Bylaws and Rules of the Medical Staff - VA Pittsburgh Healthcare ...

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Bylaws and Rules of the Medical Staff at VAPHSand procedures will be provided by competent practitioners asdesignated by their clinical privileges/scope of practice. Invasiveprocedures performed by a Nurse Practitioner/Physician Assistantwill be appropriately supervised by a physician.(a)(b)(c)(d)The attending Staff Physician is responsible for thepreparation and completion of a complete medical record foreach patient. This record shall include an updated problemlist, identification data, chief complaints, personal history,family history, history of present illness, physicalexamination, special reports such as consultations, clinicallaboratory, x-ray and others, provisional diagnosis, medicaland/or surgical treatment, operative report, pathologicalfindings, progress notes, doctor's discharge instructionssheet, including condition on discharge (discharge note) andfinal diagnosis, and final summary.The staff physician responsible for the patient must sign theadmission note if it is prepared by a resident, intern, or Mid-Level Practitioner, or make a note on the admission workupor progress notes to the effect that he/she "agrees with theadmission workup and findings" or make whatevercomments he/she thinks the case warrants, or prepare acomplete admission within 24 hours in the acute care facilitylocated at University Drive and seventy two (72) hours ofadmission to the Community Living Center located at HJHeinz Division. In the event a resident, intern, or Mid-LevelPractitioner prepares an admission workup, all will beretained, but the official workup will contain the responsibleMedical Staff physician's approval signature. All residentdocumentation will follow procedures outlined in the VHAHandbook 1400.1, Resident Supervision.There is communication among all practitioners involved in apatient’s care, treatment, and services. Care is planned andprovided in an interdisciplinary, collaborative manner byqualified competent staff. Long term care psychiatry andsubstance abuse will have documentation evident ofmultidisciplinary planning for all patients' treatmentmodalities.The Department of Veterans Affairs is responsive to aphysician's cultural values, ethics, and religious beliefs andthe needs of patient care. A physician may request not toparticipate in a particular patient's care if it directly conflictswith those beliefs or personal standards.(1) Requests for such reassignments will be made inwriting to the supervisor prior to realignment of85
Bylaws and Rules of the Medical Staff at VAPHS(e)(f)(g)(h)(i)(j)responsibility, and will include specific values, ethics,or religious beliefs involved.(2) The staff member making such a request forreassignment is responsible to realign duties andexchange a particular aspect of care for a givenpatient with a competent, qualified co-worker.(3) Under no circumstances will the request be granted ifthe patient's treatment is negatively affected.Food and nutrition products are administered only on theprescription or order of a Medical Staff member, anauthorized house staff member, or other individual who hasbeen granted authority to write such prescriptions or orders,within their scope of practice.Progress note entries should be identified as to the type ofentry being made, (e.g., Resident Note, Attending Note, OffService Note, etc.). The Attending Note must be signed bythe Attending physician.Progress notes will be written by the Practitioner at leastonce daily on all acutely ill patients. Progress notes arewritten for all patients seen for ambulatory care by themedical staff.Evidence of required supervision of all care by the attendingphysician shall be documented in the medical record, thefrequency of notes dependent upon the severity of the illnessof the patient. It is a cardinal principle that responsibility forthe care of each patient lies with the staff physician to whomthe patient is assigned and who supervises all care renderedby residents.To facilitate communication, a Service Line Vice Presidentand/or Section Chief may authenticate (sign) for anotherLicensed Independent Provider if the Vice President orSection Chief believes doing so is in the patient’s bestinterests or if the author of the note will not be able to signthe note timely.Upon determination that a Do Not Resuscitate (DNR) orderis appropriate, the order must be written or, at minimum,countersigned by the attending physician in the patient'smedical record. There must be documentation of the orderand how the decision was reached (e.g., discussed withpatient or family). At any time a DNR order is written, thepatient’s rights will be observed. Once the order has beenentered, it is the responsibility of the attending physician toensure that the order and its meaning are discussed with86
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Bylaws and Rules of the Medical Staff - VA Pittsburgh Healthcare ...

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