House Staff Manual - Winthrop University Hospital

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Diseases in all capital letters require immediate telephone notification*Labs report new cases or increased incidence only**Report Cases Directly to the NYSDOH64. CORPORATE COMPLIANCE PROGRAMMembers of the House Staff are required to adhere to the Hospital’s Corporate Compliance Program and its“Code of Conduct” which supports the Hospital’s commitment to the highest business and ethicalstandards. The program oversees compliance with regulations dealing with, but not limited to, physiciandocumentation, coding and billing, conflict of interest and competitive pricing. House Staff may berequired to participate in additional in-service training to ensure compliance. The Code of Conduct isdistributed at House Staff Orientation.65. DEATH: NOTIFICATION AND REPORTINGNOTIFICATION OF DEATHWhen called to the floor to pronounce a patient dead, the resident should notify the attending physicianimmediately and inquire as to whether the attending or the resident should inform the family, and requestan autopsy.DEATH CERTIFICATESUpon receiving the chart of an expired patient, the Admitting Department is responsible for calling theattending to notify him/her that the certificate is ready for signature. If the attending is unable to come tothe Admitting Departmentwithin four hours, it is the attending’s responsibility to request a licensed member of the House Staffto sign. If after four hours the certificate is still unsigned, the Admitting Department notifies the chief ofthe respective service. This procedure is followed up to 11:00 PM. After this time, unless there is a reasonfor immediate removal, the physician is notified to sign the certificate by 8:00 AM the following morning.DEATHS REPORTABLE TO THE MEDICAL EXAMINER'S OFFICEThe pronouncing physician must identify and report all cases which fall under the established criteria to theMedical Examiner’s (ME) Office. These include:Death by homicide or suspicion of homicide including automobile homicides and cases of criminalnegligence or violence.Deaths due wholly or in part to accidental injuries including industrial accidents (falls, motor vehicleaccidents, explosions, burns, cave-ins, drownings, asphyxia secondary to aspirated materials, etc.)Death by suicide (hanging, shooting, carbon monoxide, slashing, etc.)Death by criminal abortion or suspected abortion.Maternal deaths associated with delivery or abortion.Death by poison or suspicion of poison, including chemical and bacterial food poisoning and industrialpoisoning (In such cases, you are requested to save the stomach washings during life for examinationby the toxicologist. Also save all containers of pills, etc.)Sudden death when in apparent health or unattended by a physician.Rev. 1/08
Death by any suspicious or unusual manner.Death occurring in the institution less than 24 hours after admission, where diagnosis cannot be made.This includes deaths while a patient is in a coma. (Where the diagnosis is unquestioned and the causeof death is a natural one, a death certificate may be issued).Death occurring while on operating table.Death occurring in the Emergency Department (in such cases, you are requested to save bloodsamples that were obtained during life saving measures).Cases in the institution which are dead on arrival and unattended by a physician.Deaths while in legal custody.Fractures of bone (not pathological). Such cases are to be reported even when the fracture is otprimarily responsible for death.Deaths associated with suspected child abuse.Perioperative or peritherapeutic death which is unexpected or unexplained.If the case meets the above criteria, the physician completes a Medical Examiner Referral Form, calls theME Office for a case number, documents in the progress notes that the case was referred to the ME, and thedisposition of the case. If it is known by Winthrop that the deceased opposed an autopsy, this informationmust be given to the ME. If there is any question as to whether the individual case should come under thejurisdiction of the Medical Examiner’s Office, the pronouncing physician should telephone the ME Officefor clarification. For detailed procedures, see Admitting Department Policy No. D-5.66. DISCHARGE AGAINST MEDICAL ADVICECompetent adult patients who wish to leave the Hospital against medical advice are permitted to do so. Ifthe patient insists on leaving, he or she must be asked to complete the form entitled “Discharge fromHospital Against Medical Advice.” If a resident anticipates that a patient may sign out against medicaladvice, the resident must notify the attending physician immediately. The resident or physician must informthe patient of possible risks to his/her condition and advise the patient as to what would be in the patient'sbest interest. The physician/resident must document this discussion in the medical record. In addition, it isadvisable to call in a representative from Social Work (ext. 2341 to speak with the patient. (see Policy D-30-1.)Minor or incompetent patients are not permitted to leave the Hospital unless discharged by aphysician. Call Risk Management and Insurance Services (ext. 2206) for guidance.67. DO NOT RESUSCITATE (DNR)Every patient admitted to the Hospital is presumed to have consented to CPR unless a DNR order isrequested and an order is written in the patient's medical record. Consent for a DNR order must beobtained by an attending physician from the patient, after discussing the diagnosis and prognosis, the rangeof available resuscitation measures, the reasonably foreseeable risks and benefits of CPR and theconsequences of the DNR order. Renewal of DNR orders can be done by housestaff. In the event that thepatient lacks capacity and has not previously assigned a health care proxy, a person on the surrogate list canconsent. (See Hospital Policy P-30-3.)The DNR order must be written in the patient's medical record and the consent must be documented onthe appropriate documentation sheet.Rev. 1/08
Page 1 and 2: OFFICE OF ACADEMIC AFFAIRS222 Stati
Page 3 and 4: Winthrop-University HospitalHouse S
Page 5 and 6: WINTHROP-UNIVERSITY HOSPITALHOUSE S
Page 7 and 8: 72) Institutional Review Board73) O
Page 9 and 10: HOUSE STAFF BENEFITSAND SERVICES1.
Page 11 and 12: The New York State Department of He
Page 13 and 14: valuable information and resources,
Page 16: 25. STUDENT LOAN DEFERMENTSResident
Page 19 and 20: the program director. Residents sho
Page 21 and 22: 2. Residents shall not be scheduled
Page 23 and 24: PROCEDUREImmediate Action:1. Clinic
Page 25: All House Staff are evaluated in wr
Page 28 and 29: appropriate in every circumstance.
Page 32 and 33: Delegating professional responsibil
Page 36 and 37: TREATMENT OF EMERGENCY DEPARTMENT P
Page 38 and 39: The commencement of brain death cri
Page 42 and 43: Either the patient or person consen
Page 44 and 45: If a patient has a living will, it
Page 46 and 47: should be referred to Risk Manageme
Page 48 and 49: Refusal of treatment on behalf of a
Page 50 and 51: Sentinel events are considered unex
Page 52 and 53: Discharge plans are made based on p
Page 54 and 55: 2. Telephone orders are limited to
Page 56 and 57: 8. The Heath Information Management
Page 58 and 59: Manual kept at each nursing station
Page 60 and 61: The Microbiology Lab on the second
Page 62 and 63: Intravenous fat emulsion or solutio
Page 64 and 65: 1. Diagnostic ProceduresEmergency R
Page 66 and 67: using a bar code format and your pe
Page 68 and 69: 100. PATIENT RELATIONSStaff in the
Page 70 and 71: patient has the right to timely not
Page 72 and 73: infections in body and other body f
Page 74 and 75: Winthrop-University HospitalFrequen
Page 76 and 77: Pulmonary (Dir.) ..................

House Staff Manual - Winthrop University Hospital

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