House Staff Manual - Winthrop University Hospital

Discharge plans are made based on patients need, physician direction, and available insurance coverageand/or private payment by the patient and family. Patients unable to return home after acute care areassisted with placement to the appropriate rehabilitation, skilled nursing, terminal care, or adult homefacility dependent upon patient need.The Hospital has its own certified home health agency: "Winthrop-University Hospital Home HealthAgency". Many of the Hospital's home care patients are referred to it, if appropriate. This provides foradded continuity of care and communication. Home Care is able to provide physical, occupational andspeech therapy, paraprofessional services, social work and nursing services at home on an intermittentbasis. The attending physician of record must direct the plan of care.Referrals are accepted from all sources including medical staff, nursing, allied health professionals, family,patient, community agencies and institutions. The attending physician is consulted prior to initiation of anydischarge planning.For further information, contact Discharge Planning at ext. 2075 or the Home Health Agency at ext. 6338.84. ETHICS CONSULTATION SERVICEThe Ethics Case Consultation Service is designed to assist patients, family members, attendings, HouseStaff and other hospital staff in making ethical decisions related to patient care. The consultants, who aremembers of Winthrop’s Bioethics Committee, identify and examine the ethical problem by reviewing themedical record and meeting with the patient/family and health care team. The consultants may offer adviceor recommendations but the patient/family and health care team remains responsible for their owndecisions.An Ethics Case Consultation can be arranged by calling ext. 0333 and asking for the Ethics ConsultationService. If one is unclear as to whether a consultation is needed, that should not deter one from calling.The consultants will help to define the issues, and triage the case as needed. One may call the service withassurance of total impunity.85. HEALTH INFORMATION MANAGEMENTCONFIDENTIALITYMedical records containing the clinical histories of the patients are hospital property and containconfidential communications from patient to doctor. No report or other communication, discussion withnews media, lawyers or insurance companies, etc., concerning patients treated in the Hospital shall bereleased, published, or discussed by members of the House Staff under any circumstances.Documents you are discarding that have any patient information ion on them should be shredded.LEGIBILITYAs a legal document and a source on patient care information used by many personnel involved in the careof the patient, all entries into the medical record should be logical and legible. Every order written by amember of the houstaff should be signed as well as stamped with pre-printed information containing nameand contact info. Using the pre-printed information in addition to your signature when writing progress,operative, procedure, delivery notes and discharge summaries is strongly recommended.HISTORY AND PHYSICAL DOCUMENTATION1. Histories and physical examinations are to be completed and written on the record by the admittingresident within 24 hours after admission of the patient. The original history and physical must beplaced on the chart immediately after completion. Please do not hold the forms.It is the responsibility of the supervising resident to see that the history and physical of each patient iscompleted within the 24-hour time period.Rev. 1/08