Rules and Regulations 2013 - North Florida Regional Medical Center

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North Florida Regional Medical Center Rules And Regulations official grievances and will be investigated by appropriate staff. A written response or a verbal meeting with the patient will be provided within 30 days. t. Minor’s Rights/Responsibilities: If the patient is a neonate, child, or adolescent, the patient has the right to have a parent or guardian involved in the assessment, treatment and continuity of care. Conflicts that arise concerning the care of the patient would be resolved according to hospital policies and procedures. u. Advance Directives: To receive written information about advanced directives and healthcare decision-making options in Florida and to complain to the State about the advance directive process. v. Notification Upon Admission: To have family members and patient’s physician notified promptly when a patient is admitted. w. Free From Restraint: To be free from restraints unless medically necessary. Restraints shall not be used as a means of coercion, discipline, convenience or retaliation by staff. E. SURGICAL AND INVASIVE PROCEDURE CARE E.1. Requirements Prior to Surgery - Except in emergencies in which delay may be life threatening or will severely or permanently compromise the patient’s health, a history and physical examination, the pre-operative diagnosis, appropriate consents, required laboratory and radiology reports and consultations when requested, must be recorded on the patient's medical record prior to any surgical or invasive procedure. In the case of an emergency, where any or all of the above entries have not been made in the medical record, the operating surgeon shall state in writing that a delay would be detrimental to the patient (and shall make a comprehensive note in the medical record indicating the patient's condition prior to induction of anesthesia and the start of surgery). a. In the case of patients undergoing invasive procedures other than in the operating room, a pre-procedure 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 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. E.2. Timeliness of Physician Presence in the Operating Room - Surgeons shall be in the operating room and ready to commence surgery at the time scheduled. If a 29
North Florida Regional Medical Center Rules And Regulations surgeon is repeatedly or flagrantly late, he may have his/her privilege to schedule first case surgery suspended or may be referred to the Executive Committee for action. E.3. Anesthesiologist Responsibilities - The anesthesiologist shall maintain a complete anesthesia record to include evidence of pre-anesthetic evaluation and post-anesthetic follow-up of the patient's condition. The anesthesia record should also include thorough documentation of times and amounts of all medications given. a. The anesthesiologist is responsible for writing a pre-anesthetic note in the medical record prior to the procedure and before pre-operative medication has been administered. This note shall indicate a choice of anesthesia and the surgical or obstetrical procedure anticipated. b. The anesthesiologist is responsible for writing a post-anesthetic note after the patient has completed post-anesthesia recovery care to include at least a description of the presence or absence of anesthesia-related complications. E.4. E.5. Preceptors - A staff appointee who is classified in a preceptorship or supervisory status for specified surgery privileges must have present his/her preceptor or qualified assistant for these specified surgery procedures. Care of Dental Patients - A patient admitted for dental care is a dual responsibility of the dentist and physician appointee of the Staff. a. Dentist's responsibilities: (1) A detailed dental history justifying hospital admission; (2) A detailed description of the examination of the oral cavity and a pre-operative diagnosis; (3) A complete operative report, describing the findings and techniques. In cases of extraction of teeth and fragments removed, all tissue including teeth and fragments shall be sent to the hospital pathologist for examination; (4) The dentist is totally responsible for the oral or dental care; (5) Progress notes as are pertinent to the oral condition; (6) The discharge order; and 30
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Rules and Regulations 2013 - North Florida Regional Medical Center

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