MEDICAL STAFF

RULES AND REGULATIONS

Sturgeon Bay, Wisconsin

 Rules and Regulations
Table of Contents

 Admission and Discharge of Patients .................................................................................3

 Informed Consent .................................................................................................................4
 Hand Off Communication....................................................................................................4
 General Orders and Medication Orders ...............................................................................5
 Patient Self Referrals ...........................................................................................................6
 History and Physical Requirements .....................................................................................6
 Consultations (Within the Hospital Setting) .......................................................................6
 General Rules Regarding Surgical Care ..............................................................................8
o Consent for Operation ..............................................................................................8
o Requirements Prior to Induction of Anesthesia .......................................................8
o Dental Surgery .........................................................................................................8
o Podiatric Surgery......................................................................................................9
 Medical Screening and Transfer Certification ...................................................................10
 The Patient’s Medical Record ............................................................................................10
 Inpatient Admissions .........................................................................................................12
 Outpatient/Ambulatory Surgery ................................................................................. .13-14
 Admission to Outpatient Medical Unit .............................................................................15
 Observation Beds ...............................................................................................................16
 Hospice Admissions...........................................................................................................17
 Respite................................................................................................................................18
 Clinical Practice Protocols and Guidelines ........................................................................19
 Physician Call Responsibilities .................................................................................... 19-21
 Peer Review .......................................................................................................................21
 Departmentalization ...........................................................................................................21
 Credentialing ......................................................................................................................21
 CME – Continuing Medical Education..............................................................................21
 Accountability ....................................................................................................................21

(Updated November 2013)

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 MINISTRY DOOR COUNTY MEDICAL CENTER
STURGEON BAY, WISCONSIN 54235

RULES AND REGULATIONS

MEDICAL STAFF

I. ADMISSION and DISCHARGE of PATIENTS

A. A patient may be admitted only by a physician with admitting privileges.

1. Active (Provisional) staff may admit an unlimited number of

patients.
2. Courtesy staff may admit up to six (6) patients/year.

B. A provisional diagnosis is provided by the attending physician prior to the

patient's admission, except in cases of emergency, in which case the diagnosis is
given as soon as possible after admission.

C. Admissions to and discharges from intensive care units, and other special care
areas, shall be in conformity with the specific policies developed for such units.

D. The attending physician's responsibility includes:

1. Care and treatment of the patient. All inpatients will be seen on a

daily basis by an appropriately credentialed physician.
2. Prompt completeness and accuracy of the Physician's portion of the
patient's medical record.
3. Instructions to hospital personnel regarding the patient's care.
4. Providing reports of the condition to the patient, if appropriate to
the patient's relatives and if applicable to the referring physician.

E. The admitting physician is responsible for providing information necessary for the
protection of other patients and the hospital staff (Example: Communicable
diseases), and to provide such information as may be necessary to protect the
patient from self harm, except when excluded by law.

F. Each staff member provides the name(s) of the physician(s) who is (are) to be
called in the attending physician's absence. The staff member or his/her designee
must be accessible by telephone within fifteen (15) minutes. If no alternate
physician is available in an emergency, the chairman of the relevant clinical
department or his/her designee provides for the patient's care. In emergency
situations this may be the Emergency Room Physician. The Physician on call will
be expected to be accessible by telephone within fifteen (15) minutes and in
person within one hour when deemed essential by the emergency physician.

G. Physicians cooperate with the utilization review function.

H. Patients are discharged only on the order of the attending Physician, unless the patient
completes an "Against Medical Advice" (release from responsibility) form.

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 I. If death occurs, the deceased patient is pronounced dead by the attending physician or
another member of the medical staff within a reasonable time.

II. INFORMED CONSENT

A. It is the physician's responsibility to inform his or her patient about procedures and
treatments, including risks and benefits and alternatives. This will apply to both outpatients
as well as inpatients. This will be consistent with the hospital policy on Informed
Consents.

III. HAND OFF COMMUNICATION

A. Hand off communication including an opportunity to ask and respond to questions is

completed by physicians in the following instances: when transferring complete
responsibility to another physician, transferring on-call responsibilities to another
physician, anesthesia provider report to PACU recovery room. This hand off
communication contains any pertinent findings the physician feels is necessary for the care
of the patient.

B. 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.

C. 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.

D. Direct verbal communication shall be performed for hand-off of responsibilities to another

practitioner.

E. 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.

F. At no time is it acceptable to request the Health Unit Clerk or a non physician be

responsible to communicate the hand off report. The HUC may notify a physician that they
have a patient in the hospital. If that physician has issue with accepting that patient they
need to communicate that with the referring physician.

G. Hand-off communication needs to be up-to-date and accurate to meet goals of patient

safety.

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IV. GENERAL ORDERS AND MEDICATION ORDERS

A. Medications to be administered to patients shall be those listed in the

hospital formulary, unless otherwise specified by the physician.

B. Orders must be clearly written or entered and be specific to the medications the
practitioner wishes to prescribe for the patient. Range or blanket orders, such as
“Resume or Continue Home Meds” are not acceptable. For example, resume digoxin
0.125 mg po daily is the proper way to resume an order.

C. Orders which are illegible or improperly written will not be carried out by the staff until
rewritten or explained.

D. As needed (PRN) orders shall contain the frequency to be given and intended use.

E. Hold orders shall contain parameters to not give the medication, i.e. hold metoprolol if
SBP<90. If no parameters to hold are given i.e. hold metoprolol, the order will be
discontinued.

F. Titrating orders shall contain patient specific parameters. For example, titrate
nitroglycerin drip to keep SBP<120.

G. Orders for medications to be compounded or not commercially available shall contain

the ingredients and their concentrations so pharmacy can compound the product.

H. Herbal products are not to be ordered while patients are in the hospital.

I. Discharge medications will be written on the patient’s discharge medication list.

Medication, dose, route and frequency shall be included, as well as any special
instructions such as take with food or take on empty stomach.

J. When a patient goes to surgery, previous orders are cancelled and new orders must be
written immediately post-operatively.

K. An order may be countersigned by another Physician/LIP if the Physician/LIP has:

1. Personal knowledge of the patient's condition, care and treatment, and
2. Privileges within the scope that the order has been written.

L. All orders shall be signed, timed and dated by the ordering Physician/LIP.

M. Orders may only be carried out by personnel that are duly authorized to accept and
implement medical orders within his/her scope of practice. This may include a
Registered Nurse, Licensed Practical Nurse, Health Unit Secretary, Radiology
Technician, Laboratory Technician, Physical Therapist, Occupational Therapist, Speech
Therapist, Pharmacist, Respiratory Therapist, Medical Assistants, and Dietician. With
the exception of an R.N., the orders must concern their area of specialty.

N. Telephone orders shall be signed, timed, and dated within 48 hours of receipt by the
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 responsible Physician/LIP or by another Physician/LIP that has knowledge of the
patient’s condition, care and treatment and privileges within the scope of the order.
The person receiving the order will read it back to the person giving the order.

O. Verbal orders are not allowed unless in an emergency situation and are defined as
orders given face to face. They are appropriate if given to personnel that are duly
authorized to accept and implement medical orders within his/her scope of practice.
The person receiving the order will read it back to the person giving the order. Verbal
orders must be signed, timed and dated within 48 hours of receipt by the responsible
physician/LIP or by another physician/LIP that has knowledge of the patient’s
condition, care and treatment and privileges within the scope of the order.

V. PATIENT SELF-REFERRALS

A. Patient self-referrals are acceptable for: occupational therapy, physical therapy, and speech-
language pathology services in outpatient settings in accordance with State of Wisconsin
Practice Acts and regulatory and reimbursement guidelines.

VI. HISTORY AND PHYSICAL REQUIREMENTS

A. H&P's may only be performed by practitioners that are credentialed (privileged) at MDCMC to
perform this service.

B. Inpatient Admissions
All patients being admitted to the hospital must have:
1. An H&P completed within 24 hours of admission, or
2. An H&P completed within 30 days prior to the admission/ procedure. If using
an H&P completed within 30 days, an assessment and update of the patient’s
condition must be completed upon admission.

C. All patients undergoing an operation or procedure under anesthesia (with the exception of local
anesthetics) must have a History and Physical (H&P) documented and updated in the chart
prior to the start of the operation or procedure. Local anesthetic cases must have a basic
assessment completed.
1. The H&P shall be completed no more than 30 days prior to, or within 24 hours
after, registration or inpatient admission, but prior to surgery or a procedure
requiring anesthesia services.
2. In all cases an assessment and update of the patient’s condition must be
completed prior to the start of the operation or procedure.
3. In instances that the H&P is over 30 days old, the H&P is invalid and a new
H&P must be provided prior to the start of the operation or procedure or the
operation or procedure will be delayed or cancelled.
4. In life threatening situations, when there is no time to complete the H&P or
provide an update, this requirement will be waived.

VII. CONSULTATIONS (WITHIN THE HOSPITAL SETTING)

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A. Consultation is encouraged when diagnostic studies fail to identify the nature of the patient’s problem
or when the results of a treatment plan deviate substantially from the range of anticipated results. Any
qualified practitioner with clinical privileges in this Hospital can be called for consultation within his
area of expertise. The attending practitioner or his designee must order the consultation and the reason
for the consultation must be documented in the patient’s medical record.

B. The attending practitioner or his designee is primarily responsible for requesting consultation when
indicated, except in an emergency.

C. Consultation is required when requested by a mentally competent patient or by the legally responsible
party for a patient who is incapacitated or not competent.

D. Consultation is required for each active medical problem or procedure for which the requesting
practitioner does not hold clinical privileges.

E. If a nurse or other hospital health care professional believes that appropriate consultation is needed and
has not been obtained, he shall follow the Medical Staff Chain of Command Policy and bring the
matter in question to the attention of the attending physician. If unresolved, he shall bring the matter
to the attention of his immediate supervisor, who shall then refer the question to the attending
practitioner or his designee. If the matter remains unresolved, it may be referred to the appropriate
Department Chair or Medical Staff President. Where circumstances are such as to justify such action,
the Department Chair or Medical Staff President may then himself request the consultation.

F. It is expected that requests for consultations will be by personal contact between the attending
practitioner and the consultant. At the time of such contact, the purpose and urgency of the
consultation is to be communicated to the consultant. In addition to personal request, the attending
practitioner or his designee shall enter time-dated order for consultation and its purpose on the order
section of the patient’s medical record.

G. Completion of a consultation shall occur appropriate to the seriousness and urgency of the problem
being addressed. Consultation notes shall be dictated within 24 hours of the time the consultation has
been performed.

H. It is appropriate that the consultant summarize preliminary findings and recommendations in a written
note on the medial record at the time the patient is seen and that they communicate directly to the
referring practitioner.

I. Consultation notes shall include patient identification data, requesting practitioner, date and time of the
consultation, pertinent information from the history of the present illness and past medical history, a
directed physical examination as appropriate, pertinent hospital study results, a statement of
conclusions or impressions, and recommendations.

VIII. GENERAL RULES REGARDING SURGICAL CARE

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 A. Policies regarding Surgical Care will be reviewed and recommended by the Surgery and
Anesthesiology Department.

B. Consent for Operation

1. Written, signed, and informed surgical consent shall be obtained prior to the
operative procedure except in those situations wherein the patient's life is in
jeopardy and suitable signatures cannot be obtained due to the condition of the
patient.

2. In emergencies involving a minor or unconscious patient in which consent for

surgery cannot be immediately obtained from parents, guardian, or next of kin, the
circumstances should be fully explained on the patient's medical record. A
consultation in such instances may be desirable before emergency procedure is
undertaken, if time permits.

3. Signed, informed consent must be obtained before any procedure is performed

which may render a patient sterile. Should more than one operation be required
during the patient's stay in the hospital, each additional operative procedure requires
a specific consent before it is undertaken.

4. If two or more specific procedures are to be carried out at the same time and this is
known in advance, they may all be described and consented to on the same form.

C. History and Physical Requirements – See Section VI

D. Requirements Prior to Induction of Anesthesia

1. Proper identification of the patient shall be made prior to induction of anesthesia.

2. Except in severe emergencies, the pre-operative diagnosis, the history and physical
examination (at least in dictated form), and the required laboratory tests must be
recorded on the patient's medical record prior to any surgical procedure. Laboratory
workups must have been performed within a reasonable amount of time prior to
surgery. In an emergency, the physician shall make at least a note including a
tentative diagnosis and pertinent findings on the progress sheet prior to induction of
anesthesia and start of surgery.

E. The anesthetist or anesthesiologist shall maintain a complete anesthesia record to include evidence of pre-
anesthetic evaluation, choice of anesthesia (general, regional, spinal, or local), and post- anesthetic follow-
up of the patient's condition.

F. Dental Surgery
A patient admitted as an inpatient for dental surgery is a dual responsibility involving the dentist and
physician member of the medical staff.

1. Dentist's Responsibility
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 a. A detailed dental history justifying hospital admission.
b. A detailed description of the examination of the oral cavity and
preoperative diagnosis.
c. A complete operative report describing the findings and technique. In
cases of extraction of teeth, the dentist shall clearly state the number of
teeth and fragments removed. Tissues removed will conform to the
Surgery Department policies and procedures regarding pathology
specimens.
d. Progress notes as are pertinent to oral condition.
e. Clinical resume (or summary statement).

2. Physician's Responsibility
a. Medical history pertinent to the patient's general health.
b. A physical examination to determine the patient's condition prior to
anesthesia and surgery.
c. Supervision of the patient's general health status while hospitalized.

3. The discharge of the patient shall be on written order of the dentist member of
the medical staff. If the patient has a medical problem, the dentist should
discharge the patient to the care of the attending physician.

4. Postoperative orders are the joint responsibility of the attending physician and
the dentist.

G. Podiatric Surgery
The patient admitted as an inpatient for podiatric surgery is a dual responsibility
involving the podiatrist and physician member of the medical staff.

1. Podiatrist's Responsibility
a. A detailed podiatric history justifying hospital admission.
b. A detailed description of the examination of the foot and preoperative
diagnosis.
c. A complete operative report describing the findings and technique.
Tissues removed will conform to the Surgery Department policies and
procedures regarding pathology specimens.
d. Progress notes as are pertinent to the postoperative condition.
e. Clinical resume (or summary statement).

2. Physician's Responsibility
a. Medical history pertinent to the patient's general health.
b. A physical examination to determine the patient's condition prior to
anesthesia and surgery.
c. Supervision of the patient's general health status while hospitalized.
d. The discharge of the patient shall be on written order of the podiatrist
member of the medical staff. If the patient has a medical problem, the
podiatrist should discharge the patient to the care of the attending
physician.

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 3. Postoperative orders are the joint responsibility of the attending physician and
the podiatrist.

IX. MEDICAL SCREENING AND TRANSFER CERTIFICATION

A. Medical Screening – All patients requesting medical care (or those who have care requested
upon their behalf) shall receive an appropriate medical screening by a qualified medical provider
(MD, DO, NP, PA, or RN) to determine whether an emergency medical condition exists.

B. Transfer Certification – The physician is responsible to complete and sign a certification that,
based upon the information available at the time of the transfer, the medical benefits reasonably
expected from the provision of appropriate medical treatment at another facility outweigh the
increased risks to the individual or, in the case of a woman or unborn child, from being
transferred. The certification must include a summary of the risks and benefits upon which the
transfer is based. All transfers will be in accordance to the organizational Transfer Policy.

X. THE PATIENT'S MEDICAL RECORD

A. The physician's portion of the patient's medical record, like the patient, is the responsibility of
the attending physician. The record must include the following components:
 Provisional Diagnosis
 Diagnostic and Therapeutic Orders
 History and Physical Examination
 Statement of the course of action planned for the patient
 Progress notes
 Consultation; if appropriate
 Operative report and/or procedure and code note; if appropriate
 Discharge Summary
 Final documentation on the face sheet
 Documentation of decision to not proceed with ordinary measures considered
the usual standard of care

B. Written consent of the patient is required for release of medical information to persons not
otherwise authorized to receive this information.

C. Records may be removed from the hospital only in accordance with a court order, subpoena, or
statute. Unauthorized removal of patient records from the hospital by a physician is grounds for
suspension of the physician for a period to be determined by the Medical Executive Committee.

D. Professionals whose entries in the medical record that do not have to be cosigned by the provider
are as follows: registered nurse, licensed practical nurse, dietician, physical therapist,
occupational therapist, speech therapist, respiratory therapist, pharmacist, social worker, dentist,
or another licensed physician. Entries made on the record by medical students or physician
assistant students shall be co-signed by their supervising physician.

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E. Co-signatures are required by the Supervising Physician for Physician Assistants for the
following items: History and Physical for hospital admission or surgical intervention, Consults,
and Discharge Summaries. No rubber stamp signatures will be allowed.

F. Symbols and abbreviations may be used in the patient's record only when they have been
approved by the medical staff. An official record of approved abbreviations will be kept on file
in the Health Information Management Department and the patient care areas.

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 PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES - INPATIENT ADMISSIONS
Approved – MEC 01/17/06; MEC 11/7/95; Revised/Approved MEC 4/00; MEC Revised/Approved 10/2012

Document Responsible Provider Completion Time Components of Document Required

History & Physical Admitting Physician Within 24 Hours of admission
or if the H&P was completed
within 30 days prior to
admission/procedure, then an
assessment and update of the
patient’s condition must be
completed upon admission
Prenatal History and Admitting Physician An up-to-date prenatal history
Physical and physical may serve as the
H&P required within 24
hours of admission, providing
an interval progress note
indicating any changes has
been documented on the
record upon admission. In
the event the patient requires
a cesarean section, a history
and physical is required.
Operative Report Surgeon Immediately Following
Surgery
Initial Assessment/screening of physical, psychological,
and social status to determine the need for care or
treatment, the type of care or treatment to be provided, and
the need for further assessment. MDCMC Components
should include: chief complaint; history of present and
past illness; family history; social history; systems review;
metabolic status; habits; allergies; current medications and
physical exam.
Initial Assessment/screening of physical, psychological,
and social status to determine the need for care or
treatment, the type of care or treatment to be provided, and
the need for further assessment. MDCMC Components
should include: chief complaint; history of present and
past illness; family history; social history; systems review;
metabolic status; habits; allergies; current medications and
physical exam.
Description of the findings, the technical procedures used,
the specimen removed, the postoperative diagnosis, and
the name of the primary surgeon and any assistants
participating in the surgery.

Post Anesthesia Anesthesiologist or Within 48 Hours The elements of an adequate post-anesthesia evaluation
Evaluation Certified Registered should be clearly documented and conform to current
Nurse Anesthetist standards of anesthesia care, including:
• Respiratory function, including respiratory rate, airway
patency, and oxygen saturation;
• Cardiovascular function, including pulse rate and blood
pressure;
• Mental status;
• Temperature;
• Pain;
• Nausea and vomiting; and
• Postoperative hydration.

Consultation Consulting Physician Within 24 Hours Findings of consultation.

Verbal Orders Ordering Physician Within 48 Hours

Discharge Diagnoses Attending Physician On Discharge Complete listing of all final diagnoses including
complications and comorbidities.

Discharge Summary Attending Physician Within 15 Days of Discharge Summarization of the reason for hospitalization, the
significant findings, the procedures performed and
treatment rendered, the patient's condition on discharge,
and any specific instructions given to the patient and/or
family, as pertinent (information on DISCHARGE
ORDER pertinent).
Admitting Physician: The physician who either makes the decision to admit the patient or accept the patient to his/her service.
Attending Physician: The physician who provides and maintains primary responsibility for the patient's care during the
inpatient admission; this may be the admitting physician and/or the surgeon.
*This physician will be responsible for the majority of physician orders/progress notes in the record.
*This physician is not necessarily the discharging physician.
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 PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES
OUTPATIENT/AMBULATORY SURGERY

Approved: MEC 06/2011/ BOD 07/2011

TYPE OF Requirements
ANESTHESIA History and Physical Examination Pre procedure Note
Local or Topical Not required. Minimum documentation must include:
Anesthesia, or No
*Indications/symptoms for procedure;
Anesthesia
*current medications and dosages;
*any known allergies;
*an assessment of mental status and
*Site- specific exam.

Additional documentation is at the discretion of the

surgeon/provider as appropriate to the patient’s medical
condition.

This may be accomplished via office note, progress note of

Moderate
History minimal documentation must include:
Sedation
*Indications/symptoms for procedure;
*current medications and dosages;
*any known allergies; and,
*existing comorbid conditions, if any.
short form H&P.
A note on the day of surgery which evaluates the patient’s
current status for surgery.
*The note can be written by a physician, operating
practitioner or individual qualified to administer anesthesia.

Physical Examination minimal documentation must *A note is not required when the history and physical is
include: performed (documented) on the day of surgery.
*Mental status assessment;
*ASA class;
*Airway assessment;
*examination specific to the proposed procedure and any
comorbid conditions; and,
*examination of the heart and lungs by auscultation.

General, MAC, History minimal documentation must include: A note on the day of surgery which evaluates the patient’s
Spinal or Epidural *Indications/symptoms for procedure; current status for surgery.
Anesthesia *history of present/past illness
Regional Block *family history, social history *The note can be written by a physician, operating
*current medications and dosages; practitioner or individual qualified to administer anesthesia.
*any known allergies; and,
*existing comorbid conditions, if any. *A note is not required when the history and physical is
performed (documented) on the day of surgery.
Physical examination minimal documentation must
include:
*Mental status assessment;
*exam specific to the proposed procedure and any
comorbid conditions;
*examination of the heart and lungs and,
*assessment and written statement about the patient’s
general condition.

n
In emergency situations where there is inadequate time to record the required level of H&P exam and documentation, a
brief note including the pre-procedural diagnosis, indications and plan will be recorded prior to such procedure followed
by the full documentation as soon as the provider is able following the procedure.

When the above documentation requirements are not on the chart before the procedure, it shall be cancelled
unless the practitioner states in writing that such delay would be detrimental to the well-being of the patient.

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 PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES
OUTPATIENT/AMBULATORY SURGERY
Revised/Approved MEC 10/2012

Document/Item Responsible Provider Completion Time Components Required

Admission Order
Progress Notes
Anesthesia Record
Operative Report
Post Procedure Note
Post Anesthesia Evaluation
Discharge Documentation
(see form)
Admitting/Attending Physician
Attending Physician/Surgeon
Anesthesiologist or Certified
Registered Nurse Anesthetist
Surgeon
Surgeon
Anesthesiologist or Certified
Registered Nurse Anesthetist
Attending/Discharging Physician
On Admission
As needed.
At time of procedure by CRNA
or Anesthesiologist.
Anesthesiologist must provide
review within thirty days on those
cases where he/she is not
providing care.
Immediately Following Surgery
A post-procedure note must be on
the chart prior to the patient
leaving the PACU (unless the OP
report is on the record.)
Within 48 Hours
On Discharge
Timed/dated order for admission
of the patient for Ambulatory/
Outpatient Surgery.
Written at the discretion of the
physician to reflect changes in the
patient status.
Documentation that the
anesthesiologist has reviewed and
approved (signed-off) on every
case involving anesthesia.
Description of the findings, the
technical procedures used, the
specimens removed, the
postoperative/procedure
diagnosis, estimated blood loss,
and the name of the primary
surgeon and any assistants
participating in the surgery.
Documentation must include:
Pre-Diagnosis
Post Operative Diagnosis
Procedure and Assistants
Specimens removed
Intra-Operative Complications
Estimated Blood Loss
Condition of Patient
The elements of an adequate
post-anesthesia evaluation should
be clearly documented and
conform to current standards of
anesthesia care, including:
• Respiratory function, including
respiratory rate, airway patency,
and oxygen saturation;
• Cardiovascular function,
including pulse rate and blood
pressure;
• Mental status;
• Temperature;
• Pain;
• Nausea and vomiting; and
• Postoperative hydration.
See form which addresses: diet,
pain, activity, special
considerations, follow-up
appointment with surgeon,
problems, etc.

Discharge Diagnoses/Procedures Attending/Discharging Physician On Discharge Complete listing of pertinent

Performed diagnoses and procedures
performed.

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PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES –
ADMISSION TO OUTPATIENT MEDICAL UNIT
Approved – MEC 06/15/04; 11/17/09
Revised – MEC 08/17/04, 11/17/09

Document/Item Responsible Provider Completion Time Components Required

Physician Orders Admitting/Attending Optimally 24 hour or more

(Notify the Outpatient
Medical Unit to schedule
outpatient medical procedures
and treatments.)
Hand Off Communication
Documented Note
Physician advance notice.
Nurse (from Ordering Upon Order
Physician) to OPMU Nurse
Note must include (at a
Admitting/Attending Must accompany the physician minimum) the diagnosis and
Physician order. current condition of the
patient and the plan. The
documented note may be the
clinic note, current H&P, or
Discharge Summary

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PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES - OBSERVATION BEDS
Approved at MR/UR Meeting - 08/16/95
MEC - 11/7/95

Document/Item Responsible Provider Completion Time Components of Document Required

Admission Order Admitting Physician On Admission Timed/dated order for admission of the patient to an
Outpatient Observation Bed.

Initial Assessment/ Admitting Physician Immediately/Within 24 Initial Assessment/screening of physical,

History & Physical Hours of Admission psychological, and social status to determine the
reason why the patient is being admitted to an
Observation Bed, the type of care or treatment to be
provided, and the need for further assessment.
MDCMC Components should include: chief
complaint; history and time of onset illness; pertinent
past history, family history; social history; systems
review; metabolic status; habits; allergies; current
medications and physical findings.

An extensive ER note or progress note documented

by the admitting physician which encompasses the
criteria defined above will suffice as an initial
assessment/H&P.

This document may be written in the Progress Notes

or dictated.

Progress Notes Attending Physician Within 8 Hours - With
Subsequent Notes
Documented as the
Patient’s Condition
Warrants. 24 Hour Re-
Assessments Should be
Documented
Progress notes should reflect the status of the
patient’s condition, the course of treatment, the
patient’s response to treatment and any other
significant findings apparent at the time the progress
note is documented.
Reassessments should include plan for 1) discharge
or transfer; 2) conversion to IP or 3) continued OBS
with evaluation and rationale.

Verbal Orders Ordering Physician/ Within 48 Hours Verbal orders are tagged at the Nurses Station and
Physician Involved should be completed as soon as possible after the
With Patient’s Care order is transcribed.
May Co-Sign

Discharge Order Discharging On Discharge Timed/dated order for discharge from the Outpatient
Physician Observation Bed status.

Discharge Discharging On Discharge Complete listing of all final diagnoses including

Diagnoses Physician complications and comorbidities.

Discharge Note Attending Physician On Discharge Preferably Summarization of the reason for the Observation
or Within 15 Days of Bed admission, the outcome, follow-up plans and
Discharge patient disposition, and discharge instructions (diet,
activity, medications, special instructions).

This document may be written in the Progress Notes

Admitting Physician:
Attending Physician:
or dictated.
The physician who either makes the decision to admit the patient or accept the patient to his/her
service.
The physician who provides and maintains primary responsibility for the patient's care during the
inpatient admission; this may be the admitting physician.

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PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES - HOSPICE ADMISSIONS

Document Responsible Provider Completion Time Components of Document Required

History & Physical Admitting Physician Within 24 Hours of
Admission of Inpatient*
Admission or Direct
Hospice Admission
*If the patient is transferred
in to Hospice from an
inpatient admission, the
initial H&P will serve as the
Hospice admission H&P.
Initial Assessment/screening of physical,
psychological, and social status to determine the need
for care or treatment, the type of care or treatment to
be provided, and the need for further assessment.
MDCMC Components should include: chief
complaint; history of present and past illness; family
history; social history; systems review; metabolic
status; habits; allergies; current medications.

Operative Report Surgeon Immediately Following Description of the findings, the technical procedures
Surgery used, the specimen removed, the postoperative
diagnosis, and the name of the primary surgeon and
any assistants participating in the surgery.

Consultation Consulting Physician Within 24 Hours Findings of consultation.

Verbal Orders Ordering Physician Within 48 Hours

Discharge Attending Physician On Discharge Complete listing of all final diagnoses including
Diagnoses complications and comorbidities.

Discharge Note/ Attending Physician Within 15 Days of Summarization of the reason for hospice, the
Summary Discharge significant findings, the procedures performed and
treatment rendered, the patient's condition on
discharge, and any specific instructions given to the
patient and/or family, as pertinent (information on
DISCHARGE ORDER pertinent). This information
can be covered in one document for both and
inpatient and hospice discharge.

Attestation Attending Physician Upon Completion of

Statement Coding

Miscellaneous Notes

Diagnostic Studies: Diagnostic studies from inpatient and/or swing bed admissions may be copied and placed in the
active hospice admission. These copies may be destroyed on discharge as the original documents
will exist in the previous admissions.

Hospice Forms: Forms originated by the Hospice Program shall be integrated into the same sections as the
MDCMC forms within the medical record.

Release of Information:
Approved: MEC 2/11/97
Hospital Board 3/19/97
Through the contractual agreement between MDCMC and Hospice, a formal “ROI” or
“Authorization for Release” is not required when asked to provide copies of MDCMC Hospice
patient records to Hospice staff members.

Page 17 - Medical Staff Rules and Regulations

 PHYSICIAN MEDICAL RECORD COMPLETION RESPONSIBILITIES - RESPITE ADMISSIONS

Respite Admission: An admission facilitated by the hospice agency to allow a “break” for the patient’s caregivers (up to
five days). The patient does not require medical treatment, but does require some supervision which may temporarily not
be available within the home (per Unity Hospice 12/15/97).

Document Responsible Completion Time Components of Document Required

Provider

History & N/A N/A Not required for Respite Care Patient.
Physical

Progress Note Attending During Admission Brief note/synopsis of reason for admission,
Physician diagnosis or symptoms indicating need for
admission, progress of case, physical findings,
change in diagnosis, condition on discharge,
instructions to patient, etc.

Daily Progress Attending At time of Encounter Daily visits by the physician are not required;
Notes Physician however, if they do occur, a note should be
documented in the record.

Standing Orders Attending Within 24 Hours of Pre-printed Unity Hospice Standing

Physician Admission Orders/Protocol - Requires Physician Signature.

Verbal Orders Ordering Physician Within 48 Hours Only if applicable.

Discharge Attending On Discharge May be indicated in progress note (reason for

Diagnoses Physician admission). (No discharge summary is required
for this type of admission.)

Discharge Attending On Discharge Not required; may be documented by physician.

Instructions Physician

Miscellaneous Notes

Unity Hospice has a standing order/protocol for hospice/respite patients. Documentation requirements for “respite” patients are
minimal and basically at the discretion of the attending physician. It is desirable to obtain at least one progress note for the admission
to respite.

Diagnostic Studies: Diagnostic studies from inpatient and/or swing bed admissions may be copied and placed in the active
hospice admission. These copies may be destroyed on discharge as the original documents will exist in the
previous admissions.

Hospice Forms: Forms originated by the Unity Hospice Program shall be integrated into the same sections as the MDCMC
forms within the medical record.

Release of Information: Through the contractual agreement between MDCMC and Unity Hospice, a formal “ROI” or
“Authorization for Release” is not required when asked to provide copies of MDCMC Hospice patient
records to Unity Hospice staff members.

Page 18 - Medical Staff Rules and Regulations

XI. CLINICAL PRACTICE PROTOCOLS AND GUIDELINES

A. As a condition of consideration for continued appointment, every credentialed provider agrees to the
following:

• To comply with clinical practice protocols and guidelines that are established by, and must be reported
to, regulatory or accrediting agencies or patient safety organizations, including those related to national
patient safety initiatives and core measures, or to clearly document the clinical reasons for variance.

• To also comply with clinical practice protocols and guidelines pertinent to his or her medical specialty,
as may be adopted by the Medical Staff or the Medical Staff leadership, or clearly document the clinical
reasons for variance.

XII. PHYSICIAN CALL RESPONSIBILITIES

A. It is the policy of Door County Medical Center (MDCMC) to comply with the Emergency Medical
Treatment and Active Labor Act (EMTALA). EMTALA requires that any patient who presents on the
Hospital premises in need of emergent care or at the Emergency Department must receive an appropriate
medical screening examination by a physician or allied health professional as designated by the MEC to
determine if that patient has an emergency medical condition. If so, the patient’s condition must be
stabilized prior to discharge/transfer.

B. An emergency medical condition means a medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse)
such that the absence of immediate medical attention could reasonably be expected to result in placing
the health of the individual (or with respect to a pregnant woman or her unborn child) in serious
jeopardy; serious impairment or dysfunction of any bodily organ or part; or with respect to a pregnant
women who is having contractions.

C. The purpose of this policy is to ensure compliance with EMTALA by explaining the obligations of on-
call physicians under the law and under the regulations of the DCMH MEC. Both the Hospital and on-
call physicians have obligations under EMTALA, violations of which can give rise to patient claims for
any resulting injuries as well as the possibility of significant expenses, fines or other financial penalties.

D. All physicians on the Active medical staff shall participate in call sharing arrangements with others in
their specialty. Exceptions may be allowed by the MEC at his or her request, on the basis of age, health
status, or for other reasons. The MEC shall consider the request following the receipt of a
recommendation of a simple majority of the members of the respective department of the requesting
physician.

E. Physicians requesting call schedule changes are responsible to arrange alternate EMTALA compliant
call coverage and must notify the appropriate Hospital personnel of any changes, (i.e., acceptance of the
change by another physician having clinical privileges consistent with those of the assigned physician).

F. The on-call physician must come to the Hospital ED when requested by the ED physician, another
physician, or any Hospital employee making the request on behalf of a physician who is not available to
Page 19 - Medical Staff Rules and Regulations
 call the on-call physician directly. Seeing the patient in the on-call physician’s office or clinic is not an
option until the patient is determined to be “stable” and thus able to be discharged, or not to have an
“emergency medical condition,” as those terms are defined under EMTALA.

G. If the on-call physician disagrees about the need to come to the Hospital ED, the on-call physician must
come to the Hospital and render care irrespective of the disagreement. The on-call physician may
address the disagreement with the appropriate individual at the Hospital at a later time.

H. In the event an on-call physician fails to respond in a reasonable time period (as determined by the ER
physician) and the patient must subsequently be transferred to another facility, unless not available, the
on-call physicians name, specialty, and address are to be included with the records accompanying the
patient.

I. If requested, the on-call physician shall be physically present in the Hospital ED to assist in providing an
appropriate medical screening examination, as well as in the ongoing stabilization and treatment of an
ED patient prior to transfer or treatment. The on-call physician shall remain in the ED until released by
the ED physician.

J. Neither the Hospital, the ED physician nor the on-call physician shall consider the patient’s financial
circumstances, the patient’s insurance or means of payment in the decision to respond to, treat, or
transfer the patient.

K. For conditions requiring admission to the Hospital, the on-call physician has one hour to provide verbal
orders or to present to the ED in order to evaluate the patient and write admission orders. Time response
requirements commence when the first page or call is made to, and connects with the on-call physician.

L. Except under unusual circumstances, the on-call physician must be physically present in the Hospital ED
within 30 minutes of being requested for assistance or emergency stabilization of the patient. . Response
time requirements commence when the ED physician, nurse, or other Hospital worker makes the first
attempted (page or call) to, and connects with the on-call physician.

M. The on-call physician is not required to interrupt critical care–that is, care that requires his or her
personal management—which he or she is providing to a specific patient when contacted for on-call
services. Immediately after the physician finishes caring for the specific patient, he or she will contact
the requesting unit, respond if requested, and give an estimated time of arrival if determined to be
needed by the ED physician.

N. Unless other arrangements are made, the on-call physician shall provide timely follow-up patient care
throughout the episode of injury or illness. The on-call physician may not condition the first follow-up
office visit on advance payment or otherwise condition continued care upon the patient’s ability to pay.

O. Any violation of this policy by an on-call physician will be reported by any person with direct
knowledge of the facts to the Medical Staff President and/or Department Chairman of the physician
involved. The Medical Staff President or Department Chair will notify the President/CEO or designee
covering Administrative call. Except in the case of a flagrant violation, for the first incident, the on-call
physician may receive counseling, a rebuke, and an official warning. A copy of the warning will be
placed in the physicians Quality file.
Page 20 - Medical Staff Rules and Regulations
P. If the on-call physician commits a flagrant or second violation, he or she will be reported to the
Department Chair, who will request corrective action which may result in a suspension of privileges or
termination of medical staff membership. The Department Chair shall also provide a written report to
the MEC.

Q. The MEC may then take action as indicated by the Medical Staff Bylaws. In determining whether a
violation is flagrant, the Department Chair or MEC shall consider the total circumstances, including, but
not limited to, whether the violation was deliberate, the seriousness of the patient’s condition and
outcome, and how disruptive the violation was to Hospital operations.

XIII. PEER REVIEW

A. Information regarding the peer review process may be accessed in the Medical Staff Bylaws and the
Peer Review Policy.

XIV. DEPARTMENTALIZATION

A. Information regarding Departmentalization may be referenced in the Medical Staff Bylaws.

XV. CREDENTIALING

A. Information regarding Credentialing may be referenced in the Medical Staff Bylaws.

XVI. CME – CONTINUING MEDICAL EDUCTION

A. Medical Staff members will obtain Continuing Medical Education credits as State Code requires.
Such CME must relate, at least in part, to the privileges granted.

XVII. ACCOUNTABILITY

A. In the event a physician/provider fails to comply with established elements set forth in the Medical
Staff Rules & Regulations or Policies and Procedures, the following actions will occur:

1st Occurrence Department Chair will speak with physician/provider.

2nd Occurrence Discussion and Letter from Medical Staff President.
3rd Occurrence Physician/Provider required to attend Medical Executive Committee
meeting for review of occurrence.
4th Occurrence Reported to the Chief Executive Officer, action to be determined per
contract, medical staff bylaws etc.

B. Events will be reported through Incident Comp Web (located on the Ministry Door County Medical
Center Intranet site) and routed to the Medical Staff Department Chair by the Chief Quality Officer.

C. Each occurrence will be documented by the Department Chair or Medical Staff President and
placed in their Medical Staff Quality File and Human Resources File (as applicable.)

Page 21 - Medical Staff Rules and Regulations

 Ministry Door County Medical Center
Medical Staff
Rules and Regulations
Adoption and Approval

Initially Adopted by the Medical Staff of Door County Memorial Hospital on July 11, 1986 and Approved by
the Board of Directors August 20, 1986.

The Rules and Regulations were amended upon adoption of the Medical Executive Committee, on behalf of the
Medical Staff of Door County Memorial Hospital, and approval of the Door County Memorial Hospital Board
on Directors on the following dates:

March 1987 October 2002 March 2008

May 1987 December 2002 May 2009
July 1987 June 2004 September 2009
September 1993 November 2004 November 2009
September 1994 June 2005 July 2011
November 1994 February 2006 May 2012
January 1996 April 2006 November 2012
December 1998 February 2007 May 2013
September 1999 May 2007 September 2013
April 2000 September 2007 November 2013

Adopted by the Medical Executive Committee on behalf of the Medical Staff of Door County Memorial
Hospital, Sturgeon Bay, Wisconsin on September 15, 2009.

Medical Staff President - Signature on File

Approved by the Door County Memorial Hospital Board of Directors on September 23, 2009.

Hospital President/CEO - Signature on File

Board of Directors Chairman - Signature on File

Page 22 - Medical Staff Rules and Regulations