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

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PATIENTS’ BILL OF RIGHTS As a patient in a hospital in New York State, you have the right, consistent with law, to: 1. Understand and use these rights. If for any reason you do not understand or you need help, the hospital MUST provide assistance, including an interpreter. 2. Receive treatment without discrimination as to race, color, religion, sex, national origin, disability, sexual orientation or source of payment. 3. Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints. 4. Receive emergency care if you need it. 5. Be informed of the name and position of the doctor who will be in charge of your care in the hospital. 6. Know the names, positions and functions of any hospital staff involved in your care and refuse their treatment, examination or observation. 7. A no smoking room. 8. Receive complete information about your diagnosis, treatment and prognosis. 9. Receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment. 10. Receive all the information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent for you if you are too ill to do so. If you would like additional information, please ask for a copy of the pamphlet "Do Not Resuscitate Orders -- A Guide for Patients and Families." 11. Refuse treatment and be told what effect this may have on your health. 12. Refuse to take part in research. In deciding whether or not to participate, you have the right to a full explanation. 13. Privacy while in the hospital and confidentiality of all information and records regarding your care. 14. Participate in all decisions about your treatment and discharge from the hospital. The hospital must provide you with a written discharge plan and written description of how you can appeal your discharge. 15. Review your medical record without charge. Obtain a copy of your medical record for which the hospital can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay. 16. Receive an itemized bill and explanation of all charges. 17. Complain without fear of reprisals about the care and services you are receiving and to have the hospital respond to you and if you request it, a written response. If you are not satisfied with the hospital's response, you can complain to the New York State Health Department. The hospital must provide you with the Health Department telephone number. 18. Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors. 19. Make known your wishes in regard to anatomical gifts. You may document your wishes in your health care proxy or on a donor card, available from the hospital. PROTECTED HEALTH INFORMATION USES AND DISCLOSURES Administrative Policy and Procedure JH41.1 90
Note: This summary contains key points of this policy and the related procedures. For a complete understanding of all the relevant provisions, it is necessary to thoroughly read the full policy. WHAT: Montefiore Medical Center (MMC) will comply with applicable legal and regulatory requirements the management of Protected Health Information (PHI). The policy establishes rules, which MMC will follow when using and disclosing the PHI of its patients. All MMC Associates are required to maintain the confidentiality and privacy of PHI in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). MMC will not use or disclose PHI except as permitted by the privacy regulations. Protected Health Information (PHI) is generally defined by HIPAA as information in any form or medium (including oral, written and electronic communications), that: • Is created or received by a health plan, health care provider, health care clearinghouse or an employer • Relates to an individual’s physical or mental health, the provision of health care to an individual, or the payment for the provision of health care to an individual • Identifies, or could reasonably expected to be used to identify an individual Protected Health information includes everything from a patient’s name, address and telephone number to a patient’s clinical and billing records. WHO: This policy applies to all Montefiore Medical Center Staff Associates WHEN: The policy applies to all Protected Health Information (PHI) collected, maintained, used and disclosed by Montefiore Medical Center. MMC may use and disclose protected health information for purposes of treatment, payment and health care options. HOW: • MMC Joint Privacy Notice All individuals seeking services at MMC have the right to receive an MMC Joint Notice of Privacy Practices that contains information relating to 1. the uses and disclosures of PHI to be made by MMC, 2. The individual’s right’s relating to his/her PHI, and 3. MMC’s legal duties with respect to PHI. The Privacy Notice will be provided to individuals during their first direct encounter for service at MMC. Notices will be available at all registration and admission points within MMC, and posted in clear and prominent locations where it is reasonable to expect individuals seeking service to be able to read the notice. The notice can also be provided electronically upon request. MMC will obtain written acknowledgements from individuals attesting to the fact that a Privacy Notice has been provided to them. When MMC has an indirect treatment relationship with its patients, MMC need only make Privacy Notice available upon request and a signed acknowledgement is not required. 91
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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
Page 39 and 40: Physician Impairment and Drug Abuse
Page 41 and 42: participants the opportunity to com
Page 43 and 44: WALDO AVENUE SHUTTLE Those resident
Page 45 and 46: First Year Residents: Assignments o
Page 47 and 48: SECTION III • MONTEFIORE MEDICAL
Page 49 and 50: Administrator: Jennifer Ortiz Medic
Page 51 and 52: Medical Director: Marta Rico, MD, A
Page 53 and 54: 2532 Grand Concourse Bronx, New Yor
Page 55 and 56: Briggs Avenue Academy 3010 Briggs A
Page 57 and 58: Nurse: Maria Campos, LPN Sheila Mon
Page 59 and 60: Gloria Feliciano - Director FRANKLI
Page 61 and 62: ANESTHESIOLOGY Chairman 718-920-280
Page 63 and 64: Director John Fisher, MD 718-920-42
Page 65 and 66: Christine Clarke 718-920-5996 PROGR
Page 67 and 68: SOCIAL PEDIATRICS 3544 Jerome Ave.
Page 69 and 70: Vladimir Kvetan, MD 718-920-5440 De
Page 71 and 72: Residency Program Director Eugene S
Page 73 and 74: No procedure can be performed until
Page 75 and 76: 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: SECTION V • POLICIES AND PROCEDUR
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 and 128: All physician orders whether writte
Page 129 and 130: additional information is uncovered
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
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Unified Director of Pharmacy Frank
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successful, expanded to other areas
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• Professional Misconduct • Pho
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Outpatient testing, evaluation and
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Office Coordinator Lillian Zambardi
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E Educational Administration 28 Eme
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Paychecks, House Staff 40 Pediatric
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Medical Staff House Staff Orientation Manual - Montefiore Medical ...

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