Rules and Regulations 2013 - North Florida Regional Medical Center

NORTH FLORIDA REGIONAL MEDICAL CENTER
MEDICAL STAFF RULES AND REGULATIONS

North Florida Regional Medical Center
Rules And Regulations
TABLE OF CONTENTS
A. ADMISSION AND DISCHARGE --------------------------------------------------------------- 4
A.1. Activity Level Requirments ------------------------------------------------------------------------- 4
A.2. Admitting/Treatment Privileges --------------------------------------------------------------------- 4
A.3. Responsibility for Care of Hospital Patients ------------------------------------------------------ 4
A.4. Provisional Diagnosis/Reason for Admission ----------------------------------------------------- 4
A.5. Emergency Admissions ------------------------------------------------------------------------------ 4
A.6. Care of Patients Admitted on Emergency Basis -------------------------------------------------- 5
A.7. Physician Coverage Arrangements ----------------------------------------------------------------- 5
A.8. Patient Discharge-------------------------------------------------------------------------------------- 5
A.9. Admission Order of Priorities ----------------------------------------------------------------------- 5
A.10. Transfer of Patients Within the Hospital ----------------------------------------------------------- 6
A.11. Admission/Discharge to Special Care Units/Telemetry------------------------------------------ 6
A.12. Compliance with Utilization Resource Management Plan -------------------------------------- 6
A.13. Pronouncement of Death ----------------------------------------------------------------------------- 6
A.14. Time of Discharge ------------------------------------------------------------------------------------ 7
B. EMERGENCY SERVICES ----------------------------------------------------------------------- 7
B.1. Emergency Service Call Responsibility ------------------------------------------------------------ 7
B.2. Delineation of Clinical Privileges: Practitioners Rendering Emergency Care ---------------- 7
B.3. Responsibility for Emergency Care ---------------------------------------------------------------- 7
B.4. Emergency Department Coverage ------------------------------------------------------------------ 7
B.5. Availability of Emergency Services Physician ---------------------------------------------------- 7
B.6. Designation of Those Performing Screening Examination -------------------------------------- 8
B.7. Screening of Individuals Who Present to Hospital ----------------------------------------------- 8
B.8. Calling Private Practitioner of Patients 8
B.9. Policies/Procedures Regarding Medical Screening and Triage 8
B.10. Admission of Emergency Department Patient 8
B.11. Performance of Surgery in the Emergency Department 9
B.12. Emergency Service Medical Record 9
B.13. Signing of Emergency Medical Record 10
B.14. Review of Emergency Department Records 10
B.15. Responsibility for Studies 10
B.16. Medical Record Upon Admission 10
B.17. Transfer of Patients 10
B.18. Disaster Plan 10
B.19. Compliance with Florida Statutes 11
B.20. Emergency Department Medication Orders 11
C. HEALTH INFORMATION MANAGEMENT --------------------------------------------------- 11
C.1. Access of Information 11
C.2. Responsibility for Preparation of Complete, Legible Medical Record 12
C.3. Recording History and Physical 13
C.4. When History and Physical Not Recorded Before Surgical/Invasive Procedure 13
1

North Florida Regional Medical Center
Rules And Regulations
C.5. Progress Notes 14
C.6. Completion of Medical Record 14
C.7. Operative Reports 14
C.8. Obstetrical Records 14
C.9. Clinical Entries in the Medical Record 14
C.10. Consultations 14
C.11. Recording Diagnosis 16
C.12. Symbols and Abbreviations 16
C.13. Discharge Summaries 16
C.14. Consent of Patient 16
C.15. Readmission of Patient 17
C.16. Access to Medical Records 17
C.17. Obtaining Informed Consent 17
C.18 Surgical/Invasive Procedure Consent 17
C.19. Group Practice Authorization 17
C.20. Countersigning Responsibilities 17
C.21. Timely Completion of Medical Records 17
C.22. Incomplete Medical Records: Delinquency 18
C.23. Medical Records Delinquency Policy 18
C.24. Documentation of Need for Continued Hospitalization 18
C.25 Alterations/Corrections of Medical Records 18
D. GENERAL CONDUCT OF CARE ---------------------------------------------------------------- 18
D.1. Orders 18
D.2. General Consent Form 19
D.3. Legibility of Orders 19
D.4. Cancellation of Previous Orders 19
D.5. Medication Orders 20
D.6. Medication Administration 20
D.7. Medication from Other Sources 22
D.8. Medication Reconciliation 22
D.9. Consultation Requirements 22
D.10. Telemedicine Privileges 232
D.11. Attending Physician Responsibilities: Transfer of Patients and Requests for Consultations 23
D.12. Surrender of Medications 23
D.13. Ordering Blood 23
D.14. Doubt or Question About Patient Care 23
D.15 Pre-Printed Orders/Instruction Sheets 23
D.16. Wound Cultures 23
D.17. Responsibility for Medical Care of Each Patient 24
D.18. Alternate Physician Coverage 24
D.19. Smoking 24
D.20. Sedation 24
D.21. Autopsies 24
2

North Florida Regional Medical Center
Rules And Regulations
D.22. Restraints 24
D.23. Advance Directives 25
D.24. Oxygen and Respiratory Therapy 25
D.25 Patient Rights 25
E. SURGICAL AND INVASIVE PROCEDURE CARE --------------------------------------- 29
E.1. Requirements Prior to Surgery 29
E.2. Timeliness of Physician Presence in the Operating Room 29
E.3. Anesthesiologist Responsibilities 30
E.4. Preceptors 30
E.5. Care of Dental Patients 30
E.6. Care of Podiatric Patients 32
E.7. Dispositions of Specimens/Tissues 33
E.8. Patients With History of Pulmonary or Cardiac Disease 33
E.9. Physical Examination Prior to Surgery 33
E.10. Surgical Procedures Performed by Dentists and Podiatrists 33
F. OBSTETRICAL CARE ------------------------------------------------------------------------------ 33
F.1. Prenatal Records 33
F.2. Sterilization 33
F.3. Interruption of Normal Pregnancy 34
F.4. Induction of Labor 34
F.5. Cesarean Sections or Postpartum Tubal Ligations 34
F.6. Confirmation of Informed Consent for Delivery 34
F.7. Cancellation of Previous Orders 34
F.8. Terminations of Pregnancies 34
F.9. Anesthesia for Obstetrical Patients 34
F.10. Obstetrical Consultation for Hospitalized Pregnant Patients 34
F.11. Fetal Heart Monitoring Credentialing Requirement 35
G. NEWBORN CARE ----------------------------------------------------------------------------------- 35
G.1. Newborn and Neonatal Care Orders 35
G.2. Newborn Physical Examinations 35
G.3. Metabolic Screens 35
H. EMERGENCY MANAGEMENT PLAN --------------------------------------------------------- 35
H.1. Plan 35
I. MISCELLANEOUS 35
I.1. Policies and Procedures 35
I.2. Location of Policies and Procedures 35
I.3. Reporting Sanctions 36
I.4. Conflict Management/Resolution 36
3

North Florida Regional Medical Center
Rules And Regulations
A. ADMISSION AND DISCHARGE
A.1.
Activity Level Requirements - Physicians practicing medicine in the Gainesville
area who wish to be on the Medical Staff at North Florida Regional Medical
Center shall be required to maintain “Active” level privileges if the following
conditions are met:
a. More than 25 of the physician’s patients undergo inpatient and/or outpatient
medical admissions to the hospital and require care that would normally be
provided by a physician in the Department of Medicine (regardless of what
physician is the admitting or attending physician of record).
b. The physician consults on, or has contact with, 25 patients per year in the
hospital.
A.2.
Admitting/Treatment Privileges - Only practitioners granted Staff appointment
and clinical privileges may admit patients to this Hospital except as provided in
the Staff Bylaws and Rules and Regulations, except as specified in Article V.3.
Only practitioners granted clinical privileges may treat patients at this Hospital.
All practitioners with authority to admit patients shall be governed by the official
admitting policy of the Hospital.
A.3 Responsibility for Care of Hospital Patients - A physician member appointee of
the staff shall be responsible for the overall medical care of each patient in the
Hospital. The attending practitioner shall be responsible for the treatment and the
prompt completeness and accuracy of the medical record, for necessary
instructions and for transmitting reports of the condition of the patient, if
appropriate, to the referring practitioner. Such transfer shall be made with the
approval of the receiving physician. When responsibilities are transferred to
another practitioner, such transfer documentation should be reflected in the
medical record. The patient shall be assigned to the service concerned in the
treatment of the disease that necessitated admission. In the case of a patient
requiring admission who has no practitioner, he or she shall be assigned to the
practitioner on-call for the service to which the illness of the patient indicates
assignment.
A.4 Provisional Diagnosis/Reason for Admission - 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.
A.5 Emergency Admissions - Practitioners shall be able to justify emergency
4

North Florida Regional Medical Center
Rules And Regulations
admissions based on criteria developed by the Staff. 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 Medical Executive
Committee for appropriate action.
A.6 Care of Patients Admitted on Emergency Basis - A patient to be admitted on an
emergency basis shall be given the opportunity to select an appointee of the Staff
to be responsible for the patient while in the Hospital. If a dentist or podiatrist is
selected by the patient, a physician shall be selected to assume the medical
responsibility for the patient. Where no such selection is made or where the
selected practitioner does not assume responsibility for care of the patient for
some reason, the on-call practitioner may assume responsibility for the patient. In
no event shall a physician member of the staff be required to co-admit any patient.
A.7 Physician Coverage Arrangements - Each appointee of the staff shall name
another appointee of the staff with approved privileges in the same specialty,
unless an exception is approved by the Credentials Committee, as an alternate to
be called to attend his/her patients when the attending practitioner is not available,
or until the attending practitioner can be present. If a co-admitting physician is not
available, contact shall be made with the nearest available physician member of
the staff. In the case of a medical emergency, the designated physician shall be
called. In case the alternate is not available, the CEO or the Chief of Staff shall
have the authority to call the on-call practitioner or any other appointee of the
staff to attend the patient. Failure of an appointee of the staff to meet these
requirements may result in disciplinary action.
A.8 Patient Discharge - 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 and the patient should be
requested to sign the Hospital’s “leaving hospital against medical advice form”
(AMA form).
A.9 Admission Order of Priorities - 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. Emergency;
b. Urgent;
c. Pre-operative; or
5

North Florida Regional Medical Center
Rules And Regulations
d. Routine
The committee responsible for the URM 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
Medical Executive Committee for appropriate action.
A.10 Transfer of Patients Within the Hospital - The patient shall not be transferred
within the Hospital without the approval of the attending practitioner. The order
of priority for patient transfers shall be as follows:
a. Emergency service to appropriate nursing unit;
b. From general care unit to intensive care unit;
c. From intensive care to general care unit;
d. From temporary placement in an inappropriate nursing unit or clinical
service to the appropriate service or nursing unit for the patient being
transferred; or
e. From obstetric care unit to general care unit.
A.11 Admission/Discharge to Special Care Units - Admissions and discharges to
special care units shall be in accordance with established criteria. Exceptions shall
be approved by the unit or service medical director or special care committee.
Patients admitted to special care units shall be evaluated by a physician or a
qualified designee within two (2) hours.
A.12 Compliance with Utilization and Resource Management Plan - Practitioners shall
abide by the Hospital's Utilization and Resource Management plan to include:
a. Severity of illness and intensity of services;
b. Continued requirement of acute or transitional care services;
c. Efficient use of supportive services; and
d. Timely discharge planning.
A.13 Pronouncement of Death - In the event of a Hospital patient sudden death, the
deceased shall be pronounced dead by the attending physician if available or
6

North Florida Regional Medical Center
Rules And Regulations
his/her physician designee within a reasonable time. The body shall not be
released until an entry has been made and signed in the medical record of the
deceased by a physician appointee of the Staff. Policies with respect to release of
dead bodies shall conform to Florida Statute.
Patients who are "Do Not Resuscitate" status at the time of their death may be
pronounced by the Patient Care Coordinator, Nurse Manager or designee. An
entry will be made in the medical record at the time of pronouncement. The
attending physician or designee will be advised of the patient's death at this time.
A.14 Time of Discharge - Whenever possible, practitioners shall write discharge orders
that will allow patients to be discharged from the Hospital by 11:00 a.m. on the
day of discharge.
B. EMERGENCY SERVICES
B.1.
Emergency Service Call Responsibility - Appointees of the Staff shall accept
responsibility for Emergency Department call coverage and care, be immediately
available to the hospital, and assure follow-up care within the standards of care in
accordance with applicable sections of Article IV of these Bylaws.
B.2. Delineation of Clinical Privileges: Practitioners Rendering Emergency Care -
Clinical privileges shall be delineated for all practitioners rendering emergency
care in accordance with Staff and Hospital procedures. Treatment and
performance of operative and other procedures shall be provided within those
areas of competence indicated by the scope of the practitioner's delineated clinical
privileges.
B.3.
Responsibility for Emergency Care - The Medical Director of the Emergency
Department has oversight responsibility of the quality of care within the
Emergency Department. The Emergency Department Committee will review
quality reports on a regular basis. The Medical Director is an appointed member
of the Medical Executive Committee.
B.4 Emergency Department Coverage
a. Primary coverage schedules are prepared and posted in the Emergency
Department.
b. Specialty call schedules are posted in the Emergency Department.
B.5.
Availability of Emergency Services Physician - An emergency services physician
shall be in the Hospital and immediately available for rendering emergency
7

North Florida Regional Medical Center
Rules And Regulations
patient care 24 hours per day, seven (7) days per week.
B.6.
B.7.
Designation of Those Performing Screening Examinations - Medical screening
examinations will be performed by the emergency department physicians, the
patient’s private physician (if they intend to provide the medical screening exam
in the emergency department), emergency department physician extender or a
qualified LDRP RN (in the LDRP area). Emergency department triage personnel
are responsible for determining the order in which emergency department patients
receive the screening examination.
Screening of Individuals Who Present to Hospital - Any patient that comes to an
NFRMC facility requesting emergency services is entitled to, and will receive a
medical screening examination performed by individuals qualified to perform
such an examination to determine whether an emergency medical condition
exists.
In general, when an individual comes by him or herself or with another person
and is not technically in the Emergency Department, but on NFRMC hospital
property, or owned or operated NFRMC premises, and requests emergency care,
he or she must receive a medical screening examination within the capabilities of
that facility or, if necessary, execute an appropriate transfer according to the
guidelines of EMTALA and NFRMC policies.
B. 8. Calling Private Practitioner of Patients - When appropriate, as determined by the
emergency service physician on duty, the patient's private practitioner shall be
called in accordance with the emergency service policies and procedures.
B.9.
Policies/Procedures Regarding Medical Screening and Triage - Emergency
service policies and procedures related to the medical screening examination and
triage shall be approved by the Board of Trustees.
B.10. Admission of Emergency Department Patient - If a patient needs to be admitted to
the Hospital as an inpatient, in the judgment of the emergency physician or
physician extender, either for observation or for further treatment, the patient shall
be admitted in the name of the patient's practitioner or the practitioner on-call.
a. With the consent of attending physicians and within the guidelines
maintained in the Emergency Department, the emergency physician may
write admission orders with the following stipulations:
(1) Emergency physician admission orders shall be considered to be
temporary holding orders written with the purpose of expediting
the movement of admitted patients from the Emergency
8

North Florida Regional Medical Center
Rules And Regulations
Department to the floor.
(2) Emergency physicians will write admission orders only after the
patient has been accepted by the admitting physician and with that
physician's consent.
(3) All admitted patients will become the responsibility of the
admitting physician as soon as the admitting physician has been
contacted by the emergency physician and the admitting physician
has accepted the patient for admission to his/her service.
(4) The admitting physician will be notified of the patient's arrival on
the floor and the orders will be verified by the admitting physician.
He/she will be asked to accept or revise the orders at that time.
b. If, in the judgment of the emergency physician, the patient's condition
requires continuing practitioner attendance the emergency physician shall
continue to accept responsibility for the patient until the assigned
practitioner assumes responsibility for the patient by physically coming to
the Hospital and caring for the patient. The assigned practitioner shall
respond to the Hospital within thirty (30) minutes, and come to the
hospital as soon as appropriate for the clinical condition of the patient, if
requested by the emergency physician.
c. If, in the judgment of the emergency physician or physician extender,
consultation is required, the requested physician must respond: (1) within
thirty (30) minutes of being called in cases of emergency; or (2) within
sixty (60) minutes of being called for non-emergent cases, and come to the
hospital as soon as appropriate for the clinical condition of the patient, as
requested by the Emergency Services Physician.
B.11. Performance of Surgery in the Emergency Department - Except in cases where
transfer to surgery is contraindicated in the judgment of the emergency physician,
surgery shall not be performed in the emergency treatment area.
B.12. Emergency Department Medical Record - An appropriate emergency service
medical record shall be kept for every patient receiving emergency service and
shall be incorporated in the patient's previous inpatient medical record, if such
exists. The emergency service medical record shall include:
a. Adequate patient identification;
b. Information concerning the time of the patient's arrival and by whom
9

North Florida Regional Medical Center
Rules And Regulations
transported;
c. Pertinent history of the injury or illness including details relative to first
aid or emergency care given the patient prior to his/her 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 on discharge or transfer; and
h. Final disposition, including instruction given to the patient and/or his/her
family, relative to necessary follow-up care.
B.13. Signing of Emergency Medical Record - Each patient's emergency medical record
shall be signed by the practitioner in attendance that is responsible for its clinical
accuracy.
B.14. Review of Emergency Department Records - The Emergency Department
Medical Director or the Emergency Service Committee shall coordinate the
review of emergency service records and report results to the appropriate
committee.
B.15. Responsibility for Studies - The Emergency Department Medical Director or the
Emergency Service Committee shall be responsible for studies concerning the
quality and appropriateness of patient care.
B.16. Medical Record Upon Admission - A copy of the emergency service medical
record shall accompany patients being admitted as an inpatient.
B.17. Transfer of Patients - 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 practitioner, the patient's condition permits such a
transfer. The Hospital's policies and procedures for patient transfers to other
facilities shall be followed.
B.18. Disaster Plan - The Emergency Department Medical Director or the Emergency
Service Committee shall make certain that emergency service procedures are
properly coordinated with the Hospital's disaster plan, especially as they pertain to
the care of mass casualties.
10

North Florida Regional Medical Center
Rules And Regulations
B.19. Compliance with Florida Statutes - Emergency service policies and procedures
shall at all times conform to requirements of Florida Statutes.
B.20. Emergency Department Medication Orders – All Emergency Department
Medication Orders, written by Emergency Department physicians, unless
otherwise specified, will be one time orders.
C. HEALTH INFORMATION MANAGEMENT
C.1.
Access of Information
a. Compliance with Information Security Policies - Each member of the
Medical Staff with access to the Hospital medical records agrees to
comply with the information security policies of the Hospital set forth in
the Information Security Agreement, System Access Authorization and
Connectivity Agreement. Such policies include maintaining passwords
and Personal Identification Numbers (PIN), which allow access to
computer systems and equipment, in strictest confidence and not
disclosing passwords and/or PIN with anyone, at any time, for any reason.
Each member of the Medical Staff and privileged practitioner understands
that the records of the patients maintained are confidential and that access
to such records should be limited to those who have a need-to-know in
order to provide for care of the patient. Failure to comply with the
information security policies of the Hospital may result in termination of
access to computer systems, paper or other health information records,
resulting in the initiation of corrective action as specified in these Bylaws,
Rules and Regulations. Loss of medical staff membership or limitation,
reduction, or loss of clinical privileges for any reason may be grounds to
terminate access to the system immediately and without notice to the
practitioner.
b. Personal Identification Number - Personal Identification Number (PIN)
shall be used to authenticate entries only after the PIN owner, who is the
author of the entry, has reviewed the entry. The other forms of
authentication after review of entry will be signature (per Medical Staff
Rules and Regulations C.8).
c. Access to Previous Records - Each member of the Medical Staff shall
have access to previous hospital records of patients he/she is attending on
an outpatient basis, when affiliation with the patient is evidenced by
documentation of previous hospital care. Patient consent must be obtained
by a requesting physician, when affiliation is not evidenced in previous
11

North Florida Regional Medical Center
Rules And Regulations
healthcare records. At the time of readmission, all appropriate previous
records will be made available for the use of the attending and consulting
staff responsible at the time of and for the duration of the readmission.
d. Unauthorized Release of Information - Unauthorized release of
information from hospital records is grounds for summary suspension of
the Staff member per Medical Staff Bylaws, Section 8.4.a. Unauthorized
release includes printing of documents and re-release of these documents
to others who do not have appropriate access.
e. Hospital Property - All Radiology films, pathology specimens,
microscopic slides, photographs, videotapes, photographic slides and
medical records are the property of the Hospital. Under no circumstances
may any of these items be removed for legal purposes without prior
approval of Administration. Removal of original documents will occur
only under court order, state statute or subpoena duces tecum.
Unauthorized removal from the Hospital is grounds for automatic
suspension of the Staff member as per procedure outlined in Section
8.5.d.ii. of the Bylaws.
f. Access to Records - Access to all medical records of all patients shall be
afforded to members of the Medical Staff for bonafide study and research,
consistent with preserving the confidentiality of personal information
concerning the individual patient. All such projects shall be approved by
the Institutional Review Committee if applicable, the Medical Executive
Committee, with the agreement of the CEO, before records can be studied.
Any project requiring IRC approval shall follow the policies and
procedures of the Institutional Review Committee. Subject to the
discretion of the Chief of Staff, with the agreement of the CEO, former
members of the Medical Staff shall be permitted access to information
from the medical records of their patients covering all periods during
which they attended such patients in the Hospital.
g. Records may be removed from the hospital only in accordance with a
court order, subpoena, or statute, or for transport to the HIM Shared
Services Center, or other similar centralized location designated in
accordance with HCA policy regarding Health Information Management
systems, for processing. All records are the property of the Hospital and
shall not otherwise be taken away without permission of the
Administrator. (1/24/11)
C.2.
Responsibility for Preparation of Complete, Legible Medical Record - The
attending practitioner shall be responsible for the preparation of a complete and
12

North Florida Regional Medical Center
Rules And Regulations
legible medical record for each patient. Its contents shall be pertinent and current
for each patient. This record shall include identification data; chief complaint;
medical history; history of present illness; physical examination; diagnostic and
therapeutic orders; appropriate informed consent(s); clinical observations
including results of therapy, progress notes, consultations and nursing notes;
reports of procedures, tests and results including operative reports; conclusions at
termination of hospitalization to include relevant diagnoses and clinical resume;
and autopsy report when performed.
a. Orders may be written by the primary physician, or qualified designee and any
physician consulted by the primary physician.
b. Physician Assistants, Nurse Practitioners, Certified Nurse Midwives and
Nurse Anesthetists may write orders in the chart within the scope of their list
of approved privileges and Florida Statutes.
C.3.
Recording History and Physical - A complete admission history and physical
examination shall be recorded within twenty-four hours of inpatient admission.
Additionally, an appropriate medical history and physical examination shall be
recorded on all patients undergoing outpatient surgery and observation at the time
of the visit. This report should include all pertinent findings resulting from an
assessment of appropriate 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 this
report may be used in the patient's Hospital medical record in lieu of the
admission history and report of the physical examination, provided these reports
were recorded by the admitting physician. 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 within 24 hours of
admission. If there are no changes, a note must be entered stating “No Changes”,
dated and signed within 24 hours of admission.
C.4. When History and Physical Not Recorded Before Surgical/Invasive Procedure -
When the history and physical examination are not recorded, either dictated or
handwritten, before a surgical or invasive diagnostic procedure, the procedure
shall be canceled after informing the practitioner of the deficiency, unless the
attending practitioner states in writing that such delay would be detrimental to the
patient.
a. In the care of patients undergoing invasive procedures other than in the
operating room, a pre-procedural assessment would minimally include, but
not be limited to, pertinent historical information such as patient's chief
complaint or diagnosis, indication for the invasive procedure, allergies,
13

North Florida Regional Medical Center
Rules And Regulations
and current medications. Pertinent physical findings would be noted, the
assessment would be appropriate for the procedure performed, and the
patient's informed consent shall be documented in the chart.
C.5.
Progress Notes - 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.
a. Progress notes shall be written daily on all patients.
b. Physicians shall enter a formal transfer order in the patient chart when the
transfer of a patient is accomplished. The transferring physician shall
speak directly to the accepting physician. When a physician accepts care
for a patient this acceptance must be recorded in the progress notes.
C.6.
C.7.
C.8.
C.9.
Completion of Medical Record - A medical record shall not be permanently filed
until it is completed by the responsible practitioner or is ordered filed by the
Health Information Management Committee.
Operative Reports - Operative reports shall include a detailed account of the
findings at surgery as well as the details of the surgical technique. Operative
reports shall be recorded immediately following surgery when possible for
outpatients as well as inpatients and the report promptly authenticated by the
surgeon and made a part of the patient's current medical record, as soon as
possible after surgery.
Obstetrical Records - The current obstetrical record shall include a complete
prenatal record. In cases where there is no medical record or medical history, it
should be noted in the patient’s record. The prenatal record may be a legible copy
of the attending practitioner's office record transferred to the Hospital during or
prior to the ninth month of gestation. An interval admission note must be written
that includes pertinent additions to the history and any subsequent changes in the
physical findings.
Clinical Entries in the Medical Record - All clinical entries in the patient's
medical record shall be dated, timed, and authenticated by written signature, or in
accordance with Patient Care System requirements. The use of rubber stamp
signatures is not acceptable.
C.10. Consultations - Consultations apply to patients in the emergency room and
admitted in any status to the hospital. (10/22/12) Consultations shall be obtained,
14

North Florida Regional Medical Center
Rules And Regulations
except in extreme emergencies, under the following conditions:
a. When the identified healthcare needs of the patient exceed the clinical
experience or delineated clinical privileges of the attending physician. Except
when consultation is precluded by emergency circumstances or is otherwise
not indicated, the attending physician shall consult with another qualified
Medical Staff member in the following cases:
i) when the diagnosis is obscure after ordinary diagnostic procedures
have been completed;
ii)
iii)
iv)
when there is doubt as to the choice of therapeutic measures to be
used;
for high risk patients undergoing major operative procedures;
in situations where specific skills of other physician may be
needed;
v) or when otherwise required by the Medical Staff or Hospital
policies. 1
b. For an emergency consult, the physician requesting the consultation is
responsible for contacting the consulting specialist.
c. When requested by the patient or his/her family, and the patient's request
and need is within the organization's capacity, its stated mission and
philosophy, and applicable laws and regulations; or
d. When required by the policy of a special care unit or other medical staff
policy.
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.
a. The consultant's plans for follow-up shall be clearly documented with the
initial consultation. This report shall be made a part of the patient's
record.
b. When operative procedures are involved, the consultation note shall,
except in emergency situations so verified on the record, be recorded prior
15

North Florida Regional Medical Center
Rules And Regulations
to the operation.
c. The consultant shall specifically sign off the case at the
time deemed appropriate.
Any qualified practitioner with clinical privileges in this Hospital can be called
for consultation.
C.11. Recording Diagnosis - The principal diagnosis shall be recorded in full, and dated
and signed by the responsible practitioner at the time of discharge of all patients.
This will be deemed equally as important as the actual discharge order.
a. When cancer has been newly diagnosed or a patient is receiving the first
course of treatment at NFRMC, the AJCC stage is assigned by the managing
physician. The managing physician evaluates all available staging
information (x-rays, scans, lab tests, and operative and pathology reports),
records the staging elements (staging classification, T, N, M, and stage group)
on the staging form in the medical record and signs or initials and dates the
form. Electronic signatures are acceptable.
C.12. Symbols and Abbreviations - The hospital maintains a list of abbreviations,
acronyms, and symbols that are unacceptable in patient medical records
applicable to all orders and other medication-related documentation when
handwritten, entered as free test into a computer, or on pre-printed forms,
consistent with the policy on Unacceptable Abbreviations.
C.13. Discharge Summaries - A discharge summary (clinical resume) shall be written or
dictated on all medical records of patients hospitalized over forty-eight hours
except for normal obstetrical deliveries and normal newborn infants. In all
instances, the content of the medical record shall be sufficient to justify the
diagnosis and warrant the treatment and end result. All summaries shall be
authenticated by the responsible practitioner. All D/C Summaries should include
the following: Dates of Service (Admission and Discharge), Final Diagnostic
Impressions or Final Diagnoses, Procedures performed, Hospital Course – include
consultative findings and significant test results which support and substantiate
coordinated care and services provided, Condition at Discharge, Discharge
Instructions: Activity, Diet, Medications and Follow up. In the event of death, a
summary statement shall be added to the record either as a final progress note or
separate resume. (3/28/11)
C.14. Consent of Patient - Written consent of the patient is required for release of
medical information to persons not otherwise authorized to receive this
information.
16

North Florida Regional Medical Center
Rules And Regulations
C.15. Readmission of Patient - In case of readmission of a patient, the previous record
shall be available upon request for use by the attending practitioner.
C.16. Access to Medical Records - Access to medical records of patients will be
afforded to members of the Staff and former members of the Staff to the extent
permitted by law or by legally effective patient consents.
C.17. Obtaining Informed Consent - Practitioners shall obtain and document the
patient's informed consent including risks, benefits, and alternatives. When
consent is not obtainable, the reason shall be entered in the patient's medical
record. The medical record shall contain evidence of informed consent for
procedures and treatments for which it is required by hospital policy. The
practitioner shall document that informed consent has been obtained and that the
patient understood and agreed to the proposed treatment.
C.18 Surgical/Invasive Procedure Consent - Written, signed, informed surgical consent
should be obtained prior to the operative procedure except in extreme situations
wherein the patient’s life is in jeopardy and suitable signature cannot be obtained
due to the condition of the patient. In emergencies involving a minor or
unconscious patient for whom consent for surgery cannot be obtained from the
patient, guardian or next of kin, these circumstances should be fully explained on
the patient’s record. A consultation in such instances may be desirable before the
emergency operative procedure if time permits.
C.19. Group Practice Authorization - Physicians in group practice may authorize
practice partner(s) or cross-covering physicians to cosign, start, continue, or
terminate the patient's diagnostic/therapeutic treatment, and make entries into the
Medical Record.
C.20. Countersigning Responsibilities - The attending practitioner shall review the
history and physical examination, pre-operative notes, and discharge summaries
when they have been recorded by a physician's assistant, advanced registered
nurse practitioner, or certified registered nurse anesthetist if granted such
privileges. If changes are made on review the attending physician will sign and
date the changes.
C.21. Timely Completion of Medical Records - The attending practitioner shall
complete the medical record, to include progress notes, final diagnoses, discharge
summary and all required signatures, within thirty (30) days following the
patient's discharge. If the discharge summary cannot be dictated at the time of
discharge, a final progress note must be written to include the principal diagnosis
and significant secondary diagnoses.
17

North Florida Regional Medical Center
Rules And Regulations
C.22. Incomplete Medical Records: Delinquency - The Health Information Management
Director will maintain a continuous listing of all incomplete records and their
corresponding delinquency status. Physicians will be individually notified in
writing of the status of all incomplete records, to include total number of charts
and type of deficiency. On an as-needed basis, the Health Information
Management Director will provide to the Medical Executive Committee a report
showing the number of charts each physician has remaining incomplete in excess
of thirty (30) days. The Medical Executive Committee will utilize this report and
other relevant delinquent chart reports in evaluating physician performance
regarding timeliness of chart completion and in considering disciplinary action, if
appropriate.
C.23. Medical Records Delinquency Policy - The Medical Records Delinquency Policy
will determine the course of action for staff discipline.
C.24. Documentation of Need for Continued Hospitalization - The attending
practitioner is required to document the need for continued hospitalization after
specific periods of stay as identified by Utilization Resource Personnel and
approved by the particular Department.
C.25 Alterations/Corrections of Medical Records - Late entries/additions to medical
records will comply with current hospital policy.
D. GENERAL CONDUCT OF CARE
D.1.
Orders
a. All orders for treatment shall be in writing. An order may be
communicated verbally or over the telephone by an individual possessing
the appropriate clinical privilege related to the order and shall then be
considered to be in writing. Such an order is to be communicated only to
a duly authorized person and the order must relate to the clinical area in
which that person is a practitioner. Such persons include registered
nurses, registered dieticians, pharmacists, physical therapists, occupational
therapists, respiratory therapists, social workers, speech therapists,
licensed practical nurses, radiology technicians, nuclear medicine
technologists, ultrasonographers, and licensed personnel. Additional
classes of persons may be authorized with the approval of the Medical
Staff. After transcription, the details of the order will be repeated out loud
by the person receiving the order and confirmed by the person giving the
order. (11/22/10)
18

North Florida Regional Medical Center
Rules And Regulations
(1) The following orders may be given to a unit clerk: diet; activity;
or in-house patient transfer orders.
(2) Only registered nurses, pharmacists, and other authorized licensed
personnel may receive medication, laboratory, equipment or
supply orders. After transcription, the details of the
verbal/telephone order will be read back out loud by the licensed
staff and confirmed by the prescriber.
(3) "Do Not Resuscitate" telephone orders may be received by a
registered nurse and witnessed by a second registered nurse.
b. Verbal or telephone orders must be authenticated (countersigned) by the
practitioner giving the order as quickly as possible but authentication must
occur within 48 hours. (3/28/2011)
D.2.
General Consent Form - A general consent form including acknowledgment of
advance directive information, signed by or on behalf of every patient admitted to
the Hospital, shall be obtained by the admitting office. The admitting office shall
notify the attending practitioner whenever such consent has not been obtained and
shall make an entry in the medical record explaining the reason the consent was
not obtainable.
Written, signed, informed, invasive procedure or surgical consent shall be
obtained prior to the operative procedure except in those situations deemed an
emergency by the attending physician and suitable signatures cannot be obtained
due to the condition of the patient. In emergencies involving a minor or
unconscious patient for whom consent for surgery cannot be immediately
obtained from 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. Informed consent shall be obtained as stated in the informed consent
policy.
D.3.
D.4.
Legibility of Orders - The practitioner's orders must be written clearly, legibly and
completely, dated and timed. Orders which are illegible or improperly written will
not be carried out until rewritten and understood by the nurse.
Cancellation of Previous Orders - All previous orders are canceled when patients
go to surgery or are transferred to or from a special care unit. New orders must be
written once a patient is accepted to a new unit including “Do Not Resuscitate”.
Orders for blanket reinstatement of previous orders (such as “resume pre-op
meds” or “resume home meds”) are not acceptable and must be clarified with the
19

North Florida Regional Medical Center
Rules And Regulations
prescriber and new orders written.
In the case of irreversible illness of a patient in which death is imminent where
emergency procedures to treat cardiac or pulmonary arrest may not be desired, the
physician, after appropriate consultation with the patient and/or family and after
adequate documentation in the chart, shall write the order "Do Not Resuscitate".
Specific guidelines for this order are contained within the appropriate Hospital
policies and procedures.
D.5.
Medication Orders - All drugs and medications administered to patients shall be
those listed in the latest edition of: NFRMC Formulary, United States
Pharmacopoeia, National Formulary, and American Hospital Formulary Service.
Drugs of bonafide clinical investigations may be exceptions. These shall be used
in full accordance with the Statement of Principle involved in the use of
Investigational Drugs in Hospitals and all regulations of the Federal Food and
Drug Administration.
The physician or Allied Health Professional must write a complete medication
order consisting of drug name, dosage, route and frequency. Orders which do not
contain all these elements cannot be carried out until completed by the physician
or Allied Health Professional. (6/27/11)
Orders for controlled substances must include a hospital issued unique
identification number or legibly printed name along with the physician or Allied
Health Professional signature. All Allied Health Professionals must write legibly
the name of the specific supervising physician as well as the name of the Allied
Health Professional at the time the order is written. (6/27/11)
Pharmacy and Therapeutics:
develops and maintains surveillance over medication safety, utilization
policies and practices including establishing systems and education
programs to prevent medication errors;
monitors all reported drug reactions and drug errors in order to define
system failures; and
provides a quarterly report, consisting of statistical data involving drug
reactions and drug errors, their probable causes and actions taken to
improve systems and follow-up evaluation to assure the process
improvement is maintained.
D.6.
Medication Administration - Certain medications may be administered only by a
physician or under his/her direct supervision when given by the I.V. push method.
These medications include those in which no FDA approval is available.
20

North Florida Regional Medical Center
Rules And Regulations
D.7.
Medication From Other Sources – For the safety of the patient no medications
acquired by a practitioner from sources other than the hospital for use in patient
care in the hospital may be administered. Should there be needed exceptions, due
to non-availability, the practitioner will contact the Director of Pharmacy.
D.8 Medication Reconciliation - Applies to all personnel and all areas of NFRMC
where a patient presents to the hospital and will receive any medication including
radiopharmaceuticals. The purpose is to assure that the physician is aware of all
medications that the patient is currently taking and makes an informed decision
regarding continuation or discontinuation of those medications while the patient is
in the hospital.
Medication reconciliation, a national patient safety goal and standard of care, is
the process of identifying the most accurate list of all medications a patient is
taking including name, dosage, frequency and route. The list should include
prescription medications, sample medications, vitamins, nutraceuticals, over-thecounter
drugs, vaccines, diagnostic and contrast agents, radioactive medications,
respiratory therapy-related medications, parenteral nutrition, blood derivates,
intravenous solutions (plain or with additives) and any product designated by the
FDA as a drug. Medication reconciliation occurs for all patients who present to
NFRMC for care as an inpatient, observation patient, outpatient surgery or
procedure, senior healthcare center visit, or clinic visits such as wound care,
hyperbarics, cyberknife, and the obesity center (list may not be all inclusive).
It is the policy of NFRMC to accurately and completely reconcile medications
across the continuum of care. All members of the medical staff are expected to
actively participate in this process.
Inpatient Reconciliation
On admission to the hospital:
Every patient that is admitted as an inpatient will have a complete list of
their current medications compiled and documented in the Meditech
“Patient Home Medication” section. The physician or other qualified
healthcare provider is responsible for signing the printed home medication
list indicating reconciliation; changes may be made directly on the list by
the physician if desired.
On transfer to another level of care: Medication orders will be reviewed
and re-ordered by the physician prior to the patient being transferred from
one level of care to another such as from ICU to the floor or the floor to
ICU.
On discharge from the hospital: Upon discharge from the hospital, the
physician must review the patient’s admission home medications and
current hospital medications to determine if they should be continued,
discontinued or changed. This list must be completed by checking in the
appropriate columns and signed by the physician.
21

North Florida Regional Medical Center
Rules And Regulations
Outpatient Reconciliation also occurs in the following areas:
On presentation and release from the Emergency Department
On presentation and release from the Imaging Department
On admission and discharge from the Outpatient Surgery Department
On presentation and release from the outpatient Cardiac Cath Lab
On Presentation and discharge from the Labor and Delivery Unit
On presentation and release from Outpatient Wound Care, Hyperbarics
and Senior Healthcare Clinics
D.9 Consultation Requirements - Any qualified practitioner with clinical privileges in
this Hospital can be called for consultation within his/her area of expertise.
Primary physicians, consultants, or their designees shall respond in a timely
manner with urgent calls to be returned within thirty (30) minutes and routine
calls within a reasonable time, so that patient care is not delayed. If an urgent
request, the requesting physician shall notify the consultant.
A mandatory consult by the contracted intensivist will be required on all critically
ill patients admitted to any critical care unit. The only exceptions will be patients
having Cardiothoracic Surgery or Carotid Endarterectomy.
The intensivist on duty will manage patient triage into and out of the ICU/PCU
setting when patient demand exceeds bed availability. The intensivist will contact
the attending physician to obtain transfer orders when the patient no longer
requires critical care. The intensivist will write transfer orders if the attending
physician is not readily available to write them. If there is a situation where the
contracted intensivist and the attending do not agree on downgrading of the
patient, the Chief Medical Officer or the Chief of Staff will be contacted to help
resolve the conflict. In a situation where there is not an immediate response from
the attending and the need for bed availability is high, the intensivist will transfer
the patient to a lower level of care while continuing to reach the attending
physician by phone. (1/28/2013)
D.10 Telemedicine Privileges - Diagnostic Radiology is a clinical service, which may
be appropriately delivered through a telemedicine medium, according to
commonly accepted quality standards.
D.11 Attending Physician Responsibilities: Transfer of Patients and Requests for
Consultations - The attending practitioner is primarily responsible for transferring
patients to the care of another practitioner, or service, at the Hospital. The
attending practitioner is primarily responsible for requesting consultation when
indicated and for calling in a qualified consultant. He or she will provide
authorization to permit another attending practitioner to attend or examine his/her
patient, except in an emergency.
22

North Florida Regional Medical Center
Rules And Regulations
D.12 Surrender of Medications - Upon admission, all patients will be asked to
surrender medications brought from home to be returned to a family member or
secured in the hospital pharmacy and returned to the patient at discharge. Only
medication prescribed by the attending physician or his/her designee will be
available to the patient. Medication ordered by the attending physician will only
be supplied by the Hospital Pharmacy and administered by qualified personnel
unless otherwise defined by Hospital policies and procedures. A list of
exceptions to this requirement will be determined by the Pharmacy and
Therapeutics Committee and will be available in the Pharmacy.
D.13 Ordering Blood - Blood which has been cross-matched and is being held for a
patient will be held for 48 hours at which time the order for the blood will be
canceled unless reordered for another 48 hours.
D.14 Doubt or Question About Patient Care - In the event that professional hospital
staff has any concerns regarding the quality of care provided to a patient by any
health care provider including physicians and hospital staff, a physician’s
response to a patient’s persistent complaints without adequate resolution, and/or
behavior of any health care provider toward patients or other staff, the following
may be contacted in this order for resolution to the concern:
Department Manager – if unavailable or if response is unsatisfactory,
contact next:
Patient Care Coordinator, Risk Manager, or Division Manager who will
contact the following persons if additional assistance is needed:
Member of Administrative Council most associated with the area of
complaint or the on-call Administrator who will contact any of the
following persons for further assistance and/or clarification if needed:
President and CEO of NFRMC, any member of Administrative Council,
Chief of Staff, Chairperson of the Medical or Surgical QC Committee or
Chairperson of the Board of Trustees.
D.15 Pre-printed Orders/Instruction Sheets - Preprinted orders and/or instruction sheets
shall be reviewed by all affected departments and revised as necessary and
instituted only after approval of the Forms Committee. Such preprinted orders
and/or instruction sheets shall be reviewed and revised as necessary. All
preprinted orders and/or instruction sheets must be signed and dated by the
responsible practitioner when utilized, as required for all orders for treatment.
D.16 Wound Cultures - Wounds draining purulent material may be cultured by licensed
nursing personnel after approval has been obtained from the patient's attending or
consulting physician. This action then shall be documented in the nurses' notes.
23

North Florida Regional Medical Center
Rules And Regulations
D.17 Responsibility for Medical Care of Each Patient - A physician member of the
Staff will be responsible for the medical care of each patient in the Hospital. The
attending practitioner will be responsible for the treatment and the prompt
completeness and accuracy of the medical record, for necessary special
instructions and for transmitting reports of the condition of the patient, if
appropriate, to any referring practitioner. Whenever these responsibilities are
transferred to another practitioner, a note covering the transfer of responsibility
shall be entered on the order sheet of the medical record and verbal handoff
acknowledged with written documentation of the handoff. A progress note
summarizing the patient's condition and treatment shall be made, and the
practitioner transferring his/her responsibility shall personally notify the other
practitioner to ensure the acceptance of that responsibility is clearly understood.
The patient will be assigned to the service concerned in the treatment which
necessitated admission. In a case where there is no emergency, but a patient
requiring admission has no practitioner, he shall be assigned to the practitioner
on-call for the service to which the illness of the patient indicates assignment,
provided the practitioner agrees to accept the patient.
D.18 Alternate Physician Coverage - Each member of the Staff shall name another
qualified member of the Staff as an alternate to be called to attend his/her patients
in an emergency when the staff member is not available or until the staff member
can be present. In the case of an emergency when the appointee cannot be
reached or is unavailable, the designated alternate physician shall be called. In
case the alternate is not available, or where no alternate is named, the CEO or
designee, or the Chief of Staff will have the authority to call the on-call
practitioner or any other member of the Staff to attend the patient.
D.19 Smoking - Smoking is not permitted anywhere in the hospital building.
D.20 Sedation - Procedures involving sedation analgesia for patients for procedures
given in any location in the hospital other than the operating room, labor and
delivery unit, critical care units, or recovery room, shall be in accord with current
sedation policies.
D.21 Autopsies - All members of the Staff shall be actively interested in securing
autopsies whenever possible. No autopsy may be performed without the written
consent of the responsible party in compliance with State law. All autopsies shall
be performed by the Hospital pathologist or by a physician to whom he delegates
the duty. The criteria for cases to be autopsied are approved by the Medical Staff
and Board of Trustees and available in the Administrative Policy Manual.
D.22 Restraints - All forms of physical restraint, (including but not limited to, soft
wrist, ankle and vinyl restraints) require the following:
24

North Florida Regional Medical Center
Rules And Regulations
a. Physician’s verbal or written order will be obtained immediately after
restraints are applied for acute medical/surgical care and will be signed by
the physician within 24 hours.
b. Orders may not be written as PRN, and may not exceed the next calendar day.
The reason for the restraint will be clinically justified. The continued need for
restraint will be assessed by the physician;
c. Orders, clinical justification, evaluation and reassessment of patients who
are restrained for behavioral issues will comply with current
policy/procedures.
D.23 Advance Directives - All patients are asked whether they wish to implement an
advance directive upon admission to the hospital. Advance directives shall be
followed in accordance with Florida law and hospital policy.
D.24 Oxygen and Respiratory Therapy - Oxygen and respiratory therapy will be
administered according to the attending practitioner’s orders. In those cases
where the duration of the treatment is indefinite or unspecified, the practitioner of
the record will be notified on the third day of treatment for new orders by the
fourth day.
D.25 Patient Rights - The Medical Staff acknowledges the following patient rights and
will comply with Hospital policy for preservation of these rights:
a. Access to Care:
i) Individuals shall be accorded impartial access to treatments that are
available or medically indicated, regardless of race, creed, sec, national
origin, religion, disability, age or source of payment for care.
ii) To treatment for any emergency medical condition that will deteriorate
from failure to provide treatment. A patient has the right to have (or not
have) family involved in their care.
b. Pain: To appropriate assessment and management of pain throughout the
continuum of care.
c. Pastoral Counseling: Staff will make arrangements if so indicated when asked
upon admission or requested at any time throughout the patient’s
hospitalization.
25

North Florida Regional Medical Center
Rules And Regulations
d. Ethics: To participate in the resolution of ethical decisions, including conflict
resolution, withholding resuscitative measures or withdrawal of life support;
e. Surrogate Health Care Provider: To designate a decision maker or make a
Living Will while hospitalized. Forms will be provided to patients for that
purpose.
f. Organ Donation: To declare his/her wishes regarding organ donation. The
hospital has policies and procedures for procuring and donating organs and
other tissues.
g. Patient Grievance Procedure: To be given information upon admission
regarding the process, contacts persons and times for which to make a
grievance and to have access to the direct line at the State Agency for Health
Care Administration, phone number (888) 419-3456.
h. Privacy and Confidentiality: The patient has the right, within the law to
personal and informational privacy, including the right to:
i) Refuse to talk with or see anyone not officially connected with the
Hospital, including visitors or people officially connected with the
Hospital but not directly involved in the patient’s care;
ii) Wear appropriate personal clothing and religious or other symbolic
items as long as they do not interfere with the diagnostic procedures or
treatment;
iii) Be interviewed and examined in surroundings designed to ensure
reasonable audiovisual privacy;
iv) Expect that any discussion or consultation involving his/her case will be
conducted discreetly;
v) Have his/her medical record read only by individuals directly
involved in his/her treatment or the monitoring of its quality and by other
individuals only on his/her written authorization or that of his/her legally
authorized representative;
vi) Expect all communications and other records pertaining to his/her care,
including the source of payment for treatment, to be treated as
confidential;
vii) Request a transfer to another room if another patient or visitors in
that room as unreasonably disturbing the patient.
viii)To know when his/her admission has been flagged as confidential, and to
request that the visit not be flagged as confidential (except in the case of
prisoners). Once an admission has been flagged as confidential, disclosure
of the patient’s room number will be prohibited to visitors. No telephone
calls or deliveries will be sent without patient permission.
26

North Florida Regional Medical Center
Rules And Regulations
i. Personal Safety: To expect reasonable safety insofar as the Hospital practices
and environment are concerned. The patient has the right to be free from all
forms of abuse or harassment and the right to Security assistance when that
need arises or information is given to the facility. Community resources and
other protective services will be made available to the patient or referral made
when needed.
j. Identity: To know the identity and professional status of individuals
providing service to him/her and to know which physician or practitioner is
primarily responsible for his/her care. Participation by the patient in clinical
training programs or in the gathering of data for research purposes is
voluntary.
k. Information: To a prompt and reasonable response to questions and requests.
A patient has the right to know what patient support services are available in
the Hospital and the right to obtain from the practitioner responsible for
coordinating his/her care complete and current information concerning his/her
diagnosis (to the degree known), treatment and any known prognosis and
outcomes of care including unanticipated outcomes. Families may also be
informed with permission of the patient or when the patient is unable to
answer for themselves. This information should be communicated in terms
the patient can reasonably be expected to understand. When it is not
medically advisable to give such information to the patient, the information
should be made available to a legally authorized individual. The patient has
the right to see his/her medical record in accordance with Florida law.
l. Communication: To access people outside the hospital by means of visitors
and by verbal and written communication. When the patient does not speak or
understand the predominate language of the community, he/she should have
access to an interpreter. This is particularly true where language barriers are a
continuing problem. When the hearing impaired requires a sign language
interpreter, one will be provided.
m. Consent: To participate in decisions involving his/her healthcare. To the
degree possible, this should be based on a clear, concise explanation of his/her
condition and of all proposed technical procedures, including the possibilities
of any risk of mortality or serious side effects, problems related to
recuperation and probability of success. The patient should not be subject to
any procedure without his/her voluntary, competent and understanding
consent. When the patient is not competent, a legal guardian or next of kin
may consent. Where medically significant alternatives for care or treatment
exist, the patient shall be so informed. The patient has the right to know who
is responsible for authorizing and performing the procedure or treatment. The
27

North Florida Regional Medical Center
Rules And Regulations
patient shall have full disclosure related to research and the patient shall be
informed. if the Hospital proposed to engage in or perform human
experimentation or other research/educational projects affecting his/her care
or treatment. The patient has the right to refuse to participate in such
treatment.
n. Consultation: To consult, at his/her own request and expense, with a
specialist.
o. Refusal of Treatment: To refuse treatment to the extent permitted by law.
When refusal of treatment by the patient or his/her legally authorized
representative prevents the provision of appropriate care in accordance with
ethical and professional standards, the relationship with the patient may be
terminated upon reasonable notice.
p. Transfer and Continuity of Care: A patient may not be transferred to another
facility unless he/she has received a complete explanation of the need for
transfer and the alternatives to such a transfer, and unless the transfer is
acceptable to the other facility. The patient has the right to be informed by the
responsible practitioner or his/her delegate of any continuing healthcare
requirements following discharge from the Hospital.
q. Hospital Charges: Regardless of the source of payment for his/her care, the
patient has the right to request and receive an itemized total bill for hospital
services. The patient has the right to timely notice prior to termination of
his/her eligibility for reimbursement by any third-party payor for the cost of
his/her care. The patient has the right to receive a reasonable estimate of
charges for medical care before treatment. If the patient is eligible for
Medicare, he/she has the right to know before treatment whether his/her
physician and the hospital accept Medicare assignment rate.
r. Hospital Rules and Regulations: To be informed of the Hospital rules and
regulations applicable to his/her conduct as a patient. Patients are entitled to
information about the Hospital’s mechanism for the initiation, review and
resolution of patient complaints.
s. Complaints: To complain to the department manager, staff member, or the
administration in any patient care area regarding the quality of care received.
Presentation of a complaint does not serve to compromise a patient’s future
access to care. Patients are entitled to resolution of complaints that are
presented when possible. The patient will be involved in resolving dilemmas
about care. Formal grievances in writing or verbal grievances not promptly
resolved by staff and requiring administrative intervention will be considered
28

North Florida Regional Medical Center
Rules And Regulations
official grievances and will be investigated by appropriate staff. A written
response or a verbal meeting with the patient will be provided within 30 days.
t. Minor’s Rights/Responsibilities: If the patient is a neonate, child, or
adolescent, the patient has the right to have a parent or guardian involved in
the assessment, treatment and continuity of care. Conflicts that arise
concerning the care of the patient would be resolved according to hospital
policies and procedures.
u. Advance Directives: To receive written information about advanced
directives and healthcare decision-making options in Florida and to complain
to the State about the advance directive process.
v. Notification Upon Admission: To have family members and patient’s
physician notified promptly when a patient is admitted.
w. Free From Restraint: To be free from restraints unless medically necessary.
Restraints shall not be used as a means of coercion, discipline, convenience or
retaliation by staff.
E. SURGICAL AND INVASIVE PROCEDURE CARE
E.1.
Requirements Prior to Surgery - Except in emergencies in which delay may be
life threatening or will severely or permanently compromise the patient’s health, 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
or invasive 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 the patient's condition prior
to induction of anesthesia and the start of surgery).
a. In the case of patients undergoing invasive procedures other than in the
operating room, a pre-procedure assessment would minimally include, but
not be limited to, pertinent historical information such as patient's chief
complaint or diagnosis, indication for the invasive procedure, allergies and
current medications. Pertinent physical findings would be noted, the
assessment would be appropriate for the procedure performed, and the
patient's informed consent shall be documented in the chart.
E.2.
Timeliness of Physician Presence in the Operating Room - Surgeons shall be in
the operating room and ready to commence surgery at the time scheduled. If a
29

North Florida Regional Medical Center
Rules And Regulations
surgeon is repeatedly or flagrantly late, he may have his/her privilege to schedule
first case surgery suspended or may be referred to the Executive Committee for
action.
E.3.
Anesthesiologist Responsibilities - The anesthesiologist shall maintain a complete
anesthesia record to include evidence of pre-anesthetic evaluation and post-anesthetic
follow-up of the patient's condition. The anesthesia record should also
include thorough documentation of times and amounts of all medications given.
a. The anesthesiologist is responsible for writing a pre-anesthetic note in the
medical record prior to the procedure and before pre-operative medication
has been administered. This note shall indicate a choice of anesthesia and
the surgical or obstetrical procedure anticipated.
b. The anesthesiologist is responsible for writing a post-anesthetic note after
the patient has completed post-anesthesia recovery care to include at least
a description of the presence or absence of anesthesia-related
complications.
E.4.
E.5.
Preceptors - A staff appointee who is classified in a preceptorship or supervisory
status for specified surgery privileges must have present his/her preceptor or
qualified assistant for these specified surgery procedures.
Care of Dental Patients - A patient admitted for dental care is a dual responsibility
of the dentist and physician appointee of the Staff.
a. Dentist's responsibilities:
(1) A detailed dental history justifying hospital admission;
(2) A detailed description of the examination of the oral cavity and a
pre-operative diagnosis;
(3) A complete operative report, describing the findings and
techniques. In cases of extraction of teeth and fragments removed,
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) The discharge order; and
30

North Florida Regional Medical Center
Rules And Regulations
(7) Discharge summary.
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; and
(4) Physician is not responsible for any dental care or consequences
thereof.
*May be performed by a qualified oral surgeon if they have such
privileges in order to assess the medical, surgical, and anesthesia
risks of the proposed operative and other procedure(s).
c. Qualified Oral Surgeon’s responsibilities:
(1) A comprehensive oral surgical and medical history justifying the
hospital admission;
(2) A comprehensive physical examination;
(3) A complete operative report, describing the findings and technique.
All tissue, including teeth and fragments, shall be sent to the
Hospital pathologist for examination;
(4) Progress notes shall be recorded daily in sufficient detail to
document the course of care and to permit continuity of care and
transferability;
(5) Discharge summary (or summary statement) which includes
pertinent instructions to the patient and/or family at the time of
discharge;
(6) Consultation by a member of the Medical Staff will be obtained at
any time during the admission that the identified health care needs
of the patient exceed the delineated clinical privileges of the Oral
Surgeon.
31

North Florida Regional Medical Center
Rules And Regulations
E.6.
Care of Podiatric Patients - A patient admitted for podiatry care is a dual responsibility
involving the podiatrist and physician appointee of the staff.
a. Podiatrist's responsibilities:
(1) A detailed history justifying hospital admission;
(2) For medically uncomplicated patients, the podiatrist may, if
granted clinical privileges, perform a full medical history and
physical examination to provide medical clearance. If the patient
is medically complex, the medical clearance examination and
clearance for surgery must be performed by a physician.
(2) A detailed description of the examination of the feet and
pre-operative diagnosis;
(3) A complete operative report, describing the findings and
technique. All tissue removed shall be sent to the hospital
pathologist for examination;
(4) Progress notes;
(5) The podiatrist is solely responsible for the care of the feet;
(6) The discharge order; and
(7) Discharge summary (or summary statement).
b. Physician's responsibilities:
(1) Medical history pertinent to the patient's general health;
(2) A physician examination to determine the patient's
condition prior to anesthesia and surgery; for uncomplicated
patients the podiatrist may perform a full medical history and
physical examination. For medically complex patients the medical
clearance examination and clearance for surgery must be
performed by a physician;
(3) Supervision of the patient's general health status while
hospitalized; and
32

North Florida Regional Medical Center
Rules And Regulations
(4) Physicians are not responsible for any podiatric care of
treatment of feet or consequences thereof.
E.7.
Dispositions of Specimens/Tissues - Unless otherwise specified by hospital
policy, all tissues removed at the operation shall ordinarily be sent to the hospital
pathologist who shall make such examination as he may consider necessary to
arrive at a tissue diagnosis. His/her authenticated report shall be made a part of
the patient's medical record.
Exceptions to sending specimens removed during a surgical procedure to the
laboratory should be made only when the quality of care has not been
compromised by the exception, when another suitable means of verification of the
removal has been routinely employed, and where there is an authenticated
operative or other official report that documents the removal. The limited
categories of specimens documented in the Surgical Specimens/Tissue Exemption
List may be exempted from the requirement to be examined by a pathologist.
E.8.
E.9.
Patients With History of Pulmonary or Cardiac Disease - Any patient of any age
who gives a history suggestive of pulmonary or cardiac disease shall have
appropriate studies just prior to surgery.
Physical Examination Prior to Surgery - Patients who are admitted to the Hospital
more than thirty (30) 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 examinations have been
completed prior to surgery. (11/22/10)
E.10. Surgical Procedures Performed by Dentists and Podiatrists - Surgical procedures
performed by dentists and podiatrists shall be under the overall supervision of the
Chief of Surgery.
F. OBSTETRICAL CARE
F.1. Prenatal Records - The current obstetrical records 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 at thirty-six weeks gestation
and shall be updated with any pertinent findings.
F.2. Sterilization - Sterilization for the sole purpose of sterilization for female
patients may be done at the discretion of the attending physician and the fully
33

North Florida Regional Medical Center
Rules And Regulations
informed consent of the patient being sterilized if over the age of majority in
accordance with State and Federal laws.
F.3.
F.4.
Interruption of Normal Pregnancy - All curettage or other procedures by which a
known or suspected normal pregnancy may be interrupted shall be performed and
reported in accordance with Florida Statute.
Induction of Labor - Induction of labor shall be used in the following manner:
a. Elective inductions will be scheduled by LDRP staff. The LDRP charge
nurse will prioritize the schedule according to documented indication for
induction. If inductions need to be postponed due to labor bed
availability, the Obstetrics representation on the MEC will prioritize
inductions according to the medical need of patients; and
b. The reason for induction labor shall be stated in the history or progress
notes.
c. Intravenous oxytocin protocol and intravaginal misoprostil will be
administered according to protocol.
F.5.
Cesarean Sections or Postpartum Tubal Ligations - Every Cesarean section will
be defined as elective, non-elective, or emergency. An emergency Cesarean
should be initiated within thirty (30) minutes of the decision. Patients having
cesarean sections or postpartum tubal ligations shall have an updated history and
physical examination. A progress note on important or new physical findings
since her last physical examination on the pregnancy record shall suffice.
F.6. Confirmation of Informed Consent for Delivery - Informed consent for the
delivery shall be confirmed on the patient's arrival to labor area.
F.7.
F.8.
F.9.
Cancellation of Previous Orders - All previous orders are canceled after Cesarean
section or postpartum tubal ligation.
Terminations of Pregnancies - The reasons for the terminations must be clearly
documented in the medical record.
Anesthesia for Obstetrical Patients - All patients who are going to undergo caudal,
spinal, saddle block or epidural anesthesia should have an IV started prior to the
administration of the anesthesia.
F.10. Obstetrical Consultation for Hospitalized Pregnant Patients - Any patient admitted
to the hospital for medical reasons that has a viable pregnancy should be seen in
34

North Florida Regional Medical Center
Rules And Regulations
consult by an NFRMC credentialed obstetric physician.
F.11. Fetal Heart Monitoring Credentialing Requirement – Fetal Heart Monitoring
(FHM) training is required on initial appointment from ACOG Advanced Fetal
Heart Monitoring and Assessment course with documentation of ongoing fetal
heart monitoring education at reappointment for all physicians and allied health
members under the OB Service. (11/22/10)
G. NEWBORN CARE
G.1.
G.2.
Newborn and Neonatal Care Orders - All newborn and neonatal orders must be
written, including orders for formula and care of the newborn, and signed by the
physician.
Newborn Physical Examinations - A physical examination shall be recorded in
the medical record of all newborns.
G.3. Metabolic Screens - Metabolic screens shall be done on all newborns prior to
discharge if the newborn is discharged before 48 hours of feeding a repeat screen
will need to be done. Parents will receive instructions for follow-up.
H. EMERGENCY MANAGEMENT PLAN
H.1.
Plan - 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 plan shall be reviewed and approved
by the Staff and the Board of Trustees. Procedures will provide for the prompt
discharge or transfer of patients in the Hospital who can be moved without
jeopardy, and unified medical command under the direction of the Chief of Staff
or his/her designated substitute.
I. MISCELLANEOUS
I.1.
I.2.
Policies and Procedures - 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 or the appropriate departments of the Staff and approved
by its Executive Committee and the Board of Trustees (if appropriate), shall be
adhered to by all attending practitioners and said practitioners are responsible for
remaining abreast of all current directives.
Location of Policies and Procedures - Policies and Procedures referred to above,
and elsewhere in these Rules and Regulations, are to be found in the Policy and
Procedure Manual of the Hospital.
35

North Florida Regional Medical Center
Rules And Regulations
I.3.
I.4.
Reporting Sanctions - All practitioners must report any sanctions they receive to
the CEO and the Medical Executive Committee. Additionally, the Hospital shall
verify each practitioner’s status as an Ineligible Person.
Conflict Management/Resolution
I.4.1. Conflicts Between The Board and The Medical Executive Committee
The Medical Staff, in partnership with the Board, will make best efforts to address
and resolve all conflicting recommendations in the best interests of patients, the
Hospital, and the members of the Medical Staff. When the Board plans to act or is
considering acting in a manner contrary to a recommendation made by the
Medical Executive Committee, the Medical Staff officers shall meet with the
Board, or a designated committee of the Board and Administration, and seek to
resolve the conflict through informal discussions. If these informal discussions
fail to resolve the conflict, the Chief of Staff or the Chairperson of the Board may
request initiation of a formal conflict resolution process. The formal conflict
resolution process will begin with a meeting of the Joint Conference Committee
within thirty (30) days of the initiation of the formal conflict resolution process.
To address Board-Medical Staff conflicts, the Joint Conference Committee shall
be composed of:
• Three officers of the Medical Staff
• One other Medical Executive Committee member
• The Chairperson, Vice-Chairperson, and Secretary of the Board or other
designees of the Board
• The Chief Executive Officer or designee
If the Joint Conference Committee cannot produce a resolution to the conflict that
is acceptable to the Medical Executive Committee and the Board within 30 days
of the initial meeting, the Medical Staff and the Board shall enter into mediation
facilitated by an outside party. The Medical Executive Committee and Board shall
together select the third-party mediator, the costs for which shall be shared
equally by the Hospital and the Medical Staff. The Medical Executive Committee
and the Board shall make best efforts to collaborate together and with the thirdparty
mediator to resolve the conflict. The Board and the Medical Executive
Committee shall each designate at least three people to participate in the
mediation. Any resolution arrived at during such meeting shall be subject to the
approval of the Medical Executive Committee and the Board, in accordance with
the provisions of Medical Staff Bylaws and the Articles of Incorporation and
Bylaws of the Hospital. If, after 90 days from the date of the initial request for
mediation from an outside party, the Medical Executive Committee and Board
cannot resolve the conflict in a manner agreeable to all parties, the Board shall
36

North Florida Regional Medical Center
Rules And Regulations
have the authority to act unilaterally on the issue that gave rise to the conflict.
If the Board determines, in its sole discretion, that action must be taken related to
a conflict in a shorter time period than that allowed through this conflict
resolution process in an attempt to address an issue of quality, patient safety,
liability, regulatory compliance, legal compliance, or other critical obligations of
the Hospital, the Board may take provisional action that will remain in effect until
the conflict resolution process is completed.
In addition to the formal conflict resolution process herein described, the
Chairperson of the Board or the Chief of Staff may call for a meeting of the Joint
Conference Committee at any time and for any reason to seek direct input from
the Joint Conference Committee members, clarify any issue, or relay information
directly to Medical Staff leaders, the Board, or Administration.
I.4.2. Conflicts Between The Medical Staff and Medical Executive Committee
The Medical Executive Committee, as representatives of the Medical Staff, will
make best efforts to address and resolve all conflicting recommendations in the
best interests of patients, the Hospital, and the members of the Medical Staff.
When the Medical Executive Committee plans to act or is considering acting in a
manner contrary to the wishes of the voting members of the Medical Staff, the
Medical Staff shall present their recommendations to the Medical Executive
Committee with a written petition signed by at least ten percent (10%) of the
voting members of the Medical Staff. The Medical Staff officers shall meet with
members of the Medical Staff representing the Medical Staff’s recommendations
as set forth in the petition and seek to resolve the conflict through informal
discussions. If these informal discussions fail to resolve the conflict, the Chief of
Staff, the representatives of the Medical Staff or the Chairperson of the Board
may request initiation of a formal conflict resolution process. The formal conflict
resolution process will begin with a meeting of the Joint Conference Committee
within thirty (30) days of the initiation of the formal conflict resolution process.
To address Medical Executive Committee-Medical Staff conflicts, the Joint
Conference Committee shall be composed of:
• Three officers of the Medical Staff
• Three voting members of the Medical Staff representing the
recommendations in the written petition
• The Chairperson of the Board
• The Chief Executive Officer or designee
If the Joint Conference Committee cannot produce a resolution to the conflict that
is acceptable to the Medical Executive Committee and the Medical Staff within
30 days of the initial meeting, the Medical Executive Committee and the Medical
Staff shall enter into mediation facilitated by an outside party. The Medical
37

North Florida Regional Medical Center
Rules And Regulations
Executive Committee and the three voting members of the Medical Staff
representing the recommendations in the written petition shall together select the
third-party mediator, the costs for which shall be paid in total by the Medical
Staff. The Medical Executive Committee and Medical Staff shall make best
efforts to collaborate together and with the third-party mediator to resolve the
conflict. The Medical Executive Committee and the Medical Staff shall each
designate at least three people to participate in the mediation. Any resolution
arrived at during such meeting shall be subject to the approval of the Medical
Executive Committee and the Board, in accordance with the provisions of
Medical Staff Bylaws and the Articles of Incorporation and Bylaws of the
Hospital. If, after 90 days from the date of the initial request for mediation from
an outside party, the Medical Executive Committee and Medical Staff cannot
resolve the conflict in a manner agreeable to all parties, the Board shall have the
authority to act unilaterally on the issue that gave rise to the conflict.
If the Board determines, in its sole discretion, that action must be taken related to
a conflict in a shorter time period than that allowed through this conflict
resolution process in an attempt to address an issue of quality, patient safety,
liability, regulatory compliance, legal compliance, or other critical obligations of
the Hospital, the Board may take provisional action that will remain in effect until
the conflict resolution process is completed.
In addition to the formal conflict resolution process herein described, the
Chairperson of the Board or the Chief of Staff may call for a meeting of the Joint
Conference Committee at any time and for any reason to seek direct input from
the Joint Conference Committee members, clarify any issue, or relay information
directly to Medical Staff leaders, the Board, or Administration. (3/28/11)
38