Rules and Regulations 2013 - North Florida Regional Medical Center

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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
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Rules and Regulations 2013 - North Florida Regional Medical Center

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