Rules and Regulations 2013 - North Florida Regional Medical Center

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.
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