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| Rules
and Regulations for Medical Staff Members |
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- Medical Staff Members shall:
1.1 Provide care and treatment to patients regardless of race,
religion, sexual orientation, gender identification and/or
expression, disability or ability to pay, and seek to assist all
patients in obtaining appropriate services.
1.2 Adhere to appropriate quality standards currently in effect.
1.3 Adhere to (comply with) all medical staff policies and procedures,
bylaws, rules and regulations prescribed/modified
from time to time.
1.4 Adhere to and participate actively in QA and Peer Review activities
and guidelines.
1.5 Provide the highest quality care possible to all patients
in a compassionate and collaborative manner.
1.6 Provide effective educational opportunities to all patients
and their families and health care trainees.
1.7 Create a respectful environment for patients and their families,
health care trainees, colleagues and peers.
1.8 Recognize and incorporate in their professional (clinical,
educational and research) activities the values of Sri Ramachandra
Medical Center (SRMC).
- SRMC has an active teaching program. All patients will be assigned
to teaching clinical departments and will be seen by the assigned
House Staff and Medical Staff members. In the rare instance where
a patient's physical condition would not be benefited by the scheduled
departmental training program, the HOCS may delegate the responsibility
to a Medical Staff physician.
- Except in emergency, no patient shall be admitted to SRMC until
after a provisional diagnosis has been stated and recorded on
the admission record and the consent of the proper service obtained.
In case of emergency, the provisional diagnosis shall be stated
by the attending physician or dentist as soon after admission
as possible
- For every patient admitted, the responsible physician or dentist
must be a member of the Active, or Visiting staff and his/her
name shall be listed on the medical record. The responsible physician
or dentist must be readily available when contacted for issues
related to the care of their patients.
- Physicians or dentists admitting patients to the Hospital shall
be held responsible for giving such information as may be necessary
to insure protection of other patients from those who are a source
of danger from any cause whatever. All patients shall be attended
by members of the Active or Visiting Medical Staff and shall be
assigned to the service concerned with treatment of the condition
or disease, which necessitated admission.
- Each member of the Medical Staff, when absent from the city
or unavailable, shall name a member of the Medical Staff of appropriate
seniority who may be called to attend his/her patients in emergency.
The responsible physician or dentist shall, in these instances,
be expected to indicate the name of his/her replacement in a conspicuous
place in the medical record. In case of failure to name such an
associate, the HOCS shall have authority to call another member
of the staff, should he/she consider it necessary. It is also
the responsibility of the medical staff member to intimate in
writing, the HOCS and the medical director about the period of
absence and details of coverage.
- Every member of the Medical Staff shall make every effort to
secure autopsies whenever possible. Autopsies shall be performed
only when properly authorized. All autopsies shall be performed
by a pathologist or the Medical Staff or by a physician to whom
he/she may delegate the duty. When an autopsy is performed, provisional
anatomic diagnoses are recorded in the medical record within 3
days, and the complete protocol is included in the record within
60 days, unless the medical staff establishes exceptions for special
studies.
- Members of the Medical Staff shall participate in internal or
external disaster situations or drills as specified by the Hospital
Disaster Preparedness Committee in its manual.
- A medical screening examination is performed on all patients
who present to emergency care facilities of SRMC and request medical
care. The purpose of the medical screening examination is to determine
if the patient has an emergency medical condition, which requires
stabilization and immediate treatment. No information about capacity
to pay, insurance status etc. shall be asked of a patient or their
family prior to performance of the medical screening examination.
The medical screening examination will include information about
the chief complaint, the patient's vital signs, mental status
assessment, general appearance, and a focused physical examination
related to the patient's complaint.
- Patients may be treated by qualified appointees to the Medical
Staff, other qualified and authorized practitioners or by House
Staff (under supervision). Members of the Medical Staff are responsible
for the medical care of all patients. Medical students may be
assigned to the care of patients and are under the supervision
of the attending medical staff members. Processes for supervision
of House Staff will be determined by the clinical services and
approved by the Chairperson PG curriculum and Dean of Faculties.
- Discharge summaries are to be dictated or written prior to discharge.
- Patients will be discharged only on written order of the assigned
House Staff physician or attending physician.
- The physician or dentist in charge shall be responsible for
over-seeing the preparation of a complete medical record for each
patient. This record shall include identification data, chief
complaint, present illness, review of system, past history, family
history, physical examination, and admission note by the attending
physician or dentist, special reports, such as consultations,
clinical laboratory reports, x-ray and others, provisional diagnosis,
medical or surgical treatment, tissue reports, progress notes
everyday by the attending physician or dentist or designated person,
final diagnosis, condition on discharge, follow-up and autopsy
reports when available. At time of completion, each medical record
shall be signed by the attending physician or dentist at the places
specified by the Medical Record Committee
- An appropriate medical record shall be kept on every patient
receiving emergency service and be incorporated in the patient's
hospital record, if such exists. Records shall include:
a. Adequate patient identification, or the reason why not obtainable.
b. The time and means of arrival.
c. Pertinent history of the illness or injury, including details
relative to the first aid or emergency care given to the patient
prior to his/her arrival at the hospital.
d. Diagnostic and therapeutic orders.
e. Reports of procedures, tests, and results.
f. Clinical observations.
g. Condition of patient on discharge or transfer.
h. Final disposition, including instructions given to the patient
and/or his/her family relative to necessary follow up care.
A patient who leaves against medical advice shall be documented.
Each patient's medical record shall be authenticated by the practitioner
who is responsible for its clinical accuracy.
- The medical record is a significant tool for use by the medical
practitioner in the rendering of care to patients. Therefore:
15.1. The medical record must be complete and legible
15.2. Documentation of each patient encounter should include:
Reason for the encounter and relevant history, physician examination
findings and prior diagnostic test results; Assessment, clinical
impression or diagnosis; Plan for care; and, Date and legible
identity of the observer
Past and present diagnosis must be accessible to the treating
and/or consulting physician Appropriate health risk factors must
be identified
The patient’s progress, response to and changes in treatment,
and revision of diagnosis must be documented
The ICD-10 code reported on the health insurance claim form or
billing statement must be supported by the documentation in the
medical record.
The medical record must be complete and legible and readily available
to all such practitioners who may have occasion to encounter the
patient on either a scheduled or a non-scheduled (e.g., Emergency
Room) basis. Further more, completion of medical record documentation
requirements is a medico-legal as well as a patient care responsibility
of the physician or dentist. The determination of what constitutes
completeness is based on criteria established by medical records
committee.
In addition to Medical Staff Executive Committee approved guidelines
for record documentation at admission, for operative procedures
and following discharge, no record shall remain incomplete, including
signatures, greater than fourteen (14) calendar days from discharge.
- All orders for treatment of patients shall be in writing and
signed by the physician or dentist in the order sheet. Verbal
/ telephone orders may be given only by a physician.
16.1 When telephone or verbal orders must be used, they may be
accepted by registered nurses ONLY
16.2 Verbal/telephone orders may not be given for:
Cytotoxic
chemotherapeutic agents
Narcotics
and anesthetics
Biological
response modifiers
Do Not Resuscitate
orders
Investigational
drugs
16.3 Verbal/telephone orders must be read back to the physician.
At the completion of this step the physician becomes
responsible for the order, which is to be treated as any
other physician order and carried out by the appropriate
hospital personnel.
16.4 All telephone and verbal orders must be signed and dated
by the physician within 48 hours.
16.5 In the absence of the ordering physician, the inpatient attending
physician or another physician on the same service
can sign the order. In the absence of the above, the appropriate
HOCS may authenticate the order.
16.6 No practitioner will be asked to sign an order he/she feels
is inappropriate. If there is a difference of opinion and
the ordering physician is unavailable, the order will be
referred to the appropriate HOCS for final resolution.
16.7 Physicians who fail to authenticate a verbal order are in
non-compliance with the Rules and Regulation of the Medical
Staff and may be subject to corrective action.
- A dictated narrative summary is required on all discharges
in the format prescribed and approved by the medical records committee
- Symbols and abbreviations may not be used on the face sheet.
In other areas only approved symbols and abbreviations may be
used. A list of approved and prohibited abbreviations and symbols
shall be available in patient care areas.
Medical records are not defined as complete until such time as
all elements are addressed, and a signed narrative is entered
to the chart. Any medical record not complete (as defined above)
within fourteen (14) days of discharge of the patient is defined
as a delinquent record. No delinquent medical record will be filed
as complete until all elements of the record are addressed, except
by order of the Medical Records Committee.
- When House Staff and/or attending medical practitioners are
no longer on staff or are unavailable and have failed to complete
all outstanding records prior to their departure, the HOCS is
responsible for completion of these records. Such records must
be completed within a period of fourteen (14) days from the date
assigned by the Medical Records Officer.
- A complete history and physical examination will, in all cases,
be completed within twenty-four (24) hours after admission of
a patient, and authenticated by the attending medical practitioner
as soon as reasonably possible.
20.1 History and appropriate physical examination is also required
on all patients who have ambulatory surgery and
all patients assigned to observation
20.2. When such history and physical examination are not recorded
before the time stated for operation, the operation
will be canceled unless the attending surgeon states, and
subsequently confirms in writing, that such
delay will constitute a life-threatening hazard to the patient.
- Medical Records are the property of Medical Center and its component
facilities and may not be removed from the Medical Center without
a court order, or as required by statute. In the case of readmission
of a patient, or outpatient treatment of the patient, the patient's
record will be made available for the use of the assigned Medical
Staff, House Staff, or other medical provider. Records that have
been removed from the Medical Record Department must be made available
at all times by the requisitioner and the requisitioner is held
responsible for the record until it is returned to the Medical
Record Department or change of location notification is received.
Records shall not be removed from a clinical area without proper
notification to the Medical Records Department. Records will be
returned to the Medical Record Department each evening so they
can be retrieved for patient care if necessary. Physicians who
fail to comply with the above or who are found in possession of
a medical record not signed out to them will be referred to the
Medical Director for violation of rules.
- To the extent permitted by laws and regulations regarding confidentiality
of patient information and informed consent of patients, all Medical
Staff members in good standing will have free access to SRMC patients’
medical records for bona fide study, education and research. All
such study or research will be undertaken only in compliance with
policies of the Institutional Research and Ethics committee and
applicable national and international laws regarding protection
of human subjects.
- A surgical operation will be performed only with the informed
and written consent of the patient or his/her legal representative,
except in emergencies. The informed consent will be administered
by the operating surgeon ONLY.
All operations or procedures will be fully described by the operating
surgeon, with an operative note dictated or written immediately
after surgery for prompt placement in the Medical Record. The
attending surgeon is responsible for completing the operative
report.
It is the responsibility of the physician or dentist in charge
of the patient to see that all tissues and foreign objects removed
at operation shall be properly sent to the head of the surgical
pathology service or his/her designee, who shall make such examination
as he/she may be considered necessary to arrive at a diagnosis.
Specific exceptions to this requirement are listed in appendix
II
All tissue that is submitted to pathology shall be accompanied
by properly executed request slips. When a specimen is to be used
for both diagnosis and research, a pathologist shall examine the
complete specimen before tissue is removed for research purposes.
When a therapeutic procedure requiring informed consent is planned
based on a pathologic diagnosis rendered at another institution,
the pertinent pathology reports and slides shall be reviewed by
the Head of the surgical pathology service or his/her designee,
whenever possible. Medical devices associated with complications
and specimens with forensic implications, such as projectiles,
shall be properly described in surgical pathology, cataloged and
retained.
- Consultations
24.1 Consultation is indicated for:
(a) Cases
in which, according to the judgment of the attending physician:
(1)
The patient is a poor risk for major surgery or other major diagnostic
or therapeutic procedures or
(2)
the diagnosis is obscure, or
(3)
there is doubt as to the best measure to be utilized.
(b) All
patients who have attempted suicide or have taken a chemical overdose,
the attending physician will request
psychiatric consultation and, when clinically indicated,
will offer psychiatric treatment.
24.2 Essentials of the Consultation
A satisfactory
consultation includes examination of the patient and the record.
A written opinion, signed by the consultant,
must be included in the medical record. When operative procedures
are involved, the consultation note,
except in an emergency, will be recorded prior to the operation.
A request
for consultation which is not answered, within a reason-able length
of time, by the staff member of whom
it is requested shall be called to the attention of the Medical
Director and the HOCS.
24.3 No fee splitting arrangement shall exist between the consultant
and the primary physician. The discovery of such
arrangement shall after due process be grounds for termination
- The Pharmacy and Therapeutic Committee will establish a formulary.
The Pharmacy will stock products which meet the standards of quality
of Drug controller of India (DCI) and the appropriate state regulatory
agency. Orders may be filled for, and nurses may administer drugs
by, proprietary formulary equivalents of the original order, unless
the Staff member indicates otherwise in the order.
- No medications or drugs or herbs, dietary supplements, or other
substances intended for use in the cure, mitigation, treatment,
or prevention of disease or other medical conditions will be used
in the medical Center other than those listed in the formulary,
except as approved by the Pharmacy and Therapeutics Committee
or as approved by the HOCS or as approved by the Institutional
Research and Ethics Committee (IREC)
- Investigational Drugs
27.1 A Medical Staff member who desires to administer investigational
drugs or biologics or use investigational devices
for treatment of a medical center patient, whether for research
or otherwise, will do so only in compliance
with applicable institutional policies and applicable laws and
regulations of Institutional Research
and Ethics Committee. The Medical Staff member will comply with
all policies and obtain all approvals
required by the Institutional Research and Ethics Committee the
Pharmacy and Therapeutics Committee,
the DCI and any other applicable regulatory agencies. A consent
form, as approved by the IREC, signed
by the patient or authorized representative will be placed in
the patient’s medical record.
- All medications, including narcotics will be discontinued after
three (3) days unless renewed. A yellow flag attached to the patient's
chart prior to time of discontinuance, giving the physicians sufficient
time to rewrite the order if indicated.
- Unless otherwise ordered by the patient's attending physician,
medications brought to the Hospital by the patient will be taken
from the patient and his room while in the Hospital.
Prior to surgery or procedures (except in emergencies), oral surgeons
and dentists must record evidence of a thorough review of the
oral cavity to include a history documenting a detailed description
of the dental problem, oral examination and pre-operative diagnosis.
Operative reports should state technique(s), finding(s), the specific
number(s) of teeth and/or fragment(s).
- A patient admitted for dental care is a dual responsibility
involving the dentist and a physician member of the Medical Staff.
The physician shall be responsible for performing an admission
history and physical examination and an evaluation of the overall
medical risk. The dentist is responsible for that part of the
history and physical examination relating to dentistry. The physician
shall be responsible for the care of any medical problem that
may be present on admission or that may develop during the course
of the admission
- The physician providing consultative or general service to a
patient in the Emergency Room will be responsible for a medical
record that gives a brief history, the essential findings, diagnosis,
the treatment(s), the disposition of the patient, and the patient's
condition at the time of discharge or transfer to a ward.
Attending Emergency Department Physicians will be responsible
for the delivery of emergency medical care in the Emergency Department.
They will supervise resident Housestaff and students, ask for
consultation from and may order admission to any department within
the medical Center for which there are facilities, space and personnel
to provide care at the time.
In the event of a conflict whether an admission to particular
department is appropriate the following measures may be undertaken
31.1 During normal working hours - the matter may be resolved
in dialogue with the respective consultants failing which
the respective HOCS may decide in dialogue with each other. The
medical director or designee in his/ her
capacity as head of the institution may make a ruling in this
matter whether solicited or not
31.2 No department may refuse an admission after hours - in the
event of conflict they will admit the patient and care
for them until the following morning when the conflict can be
resolved as outlined in 31.1
Under no circumstance will a patient be admitted into the hospital
without being assigned to a service/ consultant which/who have
admission privileges
After admission of a patient to a receiving department, medical
responsibility for the patient is transferred from the Emergency
Department to the receiving department. The Emergency Department,
in conjunction with Nursing or other appropriate disciplines/departments,
will maintain written policies to govern the operation of the
Emergency Room.
- Delinquent Medical Records
32.1 Delinquent Medical Records:
32.1.1
Any medical record which is not complete as defined n these Medical
Staff Rules and Regulations
within
fourteen (14) days of the patient's discharge from the hospital
is defined as a
delinquent/incomplete medical
record.
32.1.2
All operative and procedural reports must be written or dictated,
immediately after surgery or the procedure, and
all narrative summaries must be dictated before the patient's
discharge from the hospital.
32.2 Delinquent Physician:
32.2.1
Any House staff or Medical Staff physician who has not completed
all available records during the past
14 days is delinquent. If any House staff or Medical Staff
physician has not completed all available
records during the past 14 days and the HOCS has not been
advised of any extenuating circumstances
that have precluded chart completion by the responsible physician
such as administrative,
sick, or annual leave, the delinquent physician may be placed
on temporary suspension
from training or patient care at the Medical Center until such
time as all available delinquent/incomplete
medical records are completed and verified by the Medical Records
Department.
- All notes written by the house staff must be cosigned by the
supervising physician.
- Operative Reports and Inpatient Medical Record Progress Notes
34.1 The Medical Staff policies on the dictation or writing of
operative notes (immediately after the surgical procedure)
will be strictly enforced and monitored by the Medical Records
Committee of the medical center.
34.2 For all inpatients at Medical Center, regardless of the severity
of their illness or length of stay:
34.2.1 Admitting
notes by attending physicians must be recorded on the medical
record within 24 hours of admission.
34.2.2
Admitting notes by house officers must be made within 4 hours
of admission. If there is no assigned
house officer, the attending physician must make the admitting
note.
Thereafter,
at medical center progress notes must be made daily.
34.2.3 All house staff notes will be in the SOAP format ONLY
34.2.4 All entries will be dated and timed with the persons name
printed under the signature
34.2.5 Only a black ball point pen may be used for writing notes
34.2.6 All laboratory reports must be initialed by physicians
34.2.7 All laboratory and imaging reports must be documented in
the progress note
34.2.8 More frequent notes by attending physicians and house officers
may be indicated by the patient's clinical condition.
34.2.9 Discharge notes must be made on all patients at the time
of discharge.
34.2.10 All patients undergoing surgical procedures will have
a pre- and post-operative note written in the progress notes by either the house officer or the attending surgeon.
- Each clinical service of the medical Center will establish
policies and procedures relative to special treatment procedures
such as: restraint, seclusion, suicide precautions, electro-convulsive
therapy, psychosurgery for behavioral disorders and behavior management/aversive
conditioning. Such policies and procedures should be in compliance
with appropriate standards and accepted medical standards of care.
These policies will be approved by the Executive Committee of
the Medical Staff and the Medical Director of the medical center
- Rules and Regulations may be amended, deleted, or added at any
regular meeting of the Medical Staff or a special meeting called
for that purpose and shall become effective if approved by two-thirds
vote of those voting, a quorum being present, and subject to approval
or veto of the CED.
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