Medical Staff House Staff Orientation Manual - Montefiore Medical ...

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Discharge Summary • Patient Name and Medical Record Number (8 digits) • Name of Attending and Dictating MD • Dictation Date, Admission and Discharge Dates. • Brief History (Chief Complaint) • Reason for Hospitalization • Pertinent Physical Findings and Diagnostic Results • Hospital Course/Significant Findings/Treatment Results • Discharge Disposition and Final Diagnosis • Instructions to Patients regarding Physical Activity, Medications, Diet and Follow-up Care. Operative Report • Patient Name and Medical Record Number (8 digits) • Name of Attending Surgeon and Assistants • Date of Procedure • Pre and Post Operative Diagnoses • Name of Operation/Procedure • Type of Anesthesia • Name of Anesthesiologists • Surgical Technique used • Detailed account of the procedure and findings • Specimens removed • Closure & Drains • Complications • Fluids Given • Blood Loss • Patient Condition at the end of the procedure Corrections Make alterations to the medical record very carefully and only when changes are absolutely necessary. Do not obliterate errors or use whiteout in the medical record. To correct inaccuracies, follow these procedures: • Draw a single, thin line through each inaccurate entry, making certain that it is still legible • Date and initial this line • Add a note in the margin stating why the entry is being replaced (i.e. error, wrong patient, etc.) • Enter the correction in chronological order. If not possible, refer to location of the corrected material. Date corrected entry with current date. Addendum When writing an addendum, indicate that it is an addendum and use the current date. An addendum is appropriate if the patient requests that a correction be made in the record or if 128
additional information is uncovered which may change original information previously recorded in the medical record. DEATH CERTIFICATE PROCESSING Death Certificates are processed in the HIM department at the Moses Division and in the Admitting department at the Weiler Division. The following documentation is required on every death: • Report each death immediately to HIM ext. 2210 at Moses and Admitting ext.3456 at Weiler • Pronounce patient (unless already pronounced by a PA). Document date, time and circumstances surrounding death in the patient's medical record. If a PA pronounced the death, countersign or write the death note. • Evaluate circumstances of death to ascertain whether Medical Examiner referral is required. (Name of Medical Examiner, Case Number, and Acceptance/Refusal of the case must be documented in the medical record.) • Attempt to obtain autopsy consent for all deaths that do not qualify for medical examiner referral. (Consent for Autopsy is Page 2 of Death Notification Form NR1625 M/E Rev. 10/99). The pathologist is responsible for completing the death certificate on all autopsied cases. • Notify the attending physician. • Notify the next of kin of the patient's death. • Notify Pathology Moses ext. 4979. Weiler ext. 2947 and H I M Moses 2210 of pending autopsy • Complete the Death Certificate or Medical Examiner Report as required within two (2) hours of death. • A license number is required on all death certificates as of January 1, 2003. If the physician does not yet have a license, then the physician license number of the chief resident or attending physician of the case will be used. • Complete all sections of the Notification of Death Form #1625M/E Rev. 10/99 available on the nursing unit. HOME HEALTH AGENCY VP of Clinical Operations Terry Goodwin 718-405-4401 Administrative Clinical Operations Pamela Joachim 718-405-4406 The goal of the home care program is to meet the patient's continuing comprehensive health care needs in the home. Consistent with the Medical Center's objectives, the Home Health Agency's goal is to provide our patients with continuous quality care, focusing on positive patient outcomes. PROGRAMS 129
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Medical Staff House Staff Orientati
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We would like to take this opportun
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Montefiore’s Institute for Reprod
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TABLE OF CONTENTS SECTION 1- Genera
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Plastic and Reconstructive Surgery
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SECTION 1 • GENERAL INFORMATION 1
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Contract Management Organization (C
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Neurology M 4656 3351 Steuben A 316
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MOSES NURSING STATIONS C 741-2377 P
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M 5584 Lupus Clinic M 5584 Neurolog
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MEDICAL STAFF CREDENTIALING OFFICE
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MONTEFIORE INTEGRATED PROVIDER ASSO
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• Referral by the ED physician is
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HOUSE STAFF OFFICE 150 East 210th S
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• Institutions must have a GME Co
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accreditation, then the institution
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and the conditions under which livi
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• Patient support services, such
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following: counseling, appointment
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Physician Impairment and Drug Abuse
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participants the opportunity to com
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WALDO AVENUE SHUTTLE Those resident
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First Year Residents: Assignments o
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SECTION III • MONTEFIORE MEDICAL
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Administrator: Jennifer Ortiz Medic
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Medical Director: Marta Rico, MD, A
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2532 Grand Concourse Bronx, New Yor
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Briggs Avenue Academy 3010 Briggs A
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Nurse: Maria Campos, LPN Sheila Mon
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Gloria Feliciano - Director FRANKLI
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ANESTHESIOLOGY Chairman 718-920-280
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Director John Fisher, MD 718-920-42
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Christine Clarke 718-920-5996 PROGR
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SOCIAL PEDIATRICS 3544 Jerome Ave.
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Vladimir Kvetan, MD 718-920-5440 De
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Residency Program Director Eugene S
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No procedure can be performed until
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Bronx, New York 10461 Administrativ
Page 77 and 78: Director, Education Programs Rasim
Page 79 and 80: North Central Bronx Hospital 718-51
Page 81 and 82: Arlene Saunders 718-741-2492 Admini
Page 83 and 84: printed name of the referring physi
Page 85 and 86: The radiology department at Jack D.
Page 87 and 88: Pediatric Surgery 718-920-7200 Burt
Page 89 and 90: SECTION V • POLICIES AND PROCEDUR
Page 91 and 92: Note: This summary contains key poi
Page 93 and 94: WHERE: • Advance directives are a
Page 95 and 96: • family has moral or religious o
Page 97 and 98: • OD1091-4 Affidavit of Close Fri
Page 99 and 100: Bioethics (Moses) 718- 920-6226 (We
Page 101 and 102: HOW: • Capacitated patients may r
Page 103 and 104: VERIFICATION OF OPERATIVE PROCEDURE
Page 105 and 106: INFECTION CONTROL PROGRAM Moses Nur
Page 107 and 108: person who feels that he/she may be
Page 109 and 110: CONTROLLED SUBSTANCES IN THE MEDICA
Page 111 and 112: • Practitioners will immediately
Page 113 and 114: One Quality Improvement Plan exists
Page 115 and 116: SECTION VI • SERVICE DEPARTMENTS
Page 117 and 118: Legal Certificates 718-904-3456 Fin
Page 119 and 120: CHILD PROTECTION CENTER The Childre
Page 121 and 122: CME REQUIREMENTS: Attending physici
Page 123 and 124: Hours: Monday - Friday 8:00AM - 5:0
Page 125 and 126: delivery system. Medical record inf
Page 127: All physician orders whether writte
Page 131 and 132: THE TISHMAN LEARNING CENTER HEALTH
Page 133 and 134: MAILROOM MOSES Brown Zone, Moses Ba
Page 135 and 136: The mission of the Occupational Hea
Page 137 and 138: • Families and caregivers need as
Page 139 and 140: The Patient Safety Officer and the
Page 141 and 142: Unified Director of Pharmacy Frank
Page 143 and 144: successful, expanded to other areas
Page 145 and 146: • Professional Misconduct • Pho
Page 147 and 148: Outpatient testing, evaluation and
Page 149 and 150: Office Coordinator Lillian Zambardi
Page 151 and 152: E Educational Administration 28 Eme
Page 153 and 154: Paychecks, House Staff 40 Pediatric
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