Rules and Regulations 2013 - North Florida Regional Medical Center

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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
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Rules and Regulations 2013 - North Florida Regional Medical Center

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