Rules and Regulations 2013 - North Florida Regional Medical Center

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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
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Rules and Regulations 2013 - North Florida Regional Medical Center

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