointee to the medical staff to be responsible for the patient while in the hospital. Where
no such selection is made or where the selected staff physician does not assume
responsibility for care of the patient for some reason, the on-call physician shall assume
responsibility for the patient.
9. Each appointee to the medical staff shall name another appointee to the medical staff as an
alternate to be called to attend his patients in an emergency when the attending physician is
not available or until the attending physician can be present. In case the alternate is not
available, the chief executive officer or the chief of staff shall have the authority to call the oncall physician or any other appointee to the staff to attend the patient. Failure of an appointee
to the staff to meet these requirements may result in disciplinary action.
10. Patients shall be discharged from the hospital only on the written order of the patient's
attending practitioner. If a patient leaves the hospital against the advice of the attending
practitioner, or without proper discharge, a notation shall be made in the patient's medical
record.
11. Patients shall be admitted to the hospital on the basis of the following order of priorities when
there is a shortage of available beds:
a.
b.
c.
d.
Emergency
Urgent
Pre-operative
Routine
The committee responsible for the UR functions shall review admissions that do not meet the
established criteria for the above categories if there is a need to do so. Unjustified variations
and recommended actions shall be reported to the credentials committee for appropriate
action.
12. Admissions and discharges to special care units shall be in accordance with established
criteria. Exceptions shall be approved by the chief of staff.
13. Practitioners shall abide by the hospital's utilization review plan to include:
a.
b.
c.
d.
Appropriateness and Medical Necessity of Admissions
Continued Stay
Supportive Services
Discharge Planning
14. In the event of a hospital death, the deceased shall be pronounced dead by the attending
practitioner or his designee within a reasonable time. Policies with respect to dead bodies
shall conform to local law.
15. Practitioners shall document discharge orders that will allow patients to be discharged from
the hospital. Exceptions to this rule will be surgery patients. Refer to Section E, #2.
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16. Practitioners shall make necessary arrangements in order for all elective admissions to be
admitted to the hospital. Exceptions to this rule will be surgery patients. Refer to Section E,
#2.
B.
EMERGENCY SERVICES
1. Appointees to the medical staff shall accept responsibility for emergency service care in
accordance with emergency service policies and procedures.
2. There will be a physician on the hospital campus 24 hours a day whose responsibility will be
coverage of the emergency room. The coverage will be provided under a contractual
arrangement.
In the event the contractual arrangement for E.R. coverage shall be canceled or fail to be
executed, the physician on hospital call as defined under Section J shall temporarily cover
the emergency room for those patients who have no physician or whose physician is not
available until an appropriate contractual arrangement can be executed.
If a physician participating in the hospital on-call roster is unable to take a call, it is his
responsibility to find a substitute. If a physician is delinquent, the chief of staff shall find a
replacement and assign a make-up date.
3. An appropriate medical record shall be kept for every patient receiving emergency service
and be incorporated in the patient's hospital record, if such exists. The record shall include:
a. Adequate patient identification;
b. Information concerning the time of the patient's arrival and by whom transported;
c. Pertinent history of the injury or illness including details relative to first aid or
emergency care given the patient prior to his arrival at the hospital and history of
allergies;
d. Description of significant clinical, laboratory and x-ray findings;
e. Diagnosis including condition of patient;
f. Treatment given and plans for management;
g. Condition of the patient or discharge on transfer;
h. Whether the patient left against medical advice;
i. Final disposition, including instruction given to the patient and/or his family, relative to
necessary follow-up care.
4. Each patient's emergency medical record shall be signed by the practitioner in attendance
who is responsible for its clinical accuracy.
5. The E.R. Care Committee shall coordinate the review of emergency service records, as
outlined in the hospitals overall Quality Assessment and Performance Improvement Plan.
6. The E.R. Care Committee shall be responsible for patient care evaluation concerning the
quality and appropriateness of patient care.
7. The emergency department medical record shall accompany patients being admitted as an
inpatient.
8. Patients with conditions whose definitive care is beyond the capabilities of this hospital shall
be referred to the appropriate facility, when in the judgment of the attending physician, the
patient's condition permits such transfer. The hospital's policy for patient transfers to other
facilities shall be followed.
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9. The E.R. Care Committee shall make certain that emergency department procedures are
properly coordinated with the hospital's disaster plan, especially as they pertain to the care of
mass casualties.
C.
MEDICAL RECORDS
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 for each patient.
This record shall include at least the following:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
name, address, date of birth and the name of any legally authorized representative;
emergency care provided to patient prior to arrival, if any;
complaint or reason for admission;
history of present illness, past medical history, allergic history, family history, age
appropriate assessment, social history and review of systems;
physical examination;
statement of conclusions, diagnoses or diagnostic impressions drawn from the
medical history and physical examination;
treatment plan
evidence of informed consent if required;
special reports such as consultations, clinical, laboratory and radiology services, and
others
medical or surgical treatment, operative report, pathological findings;
diagnostic and therapeutic orders;
progress notes and clinical observations,
final diagnosis;
condition on discharge;
summary or discharge note; and
autopsy report when performed.
2. A complete admission history and physical examination shall be recorded within twenty-four
(24) hours of admission. This report should include all pertinent findings resulting from an
assessment of all systems of the body. If a complete history has been recorded and a
physical examination performed within thirty (30) days prior to the patient's admission to the
hospital, 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
or updated to bring it into compliance with required state and federal regulatory requirements,
provided these reports were recorded by an appointee to the medical staff. In such
instances, an interval admission note that includes all additions to the history and any
subsequent changes in the physical findings must always be recorded.
3. Histories and physicals of outpatients may be completed by appointees to the medical staff,
or, at the request of the attending physician, a consulting physician, physician's assistant, or
nurse practitioner may actually perform the history and physical. In this case, the attending
physician shall assume responsibility for the quality, accuracy, and timeliness of the
information as well as for the actual care of the patient. Another staff appointee may perform
the history and physical, and then the attending physician and the physician who performed
the history and physical shall share responsibility for the patient's care. Whenever an
individual who is not an appointee to the medical staff performs the history and physical, the
attending surgeon shall review the history and physical examination document; conduct a
second assessment to confirm the information and findings; update any information and
findings as necessary (including a summary of the patient’s condition and the course of care
during the interim period) and the current physical/psychosocial status; and sign and date the
information as an attestation to its being current.
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4. For outpatient operative or invasive procedures, the history and physical must be dated within
thirty (30) days of the surgical date, and updated with an interval note prior to the procedure.
An interval note is a statement entered into the medical record that an H&P has been
reviewed and that there are either no significant changes to the findings contained in the H&P
since performed, or if there are significant changes, those changes are documented in the
medical record.
5. When the history and physical examination are not on the patient's chart 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.
In the event the history and physical examination had been dictated but not transcribed prior
to surgery, a progress note including: the admitting diagnosis, pertinent physical findings,
assessment of the care and plan of care shall be completed in writing before surgery is
allowed.
6. Pertinent progress notes shall be recorded at the time of observation sufficient to permit
continuity of care and transferability. Whenever possible, each of the patient's clinical
problems should be clearly identified in the progress notes and correlated with specific orders
as well as results of tests and treatment. Any adverse drug reactions will be documented.
Progress notes shall be written daily on all patients and Swing Bed patient progress notes
shall be no less than every 30 days.
7. The attending, collaborating and or supervising physician shall review and countersign the
history and physical examination, inpatient consultation and the discharge summary when it
has been recorded by a licensed resident physician, nurse practitioner, physician assistant,
or other qualified allied health professional.
8. 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.
9. Operative reports shall include a detailed account of the findings at surgery, the technical
procedures used, the specimen removed, the postoperative diagnosis, and the name of the
primary surgeon and any assistants. Operative reports shall be dictated or written in the
medical record immediately after surgery. The completed operative report is authenticated
by the surgeon and filed in the medical record as soon as possible after surgery. In all
operative or invasive procedures where separate written consent is obtained, an operative
progress note shall be written in the medical record immediately following the procedure to
provide pertinent information to any individual who may be required to attend to the patient.
10. The current obstetrical record shall include a complete prenatal record. The prenatal record
may be a legible copy of the attending physician'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.
11. All clinical entries in the patient's medical record shall be accurately dated and authenticated.
12. Final diagnosis shall be dictated or recorded in full, without the use of symbols or
abbreviations, at the time of discharge of all patients. This will be deemed equally as
important as the actual discharge order.
13. A discharge summary (clinical resume) which shall include the reason for hospitalization,
significant findings, and procedures performed, treatment rendered, condition at discharge,
and discharge instructions including medications prescribed shall be written or dictated on all
medical records of patients hospitalized. The content of the medical record shall be sufficient
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to justify the diagnosis and warrant the treatment and end result. All summaries shall be
authenticated by the responsible practitioner.
14. Written consent of the patient is required for release of medical information to persons not
otherwise authorized to receive this information.
15. In the case of readmission of a patient, all previous records shall be available for use by the
attending practitioner.
16. A practitioner's routine orders, when applicable to a given patient, shall be reproduced in
detail on the order sheet of the patient's record, or entered in the electronic record, dated and
signed by the practitioner.
17. Symbols and abbreviations may be used only when they have been approved by the medical
staff or the MEC.
18. 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 any 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 is attended by the same practitioner or by
another. Unauthorized removal of charts from the hospital will be referred to the credentials
committee for review.
19. Free access to all medical records of all patients shall be afforded to appointees to 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 MEC before records can be studied.
20. Practitioners shall be responsible for obtaining the patient's informed consent prior to
treatment. The patient shall be informed of his/her condition, the nature and risks of any
proposed treatments or procedures, and information regarding possible alternative
treatments or procedures. The patient shall also be informed of the physician who has
primary responsibility for his/her care and the existence of any professional relationships
between individuals treating him/her. The practitioner shall document in the medical record
what was explained to the patient and that the patient understood and agreed to the
proposed treatment.
21. The attending practitioner shall complete the medical record at the time of the patient's
discharge, to include progress notes, final diagnosis and discharge summary. Where this is
not possible because final laboratory or other essential reports have not been received at
time of discharge, the medical record will be available in the Health Information Department.
If the discharge summary cannot be dictated at the time of discharge, a final progress note
must be written in the medical record including a final diagnosis. The medical record must be
complete including authentication within 28 days of the patient's discharge.
22. Medical records incomplete twenty-eight (28) days after date of discharge are considered
delinquent.
23. A list of practitioners who have incomplete and/or delinquent medical records shall be
generated twice a month. Each physician shall be notified.
The practitioner will not be responsible for:
Charts not available when he/she attempted to complete them; or charts that become
delinquent while the practitioner is on vacation, or other absence, provided the Health
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Information Department is notified. An additional seven (7) days will be allowed to complete
records upon return.
Chronic delinquency shall be defined as receiving delinquency notices in three (3)
consecutive months or six (6) or more months in a twelve (12) month period.
Practitioners with chronic delinquency or delinquent charts in excess of 10 charts will be
referred to the Medical Executive Committee. Delinquent medical records are grounds for
suspension of clinical privileges of the responsible physician at the discretion of the Medical
Executive Committee.
D.
GENERAL CONDUCT OF CARE
1. All orders for treatment shall be documented in writing in the medical record or entered in the
electronic record. A verbal order shall be considered to be in writing if accepted, transcribed
and implemented by a registered nurse, respiratory therapist or technician, pharmacist, or
rehabilitation, diagnostic, radiology, or laboratory services. Verbal orders for medications can
be accepted, transcribed and implemented by a registered nurse, pharmacist, registered
respiratory therapist or certified respiratory therapy technician. Any verbal order for
medication shall be dictated by the practitioner and shall be signed by the appropriately
authorized person whom dictated, with the name of the practitioner, per his or her own name.
Verbal and telephone orders shall be strictly confined to circumstances in which patient care
needs require them. All orders shall be authenticated by the medical staff member
responsible for ordering, providing or evaluating the service within 48 hours. Do-NotResuscitate (DNR) orders and restraint orders must be authenticated at the next visit,
preferably within twenty-four (24) hours.
2. Consent for admission and treatment must be signed by or on behalf of every patient
admitted to the hospital and must be obtained at the time of admission. The admitting
department should notify the attending practitioner whenever such consent has not been
obtained. When so notified, except in emergency situations, it shall be the practitioner's
obligation to obtain proper consent before the patient is treated in the hospital.
3. The practitioner's orders must be written clearly, legibly and completely or entered in the
electronic record. Orders, which are illegible or improperly written, will not be carried out until
rewritten or understood by the nurse.
4. All previous medication orders are canceled when patients go to surgery. New orders for all
medications to be started or continued after surgery shall be clearly and completely written or
entered in the medical record. The use of phrases like “resume preop orders” is not
acceptable.
5. 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,
the Physician's Desk Reference, or Drug Facts and Comparisons.
6. Medications may have automatic stop times per current RMC policies and procedures. If the
practitioner desires to continue these medications, he must reorder them at the end of the
period. The attending physician shall be notified by the responsible nurse when drugs are
due for an automatic stop order.
7. Nurse Practitioners, physician assistants or other qualified allied health professionals may
provide patient care services on an inpatient or observation basis only with specific privileges
to do so, and under the supervision or direction of a physician appointee to the medical staff.
Inpatient consultations shall include documentation that the patient plan of care has been
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collaborated with the supervising physician or a member of the supervising physician group.
This does not replace the requirement for daily attending physician visits.
8. The attending practitioner is primarily responsible for requesting consultation when indicated
and for calling in a qualified consultant. He will provide written authorization to permit another
attending practitioner to attend or examine his patient, except in an emergency.
9. Consultations shall be held, except in extreme emergencies, under the following conditions:
j.
k.
l.
m.
n.
o.
p.
q.
When the patient is not a good risk for operation or treatment;
Where the diagnosis is obscure after ordinary diagnostic procedures have been
completed;
Where there is doubt as to the choice of therapeutic measures to be utilized;
In unusually complicated situations where specific skills of other practitioners may be
needed;
In cases where the patient's first Cesarean section is being considered, except
primigravida breech;
All curettages or other procedures by which a known or suspected normal pregnancy
may be interrupted;
Major surgical cases in which the patient is not a good risk or in which the diagnosis
or indications for surgery are in doubt;
When requested by the patient or his family.
10. 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 be made a part of the patient's record. When operative
procedures are involved, the consultation note, except in emergency situations so verified on
the record, shall be recorded prior to the operation.
11. Any medications brought into the hospital by a patient will be administered only per RMC
current Medication Administration policies and procedures. Medications brought into the
hospital by a patient or his family will not be given to the patient during his hospital stay
unless otherwise ordered by the physician.
12. Blood which has been cross-matched and is being held for a patient will be held for seventytwo (72) hours at which time the order for the blood will be canceled unless reordered for
another seventy-two (72) hours. Blood will not be released without notifying the appropriate
physician.
13. Oxygen and respiratory therapy will be administered according to the attending physician's
orders. In those cases where duration of treatment is indefinite or unspecified, the physician
of record will be notified on the third (3rd) day of treatment for new orders by the fourth (4th)
day.
The physician will write new orders as soon after notification on the third (3rd) day as
possible, not to exceed the fourth (4th) day. If new orders are not given, cardiopulmonary/diagnostic services will contact the physician for orders regarding continuing or
discontinuing the respiratory therapy.
14. Consultation request forms for radiology, pathology or other clinical interpretation shall be
filled out completely. The attending physician is responsible for providing relevant clinical
information. All requests for diagnostic testing must include information from the requesting
practitioner justifying the need for the examination(s) requested. The necessary data may be
taken from the order sheet or progress notes by a nurse.
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15. 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 in turn may refer the matter to the director of nursing service. If
warranted, the director of nursing may bring the matter to the attention of the attending
physician, the chief executive officer, or the chief of staff, as appropriate.
16. Standing orders and/or instruction sheets shall be reviewed at least annually and revised as
necessary. All standing orders and/or instruction sheets must be signed and dated by the
responsible practitioner when utilized, as required for all orders for treatment.
E.
SURGICAL CARE
1. Except in emergencies, a history and physical examination, the pre-operative diagnosis,
appropriate consents, required laboratory and radiology reports, and consultations when
requested, must be recorded on the patient's medical record prior to any surgical procedure.
In the case of an emergency, where any or all of the above entries have not been made in
the medical record, the operating surgeon shall state in writing that a delay would be
detrimental to the patient (and shall make a comprehensive note in the medical record
indicating anesthesia and the start of surgery.) In all other cases the responsible nurse shall
notify the operating surgeon, preferably no later than the night before surgery is scheduled,
and preparation for surgery including premedication shall not be performed until proper
entries are recorded in the patient's medical record. If this delay causes a change to be
made in the surgery schedule, the operation shall be rescheduled to the next available time.
2. Except in cases of emergency outpatients for O.R. shall not be admitted later than forty-five
(45) minutes prior to surgery. Patients arriving late will have their O.R. time moved back to
the next available time in O.R.
3. Surgeons shall be in the operating room and ready to commence surgery at the time
scheduled. If a surgeon is repeatedly or flagrantly late, he may have his privilege to schedule
surgery referred to the perioperative care committee for review and, if necessary, to the
credentials committee.
4. The anesthetist is responsible for writing a pre-anesthetic note in the medical record prior to
the patient's transfer to the operating area and before pre-operative medication has been
administered. This note shall indicate a choice of anesthesia and the surgical or obstetrical
procedure anticipated.
5. The anesthetist is responsible for writing a post-anesthetic note after the patient has
completed post-anesthesia recovery care to cardiopulmonary status, level of consciousness,
any needed follow-up care and/or observations, and any complications occurring during the
post-anesthesia recovery period. When a post-anesthesia visit and record entry by
anesthesia personnel is not feasible because of early patient release from the hospital, the
physician who discharges the patient from the hospital shall be responsible for meeting this
requirement.
6. If, in the opinion of the operating surgeon and/or the physician advisor of surgery, any
surgical procedure poses an unusual hazard to life, there shall be present and scrubbed as
first assistant, a qualified physician.
7. A patient admitted for dental care is a dual responsibility involving the dentist and a physician
appointee to the medical staff.
a. Dentist's responsibilities:
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1. A detailed dental history justifying hospital admission.
2. A detailed description of the examination of the oral cavity and a preoperative diagnosis.
3. A complete operative report, describing the findings and techniques. In the
case of extraction of teeth and removal of fragments, all tissue including
teeth and fragments shall be sent to the hospital pathologist for examination.
4. The dentist is totally responsible for the oral or dental care.
5. Progress notes as are pertinent to the oral condition.
6. Discharge summary, if necessary.
7. A discharge order for patients having surgery under local anesthesia.
b. Physician's responsibilities:
1. Medical history pertinent to the patient's general health.
2. A physical examination to determine the patient's condition prior to
anesthesia and surgery.
3. Supervision of the patient's general health status while hospitalized.
4. Physician is not responsible for any dental care or consequences thereof.
5. Discharge of the patient from the hospital following major anesthetics.
8. A patient admitted for podiatry care is a dual responsibility involving the podiatrist and a
physician appointee to the medical staff.
a. Podiatrist's responsibilities:
1. A history justifying hospital admission.
2. A description of the examination of the feet and pre-operative diagnosis.
3. A brief history and physical, if appropriate, for outpatient procedures done
under local anesthesia to include a list of current medications and doses,
known allergies, and medicine reactions.
4. Review and update physician, or physician appointed NP/PA, preoperative
history and physical when required.
5. Notify physician or physician appointee if there has been a significant change
in medical condition prior, during or after surgery.
6. A complete operative report, describing the findings and technique. All tissue
removed shall be sent to the hospital pathologist for examination.
7. Progress notes.
8. To discharge patient following surgery.
9. A discharge summary, if necessary.
b. Physician's responsibilities:
1. Perform or supervise physician appointed NP/PA medical history and
physical exam prior to surgery if procedure requires more than local
anesthesia.
2. Supervision of the patient's general health status when called upon by the
podiatrist.
3. Physicians are not responsible for any podiatric care or treatment of feet or
consequences thereof.
4. Discharge of the patient from the hospital following major anesthetics.
9. Written, signed, informed, surgical consent shall be obtained prior to the operative procedure
except in those situations where the patient's life is in jeopardy and suitable signatures
cannot be obtained due to the condition of the patient. In emergencies involving a minor or
unconscious patient in whom consent for surgery cannot be immediately obtained from
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parents, guardian or next of kin, 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.
10. The anesthetist shall maintain a complete anesthesia record to include evidence of preanesthetic evaluation and post-anesthetic follow-up of the patient's condition.
11. All tissues, as specified by ThedaCare Medical Center-Waupaca policy, removed at the
operation shall be sent to the hospital pathologist who shall make such examination as he
may consider necessary to arrive at a tissue diagnosis. His authenticated report shall be
made a part of the patient's medical record.
12. The rules for the scheduling of elective or non-emergency surgery will be as follows:
a. The schedule is available for posting of cases at all times.
b. The following information is required in order to post a case:
1.
2.
3.
4.
5.
6.
7.
8.
c.
The patient's full name
Age
Sex
Surgery procedure
Type of anesthesia
Operating surgeon
Time and name of person posting the case
Assistant surgeon (if indicated)
After the first time slots are filled, the order of cases will be based on the time of the
cases posted, and according to the scheduling procedure as defined by the
perioperative services committee, availability of assistant surgeon, available
operating room personnel, room cleaning, etc., as determined by the operating room
manager.
d. If cleared in advance with the operating room manager, cases may be posted at a
specified time for justifiable reason, or if they do not interfere with the normal
operating room schedule.
These cases will be scheduled in accordance with rule (c) and will be done, as near to
that time as a room is available in the order the case is posted.
13. When the operating/anesthesia team consists entirely of non-physicians (i.e. dentist with
nurse anesthetist, dentist with dentist anesthetist, podiatrist with nurse or dentist anesthetist,
etc.), there shall be a previously designated physician immediately available in case of
emergency.
14. The operating room surgeon and attending physician will see to it that patients coming to
surgery have an adequate pre-operative evaluation, meeting the requirements set down in
the pre-surgical testing guidelines.
15. Except in an emergency, consultations with another physician appointee to the medical staff
shall be required on all major surgical cases in which the patient is not a good risk, on all
critically ill patients, and on patients in which the diagnosis is obscure, or the preferred
method of treatment is in question. A satisfactory consultation includes examination of the
patient and the record. Consultations shall be recorded prior to the operation.
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16. Patients who are admitted to the hospital more than seven (7) days prior to major surgery
shall have a new physical examination to include at least the heart, lungs and other vital
signs by the attending practitioner, the operating surgeon, or the anesthesiologist. Proper
notes shall be made in the progress notes as to the findings. It shall be the responsibility of
the operating surgeon to see that such physical examination have been completed prior to
surgery.
17. Surgical procedures performed by dentists and podiatrists shall be under the overall
supervision of the physician advisor of surgery.
18. A preoperative note must be written by the physician doing the history and physical relating
the patient's medical condition to the type of anesthesia being administered. This does not
apply to procedures done under local anesthetic. There must be a statement documenting
the fact that any possible risks and complications of the surgery have been communicated to
the patient or those individuals who are responsible for him.
F.
OBSTETRICAL CARE
1. All obstetrical medical records shall have complete prenatal histories, physical examinations
and discharge summary (a discharge progress note or brief summary). Current obstetrical
records shall include a complete prenatal record.
2. The prenatal record may be electronic or a legible copy of the attending physician’s office
record transferred to the hospital shall be up to date to include findings from the last visit.
3. All patients shall have reasonable admission lab work at a minimum to include a type and Rh.
4. Staff practitioners who are covering for obstetrical services and deliveries will be continuously
available by telephone or pager for the consultations by the obstetrical nursing staff and must
be physically able to respond to the hospital within 30 minutes. If the practitioner is not able to
respond in a timely manner, prior arrangements must be made with another staff practitioner
with appropriate privileges to cover the needs of the patient.
5. Delegated Physician Responsibility: All staff members having obstetrical privileges must
delegate responsibility for their patient’s management to another similarly, qualified and
privileged physician should they be absent from the community or unavailable for any reason.
The second physician should be notified by the attending physician prior to his or her being
unavailable, and should be informed of any relevant medical information relating to the
patient likely to deliver during the absence. When care is delegated, the practitioner will notify
obstetrical staff.
6. Licensed certified nurse midwives with specific privileges may provide prenatal care,
intrapartum care, the overall management of care of a woman in normal childbirth, and the
postpartum care of a mother and newborn. The nurse midwife shall collaborate with a
physician with postgraduate training in obstetrics, pursuant to a written agreement between
the nurse midwife and the physician. The nurse midwife may not independently manage the
care of patients requiring Cesarean section or mechanical assistance with delivery or those
complications that require a referral pursuant to the written agreement.
7. Informed consent for the delivery shall be obtained on the patient's arrival to labor area.
8. An operative note shall be completed immediately after surgery or delivery, and a complete
operative report dictated within 24 hours.
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G.
NEWBORN CARE
1. The delivering provider is responsible for the immediate care of the newborn until another
provider assumes their duty.
2. A physical examination shall be recorded in the medical record of all newborns within 24
hours.
3. Newborn metabolic screening tests shall be done on all newborns prior to discharge and in
accordance with state recommendations.
H.
DISASTER PLAN
1. There shall be a plan for the care 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. The physicians' plan of participation shall be reviewed and approved by the
MEC.
2. The disaster plan will be followed per physician assignment.
3. Credentialing of volunteer licensed independent practitioners in the event of a disaster to
practitioners who do not possess privileges at ThedaCare Medical Center-Waupaca may be
granted by the Chief of Medical Staff or Vice Chief of Medical Staff or their designee(s)
pursuant to Policy and Procedure 9900.50.99.020.
I.
MISCELLANEOUS
1. The Quality Assessment and Improvement Plan of the hospital as approved by the MEC and
the Board of the hospital shall be adhered to by all attending practitioners.
2. Policies and procedures governing the use of various facilities of the hospital, preparation of
medical records, specialized forms of treatment, disposal of specimens, etc., when
determined and published by authorized committees and approved by the MEC and the
Board, shall be adhered to by all attending practitioners and said practitioners are responsible
for remaining abreast of all current directives.
3. Policies and procedures referred to above, in the procedural policies and elsewhere in these
rules and regulations, are to be found in the Policy and Procedure Manuals of the hospital.
J.
HOSPITAL CALL
1. There will be a hospital call for admission of unassigned patients, care of patients who
present at the E.R., for care of patients in the E.R. whose physician is unavailable when more
definitive care is requested by the E.R. physician, and for hospital inpatients which include
swing bed and hospice/respite patients or hospital outpatients whose physician is
unavailable.
2. The hospital call roster will be prepared by the administrative assistant.
3. Participation is required for primary care physicians on the active and associate staff who are
actively involved in the care of patients at ThedaCare Medical Center-Waupaca.
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4. Excluded from the hospital call system at their request and with approval of the MEC may be
the following:
a. Physicians with significant health problems;
b. Physicians over 65 years of age;
c. Physicians whose residence and office are located beyond a reasonable distance
from the Waupaca city limits;
d. Physicians who have special circumstances that may arise from time to time.
5. The hospital call schedule will be published one (1) month in advance. With advance notice,
scheduled time off will be taken into account and made up later. Once the schedule is
published, it is the physician's responsibility to find a replacement. If the physician is
delinquent, the chief of staff will find a replacement and assign a make-up date.
_________________________________
Chief of Staff
______________________________________
Date
________________________________
Chairman, Board of Directors
______________________________________
Date
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