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  • 1. Medical-Dental Staff Children’s Hospital of Wisconsin Rules and Regulations
  • 2. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin TABLE OF CONTENTS I. COMMUNICATION AND SERVICE STANDARDS 1 II. INPATIENT MANAGEMENT: ADMISSION, TREATMENT AND DISCHARGE 5 III. CARE OF PATIENTS UNDERGOING INVASIVE PROCEDURES 6 IV. CARE OF DENTAL, PODIATRY AND AUDIOLOGY PATIENTS 8 V. CONSULTATION AND TRANSFER OF SERVICE 9 VI. CARE OF OUTPATIENTS 11 VII. CARE OF EDTC PATIENTS 11 VIII. CARE OF PATIENTS RECEIVING TELEHEALTH SERVICES 11 IX. MEDICAL ORDERS 111 X. RESTRICTIONS ON TREATMENT OF SELF, FAMILY-MEMBERS AND CO-WORKERS 14 XI. PROCESS FOR DELINQUENT MEDICAL RECORDS 15 XII. PATIENT DEATH, TISSUE AND ORGAN DONATION, AND AUTOPSY 17 XIII. MEDICAL EDUCATION 17 XIV. CLINICAL RESEARCH AND PUBLICATION 18 XV. PHYSICIANS' MEMBERSHIP REQUIREMENTS 18 XVI. ACCEPTABLE ABBREVIATIONS 118 XVII. AMENDMENTS TO RULES AND REGULATIONS 19 XVIII. APPROVAL OF RULES AND REGULATIONS 19 R-i
  • 3. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin GENERAL OBLIGATIONS Upon accepting an appointment to practice at Children's Hospital of Wisconsin (CHW), Members of the Medical-Dental Staff agree to abide by the Bylaws, Rules and Regulations and hospital policies and procedures as well as any state and federal rules related to patient care and documentation. I. COMMUNICATION AND SERVICE STANDARDS A. Physician Roles 1. Any Medical-Dental Staff Member with privileges to admit, evaluate, treat and discharge patients independently may act as an attending physician. The Attending Physician has the primary responsibility of patient care for this patient encounter or admission. When there are co-attending physicians, the responsibility is shared equally. 2. A Consulting Physician provides input into the patient’s care. 3. The Primary Care Physician has the primary responsibility for the overall healthcare management of the patient, not just for a single visit, but for all episodes of care. 4. The Referring Physician is the physician who refers the patient to CHW for care. B. Inpatients 1. The attending physician is responsible for communicating with the patient and/or family regarding the evaluation, condition, prognosis and plan of care and plans for discharge or transfer to include reasons for discharge or transfer, and anticipated need for continued care, treatment and services. 2. The attending physician is responsible for communicating with all relevant patient care providers regarding the plan of care. 3. Adequate communication is a combination of verbal communication and medical record documentation. 4. The attending physician is expected to communicate with the primary care physician. At a minimum, this needs to occur at admission and discharge. Interim progress reports to the primary care physician are also expected to occur weekly and more often as determined by clinical circumstances. 5. The attending physician is responsible for assuring that there is communication with the referring physician. A discharge summary should be dictated and sent to the primary care and referring physician within 48 hours of discharge. 6. The attending physician is expected to communicate with physicians in training, consulting physicians and other physicians who are involved in the care of patients. C. Outpatients 1. The attending physician is expected to communicate with the primary care and referring physician in a timely manner. D. Medical-Dental Staff Code Of Professionalism This code describes the expectations that Medical-Dental Staff Members (“Member”) have of each other. The expectations described below reflect current Medical-Dental Staff Bylaws, Procedures, Rules & Regulations, organizational policies and relevant regulatory R-1 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 4. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin requirements. This code is designed to bring together the most important issues found in those documents along with some key concepts that reflect our medical staff’s culture and vision. Medical staff leaders will work to improve individual and aggregate Medical-Dental Staff performance through non-punitive approaches by providing appropriate feedback that allows each Member the opportunity to grow and develop in his or her capabilities to provide outstanding patient care and valuable contributions to our hospital and community. Fundamental Principles: Dedication to patient and family welfare (altruism) Respect for patient and family autonomy Promotion of social justice/fair distribution of medical resources Professional Responsibilities: Maintain professional competence/life-long learning Be honest with patients and families to establish trust Preserve patient and family confidentiality Maintain an appropriate physician-patient relationship Work for improvement in quality of care Work for improvement in access to care Work for improvement in safety of care Provide cost-effective health care Work for improvement in scientific knowledge Manage conflicts of interest appropriately Work collaboratively with colleagues and staff Maintain and enforce professional standards Technical Quality of Care: Provide appropriate patient care that consistently meets or exceeds generally accepted medical staff standards as defined by comparative data, the medical literature and the results of peer review activities. Achieve surgical and medical patient outcomes that consistently meet or exceed generally accepted medical staff standards as defined by comparative data, the medical literature and the results of peer review activities. Participate in continuing education related to delineated clinical privileges and medical license requirements. Provide for patient comfort including prompt and effective management of acute and chronic pain in coordination with other caregivers according to accepted guidelines in the medical literature. R-2 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 5. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin When appropriate, consider evidence-based guidelines, as approved by the Medical-Dental Staff, in selecting the most effective and appropriate approaches to diagnosis and treatment of patients. Patient Safety: Participate in the hospital’s efforts and policies to assure patient safety and reduce medical errors. Order medications, blood and blood products consistent with current medical guidelines. Maintain medical records documentation consistent with the Medical-Dental Staff Bylaws, Procedures, Rules & Regulations and Hospital policies and including but not limited to chart entry legibility and timely completion of History and Physical examination reports, Operative Reports, procedure notes, diagnostic interpretation reports and discharge summaries. When seeing or attending patients, wear your appropriate identification badge, and identify yourself to patients and families. Utilize “time out” review of patient identity prior to all procedures. Quality of Service: Ensure timely and continuous care of patients, 24 hours per day, seven days per week, by clear identification of covering physicians and by appropriate and timely answering service and electronic communications availability. For hospital-based inpatient and outpatient care, this means: Immediate response to all calls deemed emergent by the requesting caregiver Response within 24 hours to all other “non-emergent” calls Participate in emergency room coverage as determined by the departments and the Medical Executive Committee. When requesting inpatient consultation, make direct provider-to-provider contact providing a clear reason for consultation. Respond to requests for inpatient consultation within 24 hours of request. Provide non-emergent hospital-based outpatient consultation in a timely manner, with a goal of time-to-next-appointment availability of 2 weeks or less. Respond in a timely and appropriate manner to information regarding patient dissatisfaction with Medical Staff Member performance. Support the medical staff’s efforts to improve patient satisfaction rates for Members. Communicate effectively with patients and their families. Discuss end-of-life issues (including advance directives and patient and family support) when appropriate to a patient’s condition, and honor patient and family desires. R-3 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 6. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin Support the Hospital’s efforts to improve patient satisfaction for every patient’s experience. Resource Utilization: Strive to appropriately manage the use of valuable patient care resources according to current professional standards. Discharge or transfer patients to the medically appropriate level of care in a timely manner. Provide accurate timely discharge instructions in collaboration with other caregivers, with a goal of contacting subsequent caregivers electronically, by fax, or by phone within 24 hours of discharge. Peer and Co-Worker Relationships: At all times act in a professional, respectful manner toward patients and their families, other Medical-Dental Staff Members, nurses, administrators, board members and other Hospital personnel to enhance a spirit of cooperation and mutual respect and trust among members of the patient care team. Refrain from inappropriate behavior toward fellow Members of the Medical-Dental Staff, students and trainees, the Hospital staff, patients and their families, including but not limited to the following: Impulsive, disruptive, sexually harassing or disrespectful behavior Documentation in the medical record that does not relate to the clinical status of the patient and plan of care. Documentation or commentary that is derogatory or inflammatory concerning the care provided to the patient. Recognize that disagreements are inevitable and can contribute to improving care. When disagreements occur, address these in a constructive, respectful and direct manner away from patients and their families or other non-involved caregivers. Respect patient privacy by not discussing patient care information and issues in public settings. Citizenship: Practice medicine as a Member of the Medical-Dental Staff in a manner that maintains and advances the culture of collegiality and cooperation that is the hallmark of our medical staff and hospital. Utilize patient care satisfaction data provided by the Hospital to continuously improve care. When contacted regarding concerns about patient care, respond in the spirit of continuous improvement. Cooperate with the Hospital Patient Relations representative to respond to patient and family complaints. R-4 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 7. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin When provided information on Medical-Dental staff matters requesting your input, respond in a timely manner and accept decisions made by leadership. Make positive contributions to the Medical-Dental Staff and Hospital by participating actively in medical staff functions. In the spirit of early assistance, help to identify issues affecting the physical and mental health of fellow Medical Staff Members and cooperate with programs designed to provide assistance. II. INPATIENT MANAGEMENT: ADMISSION, TREATMENT AND DISCHARGE A. General Responsibilities 1. The attending physician is responsible for admitting the patient, managing the care, and discharging the patient. 2. A Medical-Dental Staff Member may choose to delegate all of part of the history and physical examination and/or update assessment and note to an appropriately privileged allied health professional, resident or medical student for completion. A Medical-Dental Staff Member must countersign the history and physical and, as applicable, update the note and assume full responsibility for the history and physical examination. 3. Documentation requirements are: a. A complete history and physical completed within 24 hours of admission, which includes: (1) Chief complaint, symptoms, duration (2) Family and social history (3) Home medications (4) Inventory of systems with positive and negative findings (5) Preliminary diagnoses b. A thorough assessment and treatment plan. c. Progress notes pertinent to the patient’s condition. d. A discharge summary. For patients with a length of stay under 48 hours, completion of the discharge communication form is acceptable. e. A discharge order. f. A discharge diagnosis. 4. Each physician is responsible for providing alternative coverage when said physician is not available. 5. Regardless of diagnosis, Medical-Dental Staff Members have an obligation to both patients and the institution to provide their expertise in the care of patients, unless valid reasons exist not to do so. B. Critically Ill Patients or Patients with a Significant Deterioration R-5 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 8. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin 1. Critically ill patients who are admitted to the PICU, or patients who are physiologically unstable on admission to the hospital or patients with significant deterioration in clinical status will be evaluated by the attending physician or Medical-Dental Staff designee or consultant as soon as possible, but not later than 4 hours after notification of admission or notification of change in condition. 2. Every critically ill, physiologically unstable infant who is admitted to the NICU should be evaluated by the attending physician or Medical-Dental Staff designee or consultant within 30 minutes of admission. C. General Medical and Surgical Patients 1. Newly admitted patients who are stable will be evaluated by the attending physician or designee within 24 hours of hospital admission. Ref: Patient Care Policies & Procedures: “Admission of a Patient to the Hospital” Ref: Scope of Service NICU and Scope of Service PICU Ref: Patient Care Policies & Procedures: “Transitional Planning – Discharge of Patient” Ref: Patient Care Policies & Procedures: “Transfers out of CHW, includes EDTC, all units and departments as per the Emergency Medical Treatment and Active Labor Act – EMTALA” Ref: Patient Care Policies & Procedures: “Verification of Correct Patient-Correct Procedure and Correct Operative-Procedure Site” III. CARE OF PATIENTS UNDERGOING INVASIVE PROCEDURES A. Consent to Surgery or Special Procedure 1. Physicians who perform procedures requiring informed consent are responsible for obtaining and documenting such consent. Ref: Patient Care Policies & Procedures: “Consent for Diagnosis and Treatment” Ref: Administration Policies & Procedures: “Research: The Process of Conducting Research on Human Subjects at CHW” B. Pre-operative and Pre-procedural Histories and Physicals 1. A history and physical examination must be completed prior to a surgical procedure. A history and physical examination, any indicated diagnostic tests, and pre-operative diagnosis should be recorded prior to surgery. In an emergency, when there is no time to complete a history and physical examination, a note of the pre-operative diagnosis and the reason for the emergency must be recorded prior to the procedure by the attending physician. C. The Surgeon is Responsible for: 1. Providing a history and physical examination to include a summary of clinically pertinent positive and negative findings justifying admission prior to the surgical procedure and the patient’s home medications. R-6 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 9. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin A history and physical examination which is performed within 30 days of the procedure may be utilized provided that a copy is filed into the medical record and is updated to reflect the patient’s status at time of admission/service. A statement confirming the patient’s status at the time of admission must be dated ,timed and signed by the attending physician If a history and physical examination is older than 30 days, a new history and physical examination must be performed and documented in the medical record prior to the procedure. History and physical examinations are acceptable from non-staff physicians, if countersigned by a privileged Member of the Medical-Dental Staff and, if all the above elements are met. A durable, legible copy of the history and physical examination is filed into the patient’s medical record and the attending physician must review the history and physical and findings as necessary, conduct an assessment to confirm the information and findings. By affixing a countersignature to this document the attending physician attests to the accuracy of that portion of the medical record. 2. Reviewing previous patient care records, applicable imaging studies, and the current patient chart. 3. Recording a preoperative diagnosis. 4. Marking the surgical site, consistent with Hospital policy. 5. Conducting and/or participating in a time-out prior to the surgical procedure, consistent with Hospital policy. 6. Performing the surgical procedure. 7. Writing a brief operative note that includes the name of the primary surgeon, any assistants, findings, procedures performed, a description of the procedure, estimated blood loss as indicated, specimens removed and postoperative diagnosis immediately following the procedure. 8. Providing a complete operative report which describes the findings and technique immediately following the procedure. This document must be signed by the surgeon. 9. Providing appropriate post-op care. 10. Recording progress notes pertinent to the patient’s condition and management of the patient. 11. Requesting consultations when appropriate. 12. Dictating and signing the discharge summary. D. The Anesthesiologist is Responsible for: 1. Conducting a pre-anesthesia assessment prior to anesthesia induction. 2. Discussing and documenting relevant anesthesia options and risks with the patient and/or family. 3. Developing and documenting the anesthesia plan. 4. Administering anesthesia and monitoring the physiological status during anesthesia. 5. Assessing the patient after the procedure and documenting the assessment in the medical record within 48 hours. R-7 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 10. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin 6. Assessing the patient before discharge from the post-anesthesia unit. 7. Assessing the short-stay patient before discharging the patient from the hospital. Ref: Patient Care Policies & Procedures: ”Medical Records” IV. CARE OF DENTAL, PODIATRY AND AUDIOLOGY PATIENTS A. A patient admitted for dental care may be admitted to the service of any Member of the Dental Staff. A co-attending physician Member should be involved in the ongoing medical care of inpatients. B. Dentists, Podiatrists and Audiologists are responsible for completing that part of their patient’s history and physical that relates to their portion of the procedure. The anesthesiologist involved with the case is responsible for conducting a pre-anesthesia assessment prior to the anesthesia induction. C. A history and physical examination which is performed within 30 days of the procedure may be utilized provided that a copy is filed into the medical record and is updated to reflect the patient’s status at time of admission/service. A statement confirming the patient’s status at the time of admission must be dated timed and signed by the Attending provider or Audiologist prior to the procedure. If a history and physical examination is older than 30 days, a new history and physical examination must be performed and documented in the medical record prior to the procedure. D. The Dentist is Responsible for: 1. Providing a dental history and physical examination to include a summary of clinically pertinent positive and negative findings justifying admission prior to the dental procedure. 2. Providing a description of the examination of the oral cavity. 3. Recording the pre-procedure or preoperative diagnosis. 4. Recording progress notes pertinent to the oral condition. 5. Requesting consultations when appropriate. 6. Performing the dental procedure. 7. Providing a signed procedure note or operative report which describes the findings and technique. In case of extraction of teeth, the dentist should state the number of teeth and fragments removed. 8. Providing a discharge summary. For patients with a length of stay under 48 hours, completion of the discharge communication form is acceptable. 9. Providing a discharge order. 10. Providing a discharge diagnosis. Ref: Scope of Service Operating Room Ref: Patient Care Policies & Procedures: ”Medical Records” R-8 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 11. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin V. CONSULTATION AND TRANSFER OF SERVICE A. Consultation: A medical/surgical consultation is a formalized deliberation between physicians regarding a particular patient’s care and/or the treatment of the patient. 1. A consultation must occur when:  There is a need for further evaluation or when patient care needs exceed expertise or clinical privileges of the attending physician.  A family or patient requests a consultation. 2. Expectations and Responsibilities of the Requesting Attending Physicians to the Consultant: The requesting attending physician or his or her designee should:  Discuss the purpose and need for the consult with the patient and family.  Follow the current process for ordering consuts (reference).  Communicate to the consultant: o The specific patient care issues that need to be addressed. o The urgency (routine, urgent, and emergent). o The level of involvement requested Opinion only Evaluate for procedure Treatment of condition Co-management Transfer of care o Whether diagnostic tests/treatments may be ordered or scheduled by the consultant service. o How and whom to contact to discuss findings and consultant recommendations. 3. Expectations and Responsibilities of the Consultant The consultant or his or her designee should:  Acknowledge receipt of the consult request.  Confirm the level of service requested and the urgency of the consult o Emergent consults are for immediate threat to life or limb. A response either in person or by telephone is expected within 15 minutes of receiving the initial page. o Urgent consults are for those issues not seen as an immediate threat to life or limb. A response by telephone is expected within 30 minutes of receiving the initial page. R-9 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 12. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin o Routine consults are those issues that do not meet either an emergent or urgent status. A response by telephone is expected within 30 minutes of receiving the initial page.  Communicate to the requesting attending Physician or his or her designee any specific requirements or prerequisites (e.g. NPO status, diagnostic evaluations).  Perform the consult within the established timeframe (reference) o Emergent consults should be done as expeditiously as possible given the specific patient care needs. o Urgent consults should be done within 4 hours of receiving the initial page request. o Routine consults should be done within 24 hours of receiving the initial page request unless other arrangements are made between the requesting attending physician or his or her designee and the consultant.  Verbally communicate with the requesting attending physician or his or her designee the initial findings or recommendations.  Document in the patient’s chart initial findings and recommendations.  Provide a full written/dictated consult in the patient record within 24 hours of evaluation of the patient.  Communicate the information to the patient or family only after discussing with the requesting attending physician or his or her designee.  Specify which service will be responsible for follow-up on pending tests during the hospital stay and after discharge.  Arrange for ongoing follow up after discharge when indicated or formally document a sign off of the consultant’s involvement in the patient’s ongoing care. 4. A satisfactory consultation includes, at a minimum, a review of the record, examination of the patient and a written opinion. 5. The consultation should be dictated whenever possible. B. Responsibilities of the Attending Physician to the Consultant 1. The attending physician is responsible for adequately communicating the reason for consultation. A consultation may be requested for any of the following: a. Opinion only. b. Treatment of a stated condition. c. Referral for consideration of a procedure. C. On-Call Physician Response 1. When needed for patient care, on-call physicians must respond within 30 minutes of the request. D. Following the consultation: 1. The consultant is expected to communicate findings to the attending physician in a timely manner, appropriate to the patient’s condition. Direct physician to physician R-10 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 13. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin communication is preferable when more immediate work-up or treatment modifications are being recommended. 2. It is the responsibility of the attending physician to decide which of the consultant’s recommendations should be incorporated into the plan of care. E. Transfer of Service 1. A transfer of service occurs only after there is agreement by the accepting physician to assume care. Ref: Administrative Policies & Procedures: “On-Call Schedules for Specialty Consultations” VI. CARE OF OUTPATIENTS A. The attending physician is responsible for providing care. Documentation must occur at the time of service. At a minimum, a short note summarizing the visit must be written in the record. B. The complete clinical note containing pertinent elements of history, physical, and diagnostic studies, home medications, and an evaluation and management plan must be written or dictated within 24 hours of service. C. For those patients receiving ongoing ambulatory services (3 or more visits), there is a review and update of significant diagnoses, procedures, drug allergies, medications and immunizations at each encounter. Ref: Patient Care Policies and Procedures: “Documentation: Patient Care” VII. CARE OF EDTC PATIENTS A. A physician referring a patient to the EDTC should inform the EDTC of the impending arrival, treatment expectations, including choice of consultant when needed, and care which was provided prior to referring the patient to the EDTC. B. EDTC physicians are expected to call the referring physician within the parameters delineated by the referring physician. C. If the EDTC physician deems a consultation necessary, patient’s condition permitting, the referring physician must be contacted to discuss the choice of consultant. D. Documentation must occur at the time of service. At a minimum, a brief note summarizing the visit, or dictation number, must be written in the record. The complete clinical note containing pertinent elements of history, physical and diagnostic studies and an evaluation and management plan must be written or dictated within 24 hours of service. Ref: EDTC only--Patient Care Policies and Procedures: “Private Physician, Notification of” Ref: Scope of Service EDTC VIII. CARE OF PATIENTS RECEIVING TELEHEALTH SERVICES R-11 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 14. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin A. “Telehealth Services” involve the use of medical information exchanges from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care, treatment and services. For purposes of the Hospital, Telehealth Services does not include traditional consulting services provided via the telephone. B. Any Telehealth Services provided at the Hospital must be provided through an established program with written standards of care that have been reviewed and recommended by the Joint Patient Care Committee and the Medical Executive Committee. C. Members of the Medical-Dental Staff providing Telehealth Services must comply with applicable law and regulation, including appropriate licensure to practice medicine in Wisconsin and as required by the law or policy of the state in which the patient is located. D. Members of the Medical-Dental Staff may provide Telehealth Services as an attending physician or consulting physician. The provider of Telehealth Services is responsible for the care provided. Documentation must occur at the time of service. At a minimum, a short note summarizing the care provided must be written in the record. E. The complete clinical note containing pertinent elements of history, physical, and diagnostic studies and an evaluation and management plan must be written or dictated within 24-hours of service. F. The quality of Telehealth Services will be reviewed as part of the regular privileging and credentialing process for any Member of the Medical-Dental Staff who provides Telehealth Services. IX. MEDICAL ORDERS A. General Rules 1. When possible, medical orders should be entered into the clinical information system by the ordering physician or their designee(s) as per Hospital policy. 2. There are no standing orders that apply universally to all patients admitted to the hospital. 3. A facsimile transmitted order with signature is acceptable as a written order. 4. All medical orders must be reviewed (and/or modified when necessary) prior to being authenticated by the ordering physician or his/her designee(s). All orders are required to be authenticated by the ordering physician or his/her designee(s) with the exception of those orders which are done under a delegated medical protocol. B. Inpatient Orders 1. All inpatient orders will be documented according to Hospital policy. 2. Medical orders must be reviewed and modified as necessary, when a patient is transferred from one unit or service to another. C. Outpatient Orders 1. Medical orders for outpatient diagnostic studies may only be ordered by a licensed physician, dentist, podiatrist or their designee as per Hospital policy, and must include clinical indications for the studies R-12 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 15. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin 2. Authorized scheduling or registration personnel may accept telephone orders for outpatient diagnostic studies. This telephone order must be followed with a written or facsimile order. D. Peri-operative Orders 1. The following applies to all situations where a patient receives anesthesia: a. The surgeon or designee is responsible for reviewing and modifying all pre- operative orders prior to entering post-operative orders. b. Post-operative orders must be entered immediately following the procedure. E. Restraint Orders 1. Guidelines for patient restraint are outlined in Patient Care Policies & Procedures: “Restraints” F. Medication Orders 1. All medication orders must be written in accordance with Patient Care Policies & Procedures: “Medical Orders”. 2. Medications which are ordered for inpatient use must be from the hospital formulary except in unusual situations. A non-formulary drug may be requested by contacting the hospital pharmacist. 3. Certain medications are restricted. These must be ordered by the knowledgeable specialist. This information is available from the hospital pharmacy. G. Investigational Drugs 1. Drugs for investigational or experimental purposes may be used only with permission of the Research and Publications Committee/Human Rights Review Board. H. Medical Student Orders 1. Medical orders entered by a Medical Student must be “verified” by the attending physician or designee before being implemented. I. Verbal Orders 1. Verbal orders are orders for medications, treatments, interventions or other patient care that are communicated as oral, spoken communications between those giving and those receiving the orders face to face or by telephone. 42 CFR 482,23 (C)(2) 2. Verbal orders are acceptable in emergency situations or when the ordering physician is performing a procedure, except in situations in which verbal orders are restricted by hospital policy (e.g. Digitalis orders). 3. Verbal orders may be accepted by a registered nurse or physician assistant. 4. The following health care workers may accept and implement verbal orders for care or services within the scope of their practice: pharmacist, respiratory care practitioner, physical/occupational therapist, registered dietitian, social worker, speech pathologist, laboratory technologists and radiologic technologists. J. Telephone Orders 1. Telephone orders are acceptable when a physician is off site, not in the patient care setting, or when a computer is not immediately available for online order entry, R-13 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 16. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin except in situations in which verbal orders are restricted by hospital policy (e.g. Digitalis orders). 2. Telephone orders may be accepted by a registered nurse or physician assistant. 3. The following health care workers may accept and implement telephone orders for care or services within the scope of their practice: pharmacist, respiratory care practitioner, physical/occupational therapist, registered dietitian, social worker, speech pathologist, laboratory technologists and radiologic technologists. K. Recording and Authenticating Verbal or Telephone Orders 1. A verbal of telephone order for medication should be legible and contain the name of the patient, date and time of the order, drug name, dose, frequency and route, and the name of the prescriber. 2. After giving a verbal or telephone order, the physician must provide time for the person accepting the order to write the order and to read it back to verify accuracy. 3. All verbal and telephone orders shall be authenticated by the prescribing Member of the Medical-Dental staff within 48 hours of receipt. Authentication includes the date, time and signature. 42 CFR 482.23(c)(2)(ii) and HFS 124.12(5)(b)(11). L. Order Sets 1. Physicians are encouraged to use order sets to expedite order entry in the clinical information system. 2. Types of Order Sets: Order sets may be created by individual physicians or groups of physicians. Such physicians will have responsibility for developing and maintaining the order sets in collaboration with the Information Services Department according to hospital policy. M. Delegated Medical Orders 1. An order is required to initiate a delegated medical order or protocol by the provider who is authorized to write orders per hospital policy and who is responsible for the care of the patient. 2. Delegated medical orders are medical interventions (orders) that are: a. Ordered and/or carried out by a physician assistant or registered nurse, or in some situations, another health care professional; b. Outlined in protocols, order sets or clinical guidelines that are approved by the supervising physician. N. Physician Signature for Delegated Medical Orders 1. An order initiating the use of a delegated medical order or protocol must be legible, in writing and authenticated by the prescribing Member of the Medical-Dental staff within 48 hours of receipt. Authentication includes the date, time and signature. 2. If a medical order is entered by a physician’s assistant or advanced practice nurse and is under protocol, order set or clinical guideline that is agreed upon with the supervising physician, it does not require co-signature by the supervising physician. 3. If a medical order is entered by a physician’s assistant or advanced practice nurse and is not outlined in a protocol, order set or clinical guideline, the supervising physician is responsible for signing the order. R-14 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 17. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin O. Refusal to Sign/Authenticate an Order 1. In the circumstances that a listed physician or their designee(s) refuses to authenticate an order, the physician or their designee shall reject the order and select the reason for the rejection in the Computerized Physician Order Entry information system. Medical Records personnel will then review the rejected order and determine the reassignment of that order. In cases where there is a dispute of who the ordering physician should be, it will be assigned to the attending physician of record for the day the order was written. Ref: Patient Care Policies & Procedures: “Medical Orders” Ref: Scope of Service Operating Room Ref: Patient Care Policies & Procedures: “Collaborative Practice” Ref: Administrative Policies & Procedures: “Research: The Process of Conducting Research on Human Subjects at CHW” Ref: Patient Care Policies & Procedures: “Medication: Administration” Ref: WI Statutes 448.Med 8.08 Ref: WI Statutes 441.16(2) X. RESTRICTIONS ON TREATMENT OF SELF, FAMILY-MEMBERS AND CO-WORKERS A. Except in an emergency situation, Medical-Dental Staff Members, AHP’s and OHP’s at Children’s Hospital of Wisconsin may not: 1. Perform surgical or diagnostic procedures requiring general anesthesia, moderate sedation or deep sedation on a current or former spouse, a child or step child, or a grandchild or step grandchild at the Hospital or at a Hospital clinic, except when standard registration and documentation procedures have been followed and a customary physician-patient relationship is established. 2. Write prescriptions for controlled substances to be filled or administered at the Hospital for themselves, a current or former spouse, a child or step child, or a grandchild or step grandchild, and may only write such prescriptions for a co-worker or Hospital employee when standard registration and documentation procedures have been followed and a customary physician-patient relationship has been established. 3. Diagnose or treat a co-worker, a Hospital employee, or a co-worker or employee family member at the Hospital, except when standard registration and documentation procedures have been followed and a customary physician-patient relationship is established. 4. Request diagnosis or treatment from a co-worker or Hospital employee, except when standard registration and documentation procedures have been followed and a customary physician-patient relationship is established. R-15 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 18. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin B. These restrictions have been established in an effort to reduce risk to CHHS, the Medical-Dental Staff and Hospital employees. Non-compliance may result in corrective action up to and including termination of Medical-Dental Staff, AHP or OHP privileges. XI. PROCESS FOR DELINQUENT MEDICAL RECORDS A. Suspension Process for Delinquent Inpatient, Short Stay and EDTC Records 1. An incomplete medical record is considered delinquent thirty (30) days post discharge or date of service. 2. Staff Members who fail to complete a medical record by forty (40) days post discharge, date of service or when appropriately assigned by Medical Records will have admitting, consulting, surgery, anesthesia and EDTC privileges suspended. Adjustments will be made for physicians who notify the Medical Records Department of a leave of absence or vacation. 3. If the medical record remains incomplete by ninety (90) days, a certified letter will be sent to the suspended Staff Member notifying them that if medical records are not completed within seventy-two (72) hours of receipt of the notice their Medical-Dental Staff Membership privileges will be terminated and treated as a resignation, pending Medical Executive Committee review. A copy of this letter shall also be sent to the appropriate Medical or Surgical Section Chief and/or Medical/Program Director. B. Suspension Process for Undictated Operative Reports 1. Operative reports must be completed immediately after the operative procedure, prior to the patient’s transfer to the next level of care. Requirements include the completion by the surgeon or his/her designee(s) of both the brief post-operative note and a dictation of the procedure describing techniques, findings and tissues removed or altered. 42 CFR 482.51. 2. If, after notice to the surgeon, an operative report remains incomplete for more than ten (10) days post procedure, the surgeon responsible for the procedure will have admitting, consulting, surgery and anesthesia privileges suspended. Adjustments will be made for physicians who notify the Medical Records Department of a leave of absence or vacation. 3. If the operative report remains incomplete by thirty (30) days, a certified letter will be sent to the suspended staff Member notifying them that if the records are not completed within seventy-two (72) hours of receipt of the notice their Medical-Dental Staff Membership privileges will be terminated and treated as a resignation, pending Medical Executive Committee review. A copy of this letter will also be sent to the appropriate Surgical Section Chief and/or Medical/Program Director. C. The Chiefs of the Departments of Medicine and Surgery shall ensure compliance with this policy. Ref: Patient Care Policies & Procedures: “Medical Records” Ref: Summary of “Medical Record Completion Requirements” R-16 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 19. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin XII. PATIENT DEATH, TISSUE AND ORGAN DONATION, AND AUTOPSY A. Reporting of Deaths 1. All deaths which occur at Children’s Hospital of Wisconsin must be reported to the Medical Examiner. B. Documenting a Death 1. The physician pronouncing death will document the patient’s death in the medical record within two hours of the event and complete the “Report of Death” and “Notice of Removal of Human Corpse, Communicable Disease Alert” forms. C. Organ/Tissue Donations 1. The attending physician or designee is responsible for informing the family of their right to give an anatomical gift. 2. No organ or tissue donation shall be obtained without the written consent of the parent or the legal guardian. D. Autopsies 1. It is the responsibility of the attending physician or designee to request an autopsy and notify the pathologist if an autopsy is to be done. 2. No autopsy shall be performed without the written consent of the parent or the legal guardian. 3. For cases not under the jurisdiction of the Medical Examiner, the attending physician must request consent for an autopsy in deaths meeting the following criteria: a. Any death that occurs within 24 hours of admission. b. Any death that occurs within 24 hours of anesthesia and/or surgery. c. Any death in which the clinical diagnosis is unclear. d. Any death associated with trauma. e. Any unanticipated death which occurs in a patient who is under a research protocol. f. Any newborn death associated with significant congenital malformation. g. Unanticipated death. 4. The pathologist will notify the attending physician of the date and time of the autopsy. Ref: Patient Care Policies & Procedures: “Death - Care of the Dying Child” XIII. MEDICAL EDUCATION A. All patients/families will be available for teaching purposes unless otherwise requested by the attending physician. R-17 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 20. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin B. Medical-Dental Staff Members are Responsible for: 1. Teaching colleagues, residents and other health care professionals 2. Assuring that the patient and family’s well being will be taken into consideration. 3. Being available to residents and fellows in person or by telephone and able to be present within a reasonable period of time, appropriate to the patient care need C. Resident Physician (Fellow, Resident and Intern) Responsibilities 1. While assigned to Children's Hospital of Wisconsin, all residents and fellows are under the supervision of the teaching director of their respective programs. 2. While participating in patient care activities, residents and fellows are responsible to the patient's attending physician or appropriate consulting physician and are subject to the Rules and Regulations of the Medical-Dental Staff and policies and procedures of the Hospital. 3. Residents and Fellows are permitted to assume increasing levels of responsibility for patient care activities commensurate with their individual progress in experience, skill, knowledge, and judgment, as determined by their Program Directors. D. Responsibility for Medical Students 1. While assigned to Children's Hospital of Wisconsin, pediatric medical students of The Medical College of Wisconsin and other medical schools are responsible to the Chair of the Department of Pediatrics at The Medical College of Wisconsin. The Chair may delegate responsibility to the Director of Medical Education or specific attending physicians as indicated, but final responsibility remains with the Chair. 2. Medical students not rotating through the Department of Pediatrics are responsible to the Director of Medical Education of the appropriate department or the chair of that department or specific assigned attending physician. XIV. CLINICAL RESEARCH AND PUBLICATION A. Research on Human Subjects 1. In order to perform research on human subjects at Children's Hospital of Wisconsin, all investigators must obtain the approval of the Children's Hospital of Wisconsin Research and Publications Committee/Human Rights Review Board. Ref: Administrative Policies & Procedures: “Research: The Process of Conducting Research on Human Subjects at CHW” Ref: Administrative Policies & Procedures: “Supervision of Resident and Fellow Physicians” XV. PHYSICIANS' MEMBERSHIP REQUIREMENTS A. Vigilance in maintaining an environment that minimizes infections, including the use of hand cleansing techniques. B. Continuing Medical Education relevant to the Member’s practice C. Timely return of reappointment information R-18 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07
  • 21. Medical-Dental Staff Rules and Regulations for Members with Privileges at Children’s Hospital of Wisconsin D. Compliance with Hospital policies regarding TB skin testing and follow-up E. Payment of dues and fines F. Compliance with required immunizations: 1. All Medical-Dental Staff Members must show evidence of immunity to rubella, rubeola, and varicella. 2. Medical-Dental Staff who do not fulfill the criteria for rubeola or rubella immunity will be required to be immunized, preferably with MMR vaccine unless a valid reason exists not to do so. Medical-Dental Staff not demonstrating immunity to rubeola or rubella could be excluded from entering the Hospital during a rubeola or rubella epidemic. XVI. ACCEPTED ABBREVIATIONS A. Use of abbreviations should be kept to a minimum. Only those abbreviations recognized by all practitioners involved in the care of the patient should be used. B. Use of any unapproved abbreviations, acronyms and symbols is prohibited in the patient’s medical record. Ref: Patient Care Policies & Procedures: “Documentation: Patient Care” Ref: Patient Care Policies & Procedures: “Abbreviations” Ref: Stedman’s Abbreviations, Acronyms, and Symbols, by Authors: Williams and Wilkins, rd Stedmans, 3 edition XVII. AMENDMENTS TO RULES AND REGULATIONS A. These Rules may be amended at any regular meeting of the Executive Committee. Such amendment shall become effective when reviewed by the Parliamentary Committee and approved by the Executive Committee and by the Board of Directors of the Hospital. XVIII. APPROVAL OF RULES AND REGULATIONS A. These Rules and Regulations shall become effective when adopted by the Executive Committee of the Medical-Dental Staff and approved by the Board of Directors. R-19 Revised: 11/18/04; 6/14/05; 11/29/05; 11/28/07