House Staff Manual - Winthrop University Hospital

More documents

Recommendations

Info

2. Telephone orders are limited to emergencies only and are one time orders. If, of necessity, ordersare given over the telephone to a licensed practitioner who is required to write down the telephoneorder and read it back to you. The telephone communication must be signed at the earliest possiblemoment with a maximum time limit of 24 hours.3. Narcotic orders: a member of the House Staff may not write a narcotic order for a patient withoutpersonally evaluating and documenting this assessment in the medical record.4. Pathology orders: standing orders for Laboratory procedures must have a stop date included on thechart with the original order.5. Patient allergies and current medication must be listed on the first order sheet by the physician whohas completed the history and physical.6. Residents must immediately co-sign orders written by students.7. Orders are only to be written using WUH accepted medical abbreviations.DISCHARGE PROCEDURES1. The principal diagnosis (the diagnosis established after study to be chiefly responsible for admission)and secondary diagnoses are to be recorded on the summary sheet of the chart when the diagnoses areestablished, and must be on the chart at the time of discharge.2. In the event that the principal diagnosis has not been established at discharge, due to pending testresults, etc., write this information on the summary sheet at the time of discharge.3. The Discharge Order and Instruction Sheet is to be completed prior to discharge. Complete allsections in full, date, time and sign.4. The medical record must be completed by the House Staff as prescribed by Hospital policy to avoidthe accrual of delinquent charts.The Discharge Summary is the responsibility of the resident who has had on-going responsibility forthe patient. Should a resident be covering a patient for less than 48 hours at the time the patientexpires, is transferred or discharged, then the Discharge Summary is dictated by the previous resident.Dictation of the discharge summary is to be completed upon discharge or expiration. Disciplinaryaction will be taken if the discharge summary remains undictated following discharge.During dictation of the discharge summary, give the first and last name of the attending physicianresponsible for the case, to facilitate mailing procedures. Dictate according to discharge summary formatas follows below.DISCHARGE SUMMARY DICTATION PROCEDURESThe summary should be a concise overview of the case. When required, additional details will be found inthe chart.1. Discharge Summary Outline:Identify yourself as the person dictating.First and last name of attending physician must be included.Give patient's name and spell it.Give patient medical record number (6 digits)Give admission and discharge dates.Then continue with the following format:Speak slowly and clearly when dictating.Rev. 1/08
2. History/Physical/Lab Findings:Give brief summary of significant points in the history and physical findings. The date of onset ofsymptoms and circumstances are particularly important. Where, when and how injury or illnessoccurred should be clearly stated.Give relevant findings as briefly as possible.Give brief summary of all significant/abnormal lab and x-ray findings.3. Condition on Discharge/Disposition:State the in-hospital course including treatment and patient's response to treatment, operations, specialexaminations, consultations, recommendations, etc. Indicate follow-up plan, discharge medications,immunizations and vaccines given during hospitalization, activity level and condition on discharge.4. Final Diagnoses:List principal diagnosis and all other diagnoses co-existing or complicating this admission. UseStandard Nomenclature terminology.CURTAILMENT POLICY: INCOMPLETE RECORDSAll physicians are responsible for complete and timely documentation of medical care given to any patienttreated at Winthrop-University Hospital. Failure to comply with charting regulations will result indisciplinary action. New York State Code 405.10 mandates medical records be completed within 30 daysof discharge. After 30 days, any record incomplete will be considered “Delinquent”.1. The appropriate chiefs of service will be notified of all House Staff with delinquent records anddisciplinary action will be taken.2. If any charts become delinquent, a notice will be given to the Chief of the Department, the ChiefResident, and the delinquent resident. A record of all action taken will be kept in the resident'spermanent file.GENERAL NOTES1. All entries in the medical record shall be written in permanent ink and contain the printed name of thepractitioner, contact number (telephone extension or beeper number), date, time and signature.2. Erasures or blacked out alterations are illegal and render the entry valueless to the patient or to theHospital in the event of litigation. If an error in documentation occurs in the medical record, draw onestraight line through the statement, print the word “error” above the cross-out, verify correction –initial and date after cross-out and document the correct narrative.3. Abbreviations are to be avoided when assigning final diagnosis, and are to be used only if onWinthrop’s Standardized List of Abbreviations.4. Records may not be taken from the Health Information Management Services Department unlessapproved by the Director.5. No records are to be taken from the main hospital building for any reason.6. Operative reports shall be dictated in detail immediately after surgery (JCAHO regulation).7. Requests for records or patient lists for studies to be used for research must be cleared and reviewed bythe Institutional Review Board (IRB). The IRB can be contacted at 516 663-2552.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 40 and 41: Diseases in all capital letters req
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 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.) ..................
show all

House Staff Manual - Winthrop University Hospital

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?