ARTICLE 1

ADMISSIONS

GENERAL

Patients will be admitted to the Hospital without regard to race, creed, color, sexual preference, national origin or ability to pay. Patients shall be admitted for the treatment of any condition or disease for which the Hospital can render patient care at appropriate standards of care, and for which the Hospital has adequate and appropriate facilities and personnel.

PROVISIONAL DIAGNOSIS

Except in an emergency, no patient shall be admitted to the Hospital unless a provisional diagnosis has been stated. In the case of an emergency, the provisional diagnosis should be stated as soon after admission as possible.

WHO MAY ADMIT

Except in an emergency, a patient may be admitted to the Hospital only by a Physician Practitioner who is a member of the Medical Staff in good standing, and who has admitting privileges, or by a practitioner to whom temporary, emergency or disaster privileges have been granted.

ATTENDING OF RECORD

The Attending Physician Practitioner shall be responsible for the overall care and treatment of the patient within the scope of his/her privileges. All medical care of a patient will be performed under the supervision and coordination of a Physician Practitioner.

ADMISSIONS OF PSYCHIATRIC PATIENTS

Any patient with the primary diagnosis of mental disorder as defined by the current edition of Diagnostic and Statistical Manual of the American Psychiatric Association shall be admitted and attended by a psychiatrist that has clinical privileges granted to do so. Where a patient is admitted with a medical condition being the primary or provisional diagnosis, and the patient is found to also have a mental disorder, the Physician Practitioner acting as the Attending of Record shall consult, as appropriate, with a psychiatrist to coordinate care of the patient to address any concomitant mental condition.

ASSIGNMENT OF PATIENTS

When possible each patient shall be attended by a member of the Medical Staff chosen by mutual agreement of the Attending Physician Practitioner and patient, and such patient will be admitted to the service of that Attending Physician Practitioner. When a patient has no preference as to a Physician Practitioner who can act as the Attending and the patient requires admission via the Emergency Room, the emergency room Physician shall contact the appropriate service for the on-call Physician’s consent to admit the patient. Should that Physician be unable to become the Attending Physician Practitioner, the on-call Physician must provide an alternative.

PROFESSIONAL RELATIONSHIP

Within 24 hours after a patient’s admission or in- House transfer, the Attending Physician Practitioner of record shall examine the patient and establish a professional and identifiable relationship with the patient, if such was not established prior to the admission or in-House transfer. The Attending of Record is responsible for the continuing care of that patient until discharge or in-House or outside transfer.

RESPONSIBLE PHYSICIAN

Except in an emergency, the Attending Physician Practitioner shall be present during key portions of any medical or surgical service or procedure provided to the patient, and shall be immediately available to furnish services during any service or procedure in the Operating Room (OR), Micro Invasive Suites, or the Emergency Room.

ACCEPTANCE OF PATIENTS

The Hospital shall accept patients of the admitting staff suffering from all types of diseases, and shall treat any patient having an emergency medical condition. All such patient care will be provided based on the capabilities of the appropriate service, and available Hospital facilities and Medical Staff and Hospital personnel. When limitations of facilities and personnel exist, the President of the Medical Staff or his or her designee shall determine admitting priorities.

PROTECTION OF PATIENTS

The type of facilities provided to the patient will be determined by the Physician Practitioner and admitting department with respect to the known needs and conditions of the patient for the protection of other patients from those who are a source of danger from any cause whatsoever or to ensure protection of the patient from self- harm.

REQUIRED LABORATORY TESTS

Within 24 hours of admission to the Hospital, all patients shall have performed and recorded those laboratory tests required by State, Federal and local laws.

EMERGENCY ROOM CONSULTANT AND ADMISSIONS

All admissions made through the Emergency Room shall be made pursuant to the Hospital’s Ambulance Diversion Protocol, which permits resource sharing among member hospitals of the Greater Cincinnati Health Council. Any individual who comes to the Emergency Room will receive a medical screening examination within the capabilities of the Emergency Room, to determine whether the patient has an emergency medical condition.

The medical screening examination shall be performed by Qualified Medical Personnel (as that term is defined under applicable Federal regulation).

When a patient is determined to have an emergency medical condition, or if a pregnant woman comes to the Emergency Room in active labor, the Hospital will provide necessary stabilizing treatment within the capabilities of the Emergency Room. Transfer of any patient will be done pursuant to Hospital policies.

A Physician Practitioner in the Emergency Room may also elect, in his or her professional judgment, to call or page an on-call Physician (resident or Attending) for consultation about any individual determined to have an emergency medical condition. When an on-call Physician is called or paged, it is the responsibility of the on-call Physician to respond to the call or page within thirty (30) minutes after contact by the Emergency Room Physician and to appear in the Emergency Room in a timely fashion to provide stabilizing treatment, if

requested by the Emergency Room Physician. If the on-call Physician (resident or Attending) cannot respond within Hospital guideline times due to circumstances beyond his/her control, including situations in which the on-call Physician is permitted to schedule elective surgery or take simultaneous call, and the on-call Attending is unable to provide an alternative Attending Physician, the call is escalated to the Department Director and President of the Medical Staff.

PATIENT RIGHTS / RIGHT TO REFUSE TREATMENT / INFORMED CONSENT

All physicians will comply with Hospital’s informed consent policies. Any procedure that requires informed consent shall be, absent an emergency, performed only after receiving a properly signed informed consent form, which contains evidence that the risks, benefits, alternative treatments and risks associated with alternative treatments have been discussed with and are understood by the patient. Where the patient is a minor, or an adult who lacks legal capacity to offer his or her informed consent as result of incompetence or incapacity, the physician may secure informed consent from a person having legal authority to offer such consent on behalf of the patient. The Attending Physician is responsible to ensure that the signed informed consent form and all documentation of the informed consent conversation is properly reflected in the patient’s medical record. Procedures that are performed on an emergency basis can be performed without securing informed consent, if, in the opinion of the Attending Physician, serious harm to the patient would result from delaying the procedure. All decisions to perform procedures on an emergency basis without the informed consent of the patient shall be documented in the patient’s medical record. Additionally, every adult patient having requisite mental capacity shall have the right to permit or refuse treatment.

ARTICLE 2

DISCHARGES

WHO MAY DISCHARGE / DISCHARGE SUMMARY

Patients shall be discharged only on the written order of the Attending of Record or a Licensed Advanced Practitioner acting within the scope of his or her authority who:

1. Has authority to discharge under State law and applicable Hospital policy
2. Has knowledge of the conditions under which a transfer or discharge can occur and are appropriate
3. Shall manage the shift, if any, in the patient’s care
4. Shall direct the outside or in-house transfer or discharge

The discharge summary should be completed within 48 hours after the patient is discharged. The discharge summary should contain the reason for hospitalization, reason for discharge, summary of significant findings, procedures performed, a summary of care, treatment and services provided, an assessment of the patient’s condition at discharge, limitations on activity and diet, a description of recommended follow-up care and medications, and a summary of all information provided to the patient and/or patient’s family. The discharge summary must be authenticated, timed and dated by the Attending of Record (no stamped signatures are permitted).

DISCHARGE PROCEDURE

Discharges, in-house and outside transfers shall be based on the patient’s assessed needs, and planning for discharge or transfer should, where appropriate, involve the patient and the patient’s family members who will be involved in post-discharge care of the patient. No patient shall be discharged to another facility unless arrangements have been made in advance for admission to the alternate facility, and the Hospital and alternate facility have agreed on who is responsible for the patient’s safety during transfer. With the exception of emergencies, when a patient is to be transferred directly from the Hospital to another facility, appropriate transfer information shall accompany the patient. Hospital personnel will also, prior to discharging a patient to an alternate facility, make good faith efforts to notify any emergency contact person(s) previously identified by the patient. With the consent of the patient, the Attending of Record or his/her designee shall communicate all appropriate information to any Physician, institution, agency or other provider to which a patient is referred following discharge from the Hospital.

If a patient leaves the Hospital against the advice of the Attending Physician Practitioner, a notation of the incident shall be made in the patient’s medical record. If Hospital personnel have prior knowledge of the patient’s intent to leave the Hospital against medical advice, the patient will be asked to sign a release form, which shall be added to the patient’s medical record.

When the health status of the patient being discharged so warrants, the Hospital will arrange or assist the patient’s family to arrange for post-discharge services to meet the needs of the patient. The Hospital will provide written discharge instructions to either the patient or those responsible for providing continuing care to the patient.

AUTOPSIES

At all times when a legitimate quality, legal or educational issue or objective is or is likely to be addressed through the performance of an autopsy, the Attending Physician Practitioner is expected to request that a decedent’s next of kin authorize an autopsy. The criteria that identify deaths in which an autopsy should be performed at the

Hospital are defined by American Society of Clinical Pathologists. Autopsies are performed by the Department of Pathology and are used to make determinations about cause of death, quality of patient care, and to evaluate the accuracy of clinical diagnoses and the effectiveness of therapeutic regimens. The Attending Physician Practitioner is required to contact the coroner’s office of any death resulting from one or more of the following: criminal violence, accident, suicide, sudden and unexplained death, death of a patient under age 2, suspected foul play, or suspicious circumstances. All autopsies shall be performed in accordance with Hospital policies on autopsies or post-mortem examinations.

ARTICLE 3

MEDICAL ORDERS

TREATMENT ORDERS

All orders for treatment must be written and signed by the Attending Physician Practitioner of record, his/her designee, a member of the housestaff of the Attending’s service, a designated consultant, an anesthesiologist, or a Licensed Advanced Practitioner acting within the scope of his or her practice as defined by state law and Hospital privileges.

All orders must be clearly written, legible and complete, and must include the date, time written, and include a legible authentication by the ordering practitioner or another practitioner who is responsible for the care of the patient and who is authorized by law and Hospital policy to independently write orders.

Ordering practitioners with poor handwriting should print or type orders where no computerized physician order entry (“CPOE”) capability exists.

For purposes of these Rules and Regulations, the term “written” shall be read to also include items documented electronically through CPOE or otherwise.

DICTATED ORDERS

A Physician Practitioner’s verbal orders (Emergency or Telephone order) are to be used infrequently, and only to meet the urgent care needs of the patient or when it is not feasible for the ordering practitioner to immediately communicate the order in written or electronic form.

Verbal orders are defined in Hospital policies on emergency and telephone orders.

Emergency orders are those orders given by a Physician Practitioner who is physically present on the unit, in emergency situations. Only members of the Medical Staff may initiate an emergency order.

Telephone orders are those orders given by a Physician, dentist, or licensed advanced practitioner acting within their scope of privileges as defined by state law and Hospital privileges.

A verbal order shall be accepted and transcribed by:

• Designee of the ordering Physician Practitioner
• Licensed Advanced Practitioner
• Registered nurse
• Licensed practical nurse
• Licensed clinical staff acting within their scope of practice
• Member of the house staff

Verbal orders should be dictated slowly, clearly, and articulately to minimize the likelihood of error. All verbal orders must be read back to the ordering practitioner by the recipient. The dictated order must be authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and who is authorized to write orders independently within a reasonable time period after the verbal order is given but not to exceed the 30-day chart completion timeframe as defined by federal regulations and Hospital policy. A timed and dated copy of the order, including the name of the ordering practitioner, the name of the individual who received the order, and the name of the individual who implemented the order should be added to the medical record of the patient.

WRITTEN ORDERS

Written orders must be legible. Prescribing practitioners with poor handwriting should print or type orders if no CPOE capability exists. Medication orders must be complete and include:

1. Patient and drug name (including a generic drug name or trademarked name if a specific product is required
2. Routine administration instructions where appropriate
3. Dosage, strength and quantity
4. Frequency of administration
5. The prescribing practitioner’s name

Orders should be clear and unambiguous and use the United Stated Adopted Names (USAN)-approved generic drug official name or trademarked name (if a specific product is required). Orders entered through the CPOE system will automatically be time and date stamped.

AUTOMATIC STOP ORDERS

Physician Practitioners must follow all pharmacy policies relating to Automatic Stop Orders.

SEDATION AND ANESTHESIA OF PATIENTS OUTSIDE THE OPERATING ROOM

Physician Practitioners using moderate or deep sedation outside of the operating room environment shall follow applicable Hospital policies.

THERAPEUTIC AGENTS AND RELATED DEVICE ORDERS

Medication orders must be clear, unambiguous and complete and include:

1. Patient and drug name
2. Routine administration instructions where appropriate
3. Dosage, strength and quantity
4. Frequency of administration
5. Ordering practitioner’s name

The Department of Pharmacy is authorized to dispense generic and therapeutic equivalents of brand/generic name therapeutic agents and related devices unless the practitioner when writing the order writes “dispense as written.” The metric system will be used in writing therapeutic agents and related device orders. The Pharmacy shall control the distribution of all therapeutic agents and related devices to patients and the distribution of all therapeutic agents and related devices to patient care areas within the Hospital. The ordering and use of therapeutic agents and related device orders will be governed by policies and procedures approved by the pharmacy and therapeutics committee and as adopted by the Medical Executive Committee.

All orders for therapeutic agents and related devices shall be in writing. An order will be considered in writing if dictated by the Attending Physician Practitioner of record to a Licensed Advanced Practitioner, a registered nurse, or other licensed clinical staff acting within the scope of their practice as defined by State law and Hospital scope of practice/job description.

RESTRAINT OR SECLUSION ORDERS

The use of any manual method, physical or mechanical device, material or equipment that immobilizes or reduces a patient’s ability to move his or her arms, legs, body or head, or a drug or medication used to manage a patient’s behavior is considered a restraint. The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving shall be deemed seclusion. Each episode of use of restraint or seclusion shall be the least restrictive method that is likely to be effective, and in conformity with Hospital Patient Care Services policies on medical and behavioral restraint, seclusion and entrapment.

ARTICLE 4

CONSULTATION/VISITORS

CONSULTATIONS

A “consultation” is defined as an examination of the patient and/or his or her clinical record by a qualified person who has been granted appropriate clinical privileges.

Examples of circumstances in which a consultation is likely to be appropriate include those situations in which:

• The patient is not a good risk for a procedure, protocol, operation or treatment
• The diagnosis is obscure or uncertain
• There is doubt as to the most appropriate therapeutic measures to be utilized

The consulting Physician should be selected based on his or her training, experience and competence in the field in which his or her opinion is sought. Requests for consultation shall be written on the order sheet and also telephoned to the consultant, who shall, where possible, answer such consultation request within the time asked.

Consultations should be obtained when the Physician Practitioner, through the exercise of independent clinical judgment, determines that such consultation is or is likely to be in the best interest of the patient.

Psychiatric consultation must be requested for and offered to patients who have attempted suicide or who have taken a chemical overdose. These patients are always assessed in terms of suicide risk, and shall be assigned a patient-sitter until such time as the patient can be evaluated or moved.

When a consultant sees the patient, the consultant must furnish and authenticate a written consultation note for the patient’s record, which should include a summary of findings, opinions and recommendations. The consultation form shall be timed and dated. If the consultant so desires, he or she may enter “see progress notes” on the consultation form and add the consultation note in chronological sequence in the progress notes of the patient’s medical record. In instances where the consultant wishes to supply a formal typed consultation report, a brief consultation note should be entered in the progress notes.

Consultants may write orders provided that the consultant must see the patient within 24 hours of the written order.

VISITING CLINICAL MEDICAL PROFESSIONAL

A visiting clinical medical professional must be a Physician, dentist, or other medical professional, in good standing on the medical staff of another medical facility, who is licensed or otherwise appropriately authorized to practice their profession. Such visiting clinical medical professionals may be invited to the Hospital to observe, or to provide or obtain clinical skills in a particular area of medical or surgical expertise on the following conditions:

1. Whenever a visiting clinical medical professional is to render patient care or perform a diagnostic or therapeutic procedure requiring patient contact, a letter requesting visiting clinical medical privileges must, beforehand be directed to the President of the Medical Staff from the Director of the Department in which the
2. visiting clinical medical professional will have patient contact. Each visiting clinical medical professional, whether observing or providing patient care, must complete a “Visiting Professional Form” and submit required documentation prior to the scheduled visit. Approval comes from the President of the Medical Staff. The Board shall appoint a member who is not otherwise employed by the Hospital to act on its behalf for purposes of approving a visiting medical professional.
3. The visiting clinical medical professional must practice within the confines of the Ohio Revised Code and these Medical Staff Bylaws. If the visiting clinical medical professional is not licensed within the State of Ohio, he or she must also obtain and show evidence of a Special Activity certificate issued by the Ohio State Medical Board.
4. All clinical activities of a visiting clinical medical professional are to be performed in conjunction or consultation with a sponsor who is a member of the Attending Medical Staff. The sponsoring Department and sponsor shall, at all times, be responsible for the supervision of any patient care rendered by the visiting clinical medical professional.
5. Informed consent by the patient should reflect agreement to the involvement of the visiting clinical medical professional.
6. No bills for services are to be rendered to patients of the Hospital by a visiting clinical medical professional unless he is she is duly licensed in good standing in the State of Ohio and is admitted as a member of the Medical Staff and is credentialed at the Hospital.
7. Visiting clinical medical professionals who provide patient care must possess malpractice insurance coverage with a minimum limit of one million dollars/claim. Alternatively, by prior written agreement approved by the President of the Medical Staff, the Department sponsoring the visiting clinical medical professional may provide malpractice insurance covering the patient care of the visitor.

ARTICLE 5

MEDICAL RECORDS

CONTENTS

The medical record of each patient shall contain at least sufficient information to identify the patient (or a notation of the reason why such information is not available); emergency care provided to the patient before arrival at the Hospital, and, where appropriate, the times and means of arrival at the Hospital; symptom/ complaint and medical history; a complete history and physical examination with proper authentication; conclusions and impressions draw from the history and physical and an admission diagnosis; a tumor staging form for patients receiving treatment for cancer; any known allergies to food and medication; diagnostic and therapeutic orders; evidence of appropriate informed consent; treatment goals and plan, which is individualized and appropriate to the needs and health status of the patient; evidence of regular review and revisions to the treatment plan; diagnoses and conditions identified during the course of care; all diagnostic and therapeutic orders and medications ordered or prescribed; all diagnostic procedures, tests and results; patient response to care, treatment and services; documentation and findings relating to the initial assessment and subsequent reassessments; clinical and consultative observations including results; documentation of complications, Hospital acquired infections and unfavorable reactions to drugs and anesthesia; acknowledgment of Hospital’s advice regarding advance directives and evidence of the advance directives of the patient; procedure and operative reports; discharge diagnoses, a completed and properly authenticated discharge summary; instructions for follow-up care and records of all communication with the patient relating to care, treatment and services; medications prescribed on discharge; the patient’s language and communication needs; any electronic patient-generated information; conclusions at the termination of hospitalization or treatment; and any other item deemed necessary by the Attending Physician. All entries in the medical record must be accurate, timely, and legible and should be timed and must be dated and signed. This is to include Physician signatures on verbal orders as well as all other entries in the medical record.

HISTORY AND PHYSICAL EXAMINATION

Admission History and Physical

A complete history and physical examination (“H&P”) shall be performed and recorded for each inpatient within twenty-four (24) hours of admission and shall be authenticated by a qualified Physician Practitioner. All entries should be timed and must be dated and signed.

The admission H&P must include these elements:

1. Chief Complaint
2. Details of Present Illness
3. Relevant past, social & family histories
4. Complete physical examination
5. Conclusion/Impression drawn from the examination
6. Course of action/Treatment plan
7. Medical Reconciliation Sheet
8. List of current medications
9. If a complete H&P has been obtained or performed within a week prior to admission, a durable, legible copy of this report may be used in the patient’s Hospital medical record, provided that any changes to the patient’s condition subsequent to the original H&P are recorded at the time of admission.
10. When a patient is readmitted within 30 days for the same or related problem, an interval H&P reflecting any subsequent changes may be used in the medical record provided the original information is readily available.

Invasive Procedure History and Physical

For individuals undergoing an invasive or operative procedure requiring general anesthesia, deep sedation, or moderate sedation, the medical record must document a current, thorough history and physical examination prior to the performance of the procedure.

The invasive or operative procedure H&P must include these elements:

1. Chief Complaint
2. Details of Present Illness
3. Relevant past, social & family histories
4. Complete physical examination
5. Conclusion/Impression drawn from the examination
6. Course of action/Treatment plan
7. List of current medications
8. For an H&P examination that is completed within 30 days prior to the procedure, the patient must be re-evaluated and an update documenting any changes in the patient’s condition must be documented in the record prior to the procedure being performed. If the procedure results in the patient’s subsequent admission to the Hospital, the H&P should be reviewed and expanded upon within 24 hours of admission if necessary depending on the patient’s condition.

Individuals Qualified to Perform History and Physical

In addition to Physician Practitioners, only housestaff and the following Licensed Advanced Practitioners who are properly privileged or authorized to complete H&P may perform an H&P. In such event, the Attending Physician Practitioner shall be responsible for monitoring the quality of the H&P, and should add his or her own personal observations when clinically indicated. The following may perform a H&P subject to the following restrictions:

1. Podiatrists and dentists may perform the portion of the H&P pertaining to podiatry and dentistry, respectively.
2. Certified Nurse Midwives (CNM), Certified Nurse Practitioners (CNP) and Clinical Nurse Specialists (CNS) who have a Standard Care Arrangement (SCA) with a collaborating Physician who is a member of the Medical Staff may perform the H&P. Countersignature by the collaborating Physician Practitioner is not required.
3. Physician Assistants (PA-C) who have a supervision agreement with a Physician Practitioner who is a member of the Medical Staff may perform the H&P.
Effective: August 20, 2014
4. Countersignature by the supervising Physician Practitioner is not required.
5. Residents in approved Graduate Medical Education programs may perform the H&P. The Attending Physician may either authenticate the H&P dictated/ written by residents or write a separate note indicating review of the resident’s note and agreement or exception to the information.
6. Certified Registered Nurse Anesthetists (CRNA) may perform the H&P. The supervising Physician Practitioner must countersign any H&P performed by a CRNA.
7. Senior medical students on an acting internship assignment may perform the H&P. The supervising resident or Attending Physician Practitioner must countersign any H&P performed by an acting intern.

Medical Screening Exams

Qualified Medical Persons Who May Perform Medical Screening Examinations.

In addition to Physician Practitioners, the Hospital permits certain qualified medical persons to conduct medical screening examinations in certain circumstances. Qualified medical persons may include a CNP, CNS, CNM, and PA-C.

Nothing in this section shall permit a CNP, CNS, CNM, or PA-C to admit patients to the Hospital, which is solely the prerogative of Medical Staff appointees who have been granted such admitting privileges.

DIAGNOSTIC AND THERAPEUTIC ORDERS

The qualified and licensed practitioner responsible for the order must authenticate all diagnostic and therapeutic orders.

Qualified licensed practitioners include members of the Medical Staff and Licensed Advanced Practitioners, (CNM, CNP, CNS, CRNA, PA-C), who are acting within the scope of their practice as defined by state law and approved Hospital privileges, where applicable.

All verbal orders (telephone or emergency orders) must be documented in the medical record as an emergency or telephone order and authenticated within a 48-hour time period, as required by state law.

PROGRESS NOTES

Progress notes shall be recorded in the medical record at the time of observation and shall reflect a pertinent chronological report of the patient’s course in the Hospital and shall reflect any change in condition and the results of treatment. Licensed Advanced Practitioners (CNM, CNP, CNS, CRNA, PA) may document progress notes as allowed by state law, and within the scope of their Hospital-approved privileges. All entries should be timed, and must be dated and signed.

OPERATIVE REPORTS

A brief operative progress note must be entered in the medical record immediately after invasive and operative procedures. A diagnosis or provisional diagnosis shall be noted in the medical record prior to any procedure.

Effective: August 20, 2014

Operative reports must be dictated or written in the medical record within 24 hours after they are performed and contain a name and a description of the procedure, estimated blood loss, a description of the findings, the technical procedures used, the specimens removed, the postoperative diagnosis. In every event, the operative report will be completed before the patient is transferred to the next level of care.

Post-operative observation notes recording the patient’s vital signs, level of consciousness, medications, blood and blood components administered, and notes of any unusual events or complications shall be made as appropriate.

REPORTS OF PATHOLOGY, CLINICAL LABORATORY EXAMINATION, RADIOLOGY, AND NUCLEAR MEDICINE EXAMINATION OR TREATMENT, ANESTHESIA RECORDS, AND ANY OTHER DIAGNOSTIC OR THERAPEUTIC PROCEDURES

Such reports are promptly completed and filed in the medical record. Reports of critical laboratory and radiology reports must be called to the attention of the Physician per the requirements of Hospital policies. All entries should be timed, and must be dated and signed.

CONCLUSIONS AT THE TERMINATION OF HOSPITALIZATION (DISCHARGE SUMMARY)

A discharge summary shall be written or dictated on all medical records of patients hospitalized over forty-eight (48) hours.

A final progress note may substitute for the discharge summary in all patients with problems of a minor nature who require less than a forty-eight (48) hour period of hospitalization and in the case of a normal newborn infant and uncomplicated obstetrical deliveries.

Discharge notes may be dictated/transcribed by a Licensed Advanced Practitioner acting within the scope of his or her practice as defined by state law and approved Hospital privileges. Discharge summaries must be countersigned by the Attending Physician Practitioner, or, if applicable, by the responsible CNM.

DRG DOCUMENTATION

All relevant diagnoses as well as the summary of operative procedures performed shall be recorded in the medical record on a prescribed form within twenty-four (24) hours of discharge using acceptable disease and operating terminology. Entries may be dictated/transcribed by a Licensed Advanced Practitioner acting within the scope of his or her practice as defined by state law and approved Hospital privileges.

AUTHENTICATION

All entries in the medical record must be timed, dated and signed. This is to include authentication of verbal orders and all other entries in the medical record. Authentication means establishment of the identity of the author of the entry by written signature, identifiable initials or computer keys.

The medical record should offer written evidence of the Attending Physician Practitioner’s involvement in the care of the patient as result of the Physician Practitioner’s authentication of medical record entries made by house staff. All entries made by medical students require the authentication of the supervising licensed Physician (Attending or resident). Signature by the responsible Attending Physician Practitioner is required on any Operative/Procedure Report or Discharge Summary (or Final Progress Notes) dictated/written by a resident. The Attending Physician Practitioner may either authenticate the H&P dictated/ written by residents or write a separate note indicating review of the resident’s note and agreement or exception to the information.

Effective: August 20, 2014

The medical record should offer further written evidence of the supervising Physician Practitioner’s involvement in the care of the patient by countersignature of entries made by CRNA, and that each collaborating or supervising Physician Practitioner is appropriately involved in the care of the patient and supervision of each CNM, CNP, CNS or PA-C with whom the Physician Practitioner has an agreement. Countersignature by collaborating or supervising Physician Practitioner is required to the extent required by State law and Hospital policy for these practitioners.

The Attending Physician Practitioner is responsible for ensuring that the medical record of each patient under his or her care is completed within 30 days after patient discharge.

Each Physician Practitioner will receive notification from the Medical Record Department regarding incomplete or delinquent medical records as follows:

1. Primary notification: Initial log-in to the record completion system. Each Physician Practitioner is expected to log in to the electronic document management system regularly to monitor delinquency status through electronic medical records.
2. Secondary notification: Medical records will send a reminder letter after 14 days delinquent.
3. If not completed after reminder letter, Medical Records will send a delinquent letter after 31 days.
4. If not completed after delinquent letter, Medical Records will send a Medical Executive Committee (MEC) referral letter after 46 days deficient.

5. If Physician Practitioner has NOT responded after being delinquent in the MEC report for three consecutive months in a row, the medical records department will send out a certified letter to the practitioner involved stating the possibility of suspension. If delinquencies have not been resolved by the following MEC meeting, the Physician Practitioner will be notified of privilege suspension as follows:
6. All privileges to admit patients, to consult with respect to patients, to administer anesthesia, to perform surgery and special procedures are suspended; and
7. The Physician Practitioner will be removed from the “Attending of the month” rotation schedule and will be prohibited from seeing patients in the ambulatory clinics or emergency department of the hospital; and
8. If the suspended Physician Practitioner is also a Department Director, chairperson of the Credentials Committee or chairperson of the Clinical Leadership Council or other committee, he or she shall be prohibited from participation in the Department and committee activities. When appropriate, the President of the Medical Staff will appoint a current committee member as interim chairperson.

The Physician Practitioner who is suspended for delinquent or incomplete medical records will be permitted to continue to attend those patients he or she admitted or scheduled prior to the date on which the suspension notice was mailed by the Medical Records Department. Each medical records suspension will be noted in the appropriate Physician Practitioner’s reappointment file. All privileges will be reinstated when the medical record is complete and/or delinquencies remedied. When a Physician Practitioner is suspended as a result of having delinquent medical records, he or she will be required to complete all records that are 15 days post-discharge/encounter and older prior to the suspension being revoked.

MEDICAL RECORDS - REMOVAL

Medical records shall be removed from the Hospital’s jurisdiction and safekeeping only in accordance with a valid court order, subpoena, or as required by applicable statute. The Medical Records Department will comply with valid requests authorizing the release of copies of medical records. In case of readmission of a patient, all previous medical records shall be made available for the use of the Attending Physician Practitioner.

ABBREVIATIONS

Final diagnoses, names of medications prescribed and procedures performed shall be recorded in full, without the use of either symbols or abbreviations. The Medical Records Committee shall recommend, and the Medical Executive Committee shall approve, a list of unacceptable abbreviations. This list shall be incorporated into Hospital policies as appropriate. Compliance with the abbreviation list is determined through retrospective records review by the Medical Records Committee.

DOCUMENTING IN THE RECORD

For paper documentation, write or print legibly in blue or black ink. Any incorrect entry recorded on paper should have a single horizontal line placed through the incorrect entry with “error” or “wrong chart” written next to it. The author should date and initial at the incorrect entry. An entry should never be obliterated in any way.

ARTICLE 6

SURGICAL CARE

PHYSICAL FACILITIES

Operating rooms will be assigned to clinical service areas according to patient and procedure volumes.

TESTING / SCREENING / INFORMED CONSENT FOR INVASIVE PROCEDURES

Physician Practitioners must follow applicable Anesthesia policies regarding testing and screening of patients prior to surgery. Except in the case of an emergency invasive procedure, the Attending Physician shall explain the risks, benefits, sedation necessary, likelihood for blood use, and alternatives available with respect to the procedure, and will secure informed consent for the procedure.

PRE-OPERATIVE VERIFICATION

Prior to the start of any procedure, a pre-operative verification will be performed.

This verification will consist of:

1. Review of the relevant documentation and images of the patient
2. Determination that the person on whom the procedure is about to be commenced is the correct patient
3. Where appropriate, the licensed independent practitioner responsible for the procedure will review the plan of sedation or anesthesia
4. Evaluation of the condition of the patient before the initiation of moderate or deep sedation or induction of anesthesia.

SURGICAL SCHEDULING GUIDELINES

Non-emergency cases, or elective cases, must be scheduled through Surgical Scheduling. Emergency cases are scheduled through the OR charge nurse on duty. Where the scheduling of an emergency procedure displaces a previously scheduled non-emergency case, the Attending Physician on the displaced case will be notified.

If there are more emergency cases for which booking is requested than available capacity allows, the physicians requesting the emergency booking will communicate and work collaboratively to prioritize the appropriate procedure order based on patient acuity. If the physicians requesting the emergency bookings are unable to reach agreement on the appropriate priority, the Department Directors(s) may intervene as necessary to establish the appropriate procedure order. If the Department Directors(s) are unable to establish an appropriate procedure order, the issue may be escalated to the President of the Medical Staff, who, in such case, shall have the final decision making authority to establish an appropriate procedure order.

MEDICAL RECORD OF ANESTHESIA AND OPERATIVE REPORT

The medical record of any patient undergoing an operative or other high-risk procedure where moderate or deep sedation or anesthesia is administered shall thoroughly document the appropriate information relating to the procedure. A diagnosis or provisional diagnosis shall be noted in the medical record prior to the procedure. Procedure reports or progress notes relating to operative or other high risk procedures shall be dictated or written immediately, but shall in every event be completed before the patient is transferred to the next level of care. For any invasive procedure, a written or dictated note should be made in the patient’s medical record indicating whether a general or local anesthesia is used. The Attending Physician is required

to dictate his or her “Report of Operation” as soon as possible, but no later than 72 hours after the conclusion of the procedure. The general operative record should include the names of all licensed independent practitioners and other health care personnel participating in the procedure, the name and a description of the procedure, findings, estimated blood loss, specimen removal, and a post-operative diagnosis, and shall be authenticated and made available in the patient’s medical record as soon as possible.

POST-OPERATIVE CARE NOTES

Post-operative observation notes recording the patient’s vital signs, level of consciousness, medications, blood and blood components administered, and notes of any unusual events or complications shall be made as appropriate.

TISSUE REMOVED DURING PROCEDURE

Where the physician removing a specimen during an operation or biopsy determines that a pathological evaluation is necessary, the specimen will be properly labeled and sent to the Hospital Pathology Department. The tissue may be, at the discretion of the Department Director of Pathology, analyzed by either an internal Hospital resource or an external reading panel of pathologists to conclude such examination as is necessary to arrive at a pathological diagnosis. In each case, the authenticated pathology report shall then be made a part of the patient’s medical record. The Pathology Department may exempt certain tissues from submission for pathological evaluation. Examples of tissues which are typically exempted from pathological evaluation include lenses, gallstones, various other calculi, prosthesis or implants, foreign bodies, the eye, portions of splenic tissue taken from a patient in the renal dialysis transplant program, and any donor organ. Where a specimen is transferred, it shall be properly labeled and sent along with a request for a copy of the pathology report from the outside facility. The request and pathological reports shall be included in the patient’s medical record.

PATHOLOGY CONSULTATION

If an Attending Physician desires a consultation with another pathologist, after a proper release form is received to permit the consultation, the pathologist shall send the appropriate tissue and/or slides to the designated consultant.

SPECIMEN REMOVAL

Any member of the Medical Staff who removes one or more specimens or microscopic slides from the Pathology Department shall sign a log indicating which slides have been borrowed and that he or she accepts responsibility for the proper care and return of the slides to the Pathology Department.

ARTICLE 7

IMPAIRED PHYSICIANS

GENERAL POLICY AND PURPOSE

The objectives of this impaired physician policy are to preserve each patient’s right to competent medical care, and to promote prompt, effective, confidential evaluation, referral and treatment of a Physician Practitioner suffering an impairment. The Medical Staff will assist any Physician Practitioner who has a physical, emotional, or mental impairment that requires assistance, intervention, treatment or monitoring to regain an optimal level of functioning in order to assure quality patient care. The impaired Physician Practitioner is one who is unable to practice medicine with reasonable skill and safety to patients because of an impairment. For the purpose of this policy, an impairment shall mean any condition, which is, or may be adversely affecting patient care at the Hospital, including: physical or medical conditions, psychiatric disorders, emotional disorders, behavioral disorders, deterioration through the aging process or loss of motor or perceptive skill, or habitual or excessive use or abuse or drugs, including alcohol.

SELF-REFERRAL

Any Physician Practitioner having an indication that he or she may be suffering an impairment must make a confidential self-report to his or her Department Director.

IDENTIFICATION OF IMPAIRED PRACTITIONER

Any individual in the Hospital who has a reasonable suspicion, arising from personal observation or knowledge, that a Physician Practitioner is suffering an impairment is encouraged to give an oral or written report to their immediate superior, or to the Director of the Department in which the Physician Practitioner practices. The report should be factual and include a description of the incident(s) or behavior(s) that led to the belief that the Physician Practitioner might be impaired. The person receiving the report is responsible for gathering information regarding the suspect behavior, and/or relaying the information to the Department Director.

EVALUATION OF REPORT OF SUSPECTED IMPAIRMENT

The Department Director has the responsibility to evaluate a report of impairment in order to establish whether the allegation of such impairment has merit. This evaluation will be confidential and handled in a manner that focuses on protecting the interests of patient care. The evaluation shall not be treated as a disciplinary investigation. Where the Department Director deems it appropriate, based on the severity of the allegation, the Department Director may involve the President of the Medical Staff in such evaluation. The President of the Medical Staff may in turn, appoint a committee to perform such evaluation of the report of impairment. Committee participants may include, but shall in no way be limited to the inclusion of, a psychiatrist, a Physician Practitioner who is recovering from a drug or alcohol addiction, one or more members of the Department, and members of the Medical Executive Committee.

The Physician Practitioner will be advised of the report of suspected impairment, and shall be expected to participate and cooperate fully with all participants in the evaluation process. If the participants in the evaluation process determine that the report of suspected impairment is credible, the Physician Practitioner may be requested to participate in a neutral evaluation

of the suspected impairment by an independent professional having appropriate expertise and experience in treating individuals suffering from similar impairments as that suspected. The person(s) performing the evaluation shall, absent extraordinary circumstances, make a recommendation within 60 days of receipt of the initial report of suspected impairment.

Based on a reasonable review of the facts and circumstances surrounding the report of suspected impairment, the participants in the evaluation process can make one or more of the following recommendations:

1. No evidence of an impairment is indicated;
2. No diagnostic, therapeutic, or rehabilitative program is indicated;
3. To monitor the Physician Practitioner’s activities and patient care until a determination with respect to the existence of an impairment can accurately be made. Diagnostic reports may be required at specified interval(s);
4. Advise the Physician Practitioner to initiate a voluntary diagnostic, therapeutic program, and/or rehabilitative program, such as the Ohio Physician Health Program. This recommendation will typically also include a requirement that periodic reports about the status, treatment, and prognosis of the Physician Practitioner be provided by the facility or professional providing treatment; or
5. A request that the Physician Practitioner voluntarily withdraw from membership on the Medical Staff and/or to resign clinical privileges until satisfactory rehabilitative progress is demonstrated.

DETERMINATION OF APPROPRIATE CORRECTIVE ACTION

Any recommendation by the participants in the process of evaluating a report of suspected impairment that would result in the restriction, suspension, revocation or termination of membership on the Medical Staff or the exercise of clinical privileges must also be evaluated by the Medical Executive Committee. If the Medical Executive Committee supports such a recommendation, but the Physician Practitioner disputes the findings or recommendation, the due process outlined in Section III of these Bylaws, the Fair Hearing Plan, shall be implicated.

The Hospital shall have the right, but not the obligation, to seek the advice of legal counsel in any case involving a report of suspected impairment for the purpose of determining whether the Hospital has any obligation to make a report about the facts and circumstances giving rise to the allegation to law enforcement or other governmental agencies.

REINSTATEMENT

After a Physician Practitioner’s clinical privileges and/or Medical Staff membership have been restricted, suspended, revoked or terminated, the Hospital shall not reinstate the Physician Practitioner until it is established, to the satisfaction of the Medical Executive Committee, that the Physician Practitioner has successfully completed or participated in a rehabilitation program suitable to the nature of his or her impairment.

Effective: August 20, 2014

In the event that the Hospital determines restoration of privileges may be appropriate, the Hospital reserves the right to restore only a portion of the Physician Practitioner’s clinical privileges.

For a request for reinstatement to be evaluated, the Physician Practitioner must authorize the program director of the rehabilitation program to submit a letter to the Hospital setting forth:

1. Whether the Physician Practitioner is or has participated in the program;
2. Whether the Physician Practitioner is in compliance with all of the terms of the program;
3. Whether the Physician Practitioner attends program meetings regularly (if appropriate);
4. To what extent the Physician Practitioner’s behavior and conduct are monitored;
5. Whether, in the opinion of the rehabilitation program practitioners, the Physician Practitioner is rehabilitated;
6. Whether an after-care program has been recommended to the Physician Practitioner and, if so, a description of the after-care program; and
7. Whether, in the program director’s opinion, the Physician Practitioner is capable of resuming medical practice and providing continuous, competent care to patients.

Prior to making a decision to reinstate any Physician Practitioner who is found to be suffering from an impairment, the Hospital and the Medical Staff shall have the right to require that the Physician Practitioner provide other opinions by licensed professional as to the competency of the Physician Practitioner to resume practice at the Hospital. All such decisions shall be made based on a reasonable assessment of the facts and circumstances of the impairment, and shall be made keeping the best interests of the patients of the Hospital in mind. The Medical Staff or Hospital may, in the sole discretion of the Medical Executive Committee, identify one or more licensed professionals engaged to offer such opinions, or the Medical Executive Committee may authorize any physician or licensed professional participating in the Physician Practitioner’s rehabilitation process to offer an opinion. If a determination is made that the Physician Practitioner should be reinstated, any or all of the following may be required:

1. That the Physician Practitioner identify two other members of the Medical Staff primarily engaged in the same or substantially similar specialty, who are willing to assume responsibility for the care of the patients of the returning Physician Practitioner in the event that he or she is unable or unavailable to provide continuous care to them;
2. That the Physician Practitioner provide periodic reports from the licensed professional responsible for the ongoing care and treatment of the Physician Practitioner. Such report may be required for the period of time specified by the President of the Medical Staff;
3. The Department Director or a designee may be appointed to monitor the Physician Practitioner’s exercise of clinical privileges; and
4. The Physician Practitioner may be required to submit to random alcohol or drug screening tests (if appropriate to the impairment) at the request of the President of the Medical Staff.

CONFIDENTIALITY OF IMPAIRMENT EVALUATIONS

All records, files, correspondence and other information or documents relating to an evaluation of a Physician Practitioner for suspected impairment shall be privileged and confidential, and shall be available only to persons involved in the evaluative or progress monitoring processes. These records will not be included in a Physician Practitioner’s credentialing file unless it is deemed necessary to take action to suspend, modify, revoke or terminate the Physician Practitioner’s Medical Staff membership or clinical privileges. Persons making a good faith report of suspected impairment, participants in the evaluation or monitoring processes, and those involved in the development of a plan of action to address an impairment shall have the benefit of any and all immunity from suit available under State and Federal laws.

NON-COMPLIANCE BY PHYSICIAN PRACTITIONER FOUND TO BE IMPAIRED

If an impaired Physician Practitioner fails to comply with the requirements of any rehabilitative plan of action to address the impairment, the President of the Medical Staff may make a recommendation for corrective action up to and including termination of Medical Staff membership and clinical privileges.

ARTICLE 8

CONFIDENTIALITY

GENERAL

Each member of either the Medical Staff or the Allied Health Staff shall be expected to comply with applicable local, State and Federal law relating to patient confidentiality and the protection of protected health information. Medical records and patient-specific information, records of peer review activities, risk management materials including incident reports, Medical Staff and Allied Health Staff credentialing records and files, minutes of Medical Staff and Hospital meetings, and other confidential Medical Staff and Hospital records, data and information (collectively “Confidential Materials”) may not, without proper authorization, be used for purposes other than patient care, peer review, risk management, IRB approved research, education and other Medical Staff or Hospital functions. Confidential Materials may not be removed from the Hospital, duplicated, transmitted, or otherwise disclosed to parties outside the Hospital without proper authorization.

ACCESS

Only members of the Medical Staff, Allied Health Staff or other authorized Hospital personnel involved in the care of the patient or engaged in peer review, risk management, Medical Staff or Allied Health Staff credentialing, IRB approved research, educational pursuits, or other appropriately authorized activities shall have access to Confidential Materials.

MISUSE OF CONFIDENTIAL MATERIALS OR IMPROPER ACCESS

Sharing or misuse of passwords or access to any paper or electronic system containing patient or other Confidential Material is prohibited. If the Hospital becomes aware of a situation involving the sharing or misuse of passwords or access, the alteration, removal or improper use of Confidential Materials, all involved persons shall be immediately required to change the passwords and take all appropriate precautions to safeguard the Confidential Materials. If a member of the Medical Staff shall be involved in such incident, he or she may be subject to corrective action up to and including termination of clinical privileges and/or Medical Staff membership. Where a recommendation for corrective action could lead to the suspension or termination of clinical privileges and/or Medical Staff membership, the Physician Practitioner in question shall have the right to request a hearing pursuant to Section III of these Bylaws, which outlines the Fair Hearing Plan.

ARTICLE 9

GENERAL RULES REGARDING PRACTICE IN THE HOSPITAL

DEPARTMENT AND COMMITTEE RULES

Members of the Medical Staff and Allied Health Staff should refer to clinical Departmental policies and procedures for specific guidance pertaining to that Department or committee. The Medical Executive Committee shall review and act upon reports and policies periodically.

MEDICAL STAFF DUES

The Medical Executive Committee of the Medical Staff shall establish the amount and manner of disposition of the annual Medical Staff dues. Dues will be assessed to all members of the Medical Staff Active, Courtesy and Affiliate categories on an annual basis. Unless excused by the Medical Executive Committee for good cause, failure to render payment of Medical Staff dues as they become due and payable may result in summary suspension of the Medical Staff appointment and clinical privileges of the Physician Practitioner until the delinquency is remedied.

APPLICATION AND REAPPOINTMENT FEES

The Medical Executive Committee shall establish the amount and manner of disposition of application and reappointment fees for the initial appointment to the Medical Staff or Allied Health staff. The fee will be charged to practitioners applying for an Attending, Courtesy or Affiliate Medical Staff categories, or Licensed Advanced Practitioner category of the Allied Health staff. A statement of the application fee will accompany the application and payment must be returned with the completed application.

MALPRACTICE INSURANCE COVERAGE

Each member of the Attending, Courtesy and Affiliate Medical Staff must maintain malpractice insurance coverage with minimum limits of one million dollars per claim and three million dollars aggregate. Any private malpractice liability insurance company must be rated A- or higher by A.M. Best unless the insurance coverage has been approved in advance by the Department of Risk Management.

RESEARCH CONDUCTED ON HUMAN SUBJECTS

All proposals for research involving human subjects, whether sponsored or non-sponsored, shall be conducted in a manner that minimizes risks to the welfare, health and safety of the study participants. Patients’ rights, including the right of privacy, shall be preserved, and an informed consent form shall be obtained from the patient, or his or her authorized representative, prior to such participation. The Institutional Review Board of the University of Cincinnati (“Review Board”) shall oversee all research on human subjects conducted at the Hospital by any member of: the Medical Staff, nursing staff, Allied Health Staff, or Hospital administration. The Review Board shall evaluate, make recommendations, approve, monitor, maintain records, and report on the requested or actual use, if approved, of investigational new drugs, medical devices and treatment protocols to be administered to patients of the Hospital. Review Board activities shall be governed under the Multiple Project Assurance of Compliance with the Department of Health and Human Services regulations for the protection of human subjects of research.

The Hospital may not approve research covered under this policy if it has not been approved by the Review Board, however, the hospital administration may decline to conduct research previously approved by the Review Board. Investigators may not begin research involving human subjects until the Review Board has approved the study or has determined that it is exempt.

>POLICIES AND PROCEDURES

All physicians will comply with all Hospital policies applicable to physicians. This shall include, but not be limited to, policies regarding harassment and disruptive conduct of medical staff members.

Adoption
Adopted: Medical Executive Committee – March 11, 2009
Adopted: Medical Staff – March 11, 2009
Adopted: Board of Trustees – May 12, 2009

First Revision
Revised: Medical Executive Committee – February 15, 2011
Amended: Medical Staff – April 2, 2011
Adopted: Board of Trustees – April 27, 2011

Second Revision
Revised: Medical Executive Committee – September 20, 2011
Amended: Medical Staff – December 6, 2011
Adopted: Board of Trustees – February 29, 2012

Third Revision
Revised: Medical Executive Committee – April 17, 2012
Approved: Medical Staff – June 19, 2012
Adopted: Board of Trustees – September 26, 2012

Fourth Revision
Revised: Medical Executive Committee – August 21, 2012
Approved: Medical Staff – October 13, 2012
Adopted: Board of Trustees – November 28, 2012

Fifth Revision
Revised: Medical Executive Committee – May 20, 2014
Approved: Medical Staff – August 8, 2014
Adopted: Board of Directors – August 20, 2014