Rules and Regulations 2013 - North Florida Regional Medical Center

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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
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Rules and Regulations 2013 - North Florida Regional Medical Center

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