This document discusses theories that could guide occupational therapy work with immigrant and refugee populations. It outlines the Person-Environment-Occupation-Performance model and theories from immigration studies including the trajectory approach, cross-national framework, and life course modifiers. Key concepts discussed are occupational engagement, sense of doing, being, belonging, and becoming. The document evaluates how assessments and interventions could be adapted to be accessible and culturally relevant for diverse disabilities and social groups within immigrant communities.

1. Elnaz Alimi
1. Which theory bases would you use to guide your project and
future work in this area? Please discuss both a) an occupational
therapy model(s), as well as b) related knowledge theory bases
you would prioritize from outside the field of OT that you think
are important to use to guide interactions with this population.
2. Given these theory bases from #1, how would you define and
conceptualize and with this population?
3. How would you assess needs and evaluate outcomes related
to these two concepts with immigrants and refugees? E.g.,
which assessment tools would you use and why?
4. How would you adapt your assessment and intervention
process so it is a) accessible to people with diverse disabilities
in this population, while also being b) culturally relevant to
people from within this social group?
1. Theories and Models
This project will be guided by both occupational based model
Person-Environment- Person-Participation known as PEOP and
other related knowledge theory bases related to immigration
studies. All of these theories are explained as following. The
detailed explanations about these theories are eliminated and
the main features of them that are align with this project are
illustrated.
1.1. Person-Environment-Occupation-Performance (PEOP)
Model
The Person-Environment-Occupation-Performance (PEOP)
Model was generated in 1985 and published in 1991.
Development of this model was a response to need for more
occupational based models over the paradigm shift.
(Christiansen & Baum, 1991, 1997; Christiansen et al., 2005). It
is envisioned that although there are some similarities with

2. other models, yet different from other models in terms of its
focus on occupational performance and participation, as well as
using a top-down approach (Christiansen et al., 2005). The
PEOP model is defined as a system model that looks at the
function in the systems as a whole and considers the interaction
over its components. Occupational performance has been
received close attention in the PEOP model and contains three
main components: (1) characteristics of the person (including
physiological, psychological, motor, sensory/perceptual,
cognitive, or spiritual), (2) characteristics of the environment
(including cultural, social support, social determinants, and
social capital, physical and natural environments, health
education and public policy, assistive technology), and (3)
characteristics of the activity, task, or role. The most recent
edition is developed to provide therapists to identify the client’s
enablers and barriers to occupational performance, and might be
employed both individual and organizational/community based
(Christiansen et al., 2005). PEOP pays close attention to the
importance of occupational competency in order to attain
occupational participation. Occupational participation in PEOP
is wider compared to occupational performance as it embeds the
ability to engage in preferred lifestyle choices to participate in
meaningful and purposeful roles and activities (Christiansen et
al., 2005). Occupational performance and participation are
considered as main focus of this model by placing these
concepts strategically in the center of the model.
Performing occupations, people interact with their environment.
Thus, there are reciprocal interactions; a people’s goals and
intentions influence their occupational performance, and the
action affects their environment and their personal
characteristics at the same time. The reciprocal interaction
between the person and environmental characteristics influences
occupational performance positively or negatively. When there
is an appropriate person-environment overlap in supporting the
desired occupation, success in occupational performance
eventually results to participation and well-being [two outcomes

3. that this project is looking for]. In addition, the PEOP model is
a client-centered model in which clients are supposed to set
goals actively and participate in planning that promotes
occupational performance. Guiding practice by PEOP model
requires a collaborative and engaging relationship between the
client and practitioner. Practitioners captures the issues and
options presented by the client’s needs and goals by asking the
appropriate questions to elicit client’s narrative. The model
identifies factors in the personal performance
capabilities/constraints and the environmental performance
enabler/barriers that are central to the occupational
performance, which in turns lead to development of a realistic
and sequenced intervention plan (Wong and fisher, 2015).
1.2. Related Knowledge Theories: Immigrants Studies Theories
1.2.1. The Trajectory Approach
The idea of a trajectory means that we perceive factors or
contributors related to immigrant health to operate together as a
dynamic system over course of time developing a relationship
between a population and the health-related system. The term
‘‘health-related system,’’ in this approach, looks at the
combination of health services with the economic, community,
social and cultural supports necessary for their effective
delivery. Figure 1 is an illustration of an immigrant/refugee
health trajectory, moving from relatively good health status at
first arrival to decreasing (and then slightly increasing) status
over time as a function of marginalization from health and
supporting resources, inspired by diverse contributing factors
[10].
Fig. 1 Concept of immigrant/refugee health trajectory
Poverty and limited resources: 21 percent of children who are
living in immigrant families live in poverty, in comparison with
14 percent in American-born families [10]. Data from the
National Survey of American Families [10] reports that
excruciating conditions are greater for children of immigrants

4. than for children of US born in three areas: food, housing and
health care. Some research even shows that immigrants are
often keeping away from public programs and assistance even
when they are eligible, due to concern about consequences for
their legal status [10]. Housing segregation by race/ethnicity
(regardless of income) is associated with a variety of health risk
factors [10]. Neighborhood characteristics (e.g., crime, lack of
recreation space) intertwined with socioeconomic status also
have an impact on such health conditions as obesity, violence
and substance use [10].
Lack of insurance and monetary support: Most immigrants are
in working families with adults often holding more than one
job; however, the nature of their jobs (low income, no health
insurance) as well as restricted access to insurance for other
reasons leads to the situation that approximately 42–51 percent
of non-citizens have no access to health coverage, compared to
15 percent for native citizens [10]. Lack of insurance associated
with reduced access to care, and consequently to
disadvantageous health status [10].
Difficulties in access to health care and treatment bias: If we
turn blind eyes on age, legal status or insurance coverage,
immigrants receive about half the health care services which are
provided to Americans-born populations. Financial, cultural and
language barriers all make it hard for immigrants to afford care,
understand medical advice or recommendations from English
language doctors and nurses [10].
Differences in health knowledge and practice: people who have
migrated to the US from all over the world may come with
different knowledge and perception about health, health care
systems and the community resources. Or, some immigrant
populations may have no proper information regarding
preventive and treatment procedures available in the US for
specific health conditions [10].
Migration and immigration experiences including acculturative
stress: Three crucial sets of factors must be considered as
unique ones to immigrants/refugees’ population [10]: home

5. country trauma, migration trauma, and the influence of social,
cultural, and economic change after arriving in the US.
Immigrant and refugee families might experience social role
shifting, generational family disruption, economic hardship,
language and other related challenges. There is a high risk that
these factors have a negative influence on health status. Related
to this set of factors is the role-shifting that happens among
immigrant families. This might result in undeniable impacts on
health outcomes and health care [10].
Lack of community efficacy: Because of the language barriers,
unfamiliarity with resources, fear and mistrust to the system,
large groups of immigrant populations are reluctant to take
action or make complaints regarding such conditions
(community conditions that impact health status. e.g. housing
and limited services) and may feel they are not able or eligible
to do anything to change the community. This sort of
association between perceived self-efficacy and health outcomes
is supported by other research as well [10].
Lack of data and systems to address health needs of immigrant
and refugee populations: Before such disparities can be
addressed, they must be figured out. That is, data need to be
gathered and maintained on health status and disparities among
racial-ethnic minority populations of immigrant origin [10].
1.2.2. A cross-national framework for understanding immigrant
health
The health status of people who have not migrated is totally
influenced by the environments they are living in, while the
health of immigrants’ population, their families and
communities of origin is dependent on the environments in both
sending and receiving countries. As shown in Fig. 2 and
discussed below, sending-country (home country) factors may
influence immigrant health before and after immigration, along
the life course, alone or in combination with receiving-country
(host country) factors. The impact of cross-national factors
might demonstrate differently depending on the etiology of

6. specific outcomes (infectious versus chronic disease), critical
exposure periods, and age at migration [2].
Fig. 2 Cross-national frame work for research on immigrant
health (citation?)
Social determinants in sending countries: Social determinants of
health in home countries influence immigrant health before and
after migration as well as over the life course. The level of
effect of social determinants on health may be different by
country’s level of economic development. Gender is another
social determinant that influences either migration or health.
Similarly, migration affects gender relations and modifies them
in both the sending and receiving countries in ways that may
have health implications [2].
Health distributions in sending countries: Studies showed that
in the U.S., since the 1970s, the majority of immigrants have
arrived from developing countries in Latin America and Asia,
where the prevalence of infectious diseases is higher than in the
U.S [2].
Push and pull factors: Push and pull factors (e.g., wage
differentials or other, non-labor market failures) keep the
migration continuing, but can also be considered as
determinants of health. For instance, political violence,
unemployment, and the social and economic policies that
produce them may be considered as push factors as well as
social determinants of health in sending countries. Push and
pull factors often interact with gender. But this interaction can
be varied in different circumstances [2].
Life course: There is a large body of evidence suggesting that
social economic status in childhood has a long-life impact on
health along the life course [12]. Therefore, immigrants’
childhood socioeconomic conditions in sending countries and
age at migration may influence the health of adult immigrants in
receiving countries. In addition, infectious or environmental
exposures in sending countries may develop into active disease
in destination countries [2].

7. Health distributions in receiving country: Having arrived in the
host country, immigrants are vulnerable to the health
distributions and epidemics in the host country. For instance,
HIV was first identified in the U.S. and Haiti. Also, migration
may result in exposure to new health norms in the receiving
country [2].
Social determinants in receiving countries: Sociologists
interested in immigration studies have suggested that immigrant
adaptation is influenced d by the context of reception, including
economic opportunities for upward mobility and racial
discrimination. Governmental, societal, and community
dimensions of the context of reception all have the potential to
affect immigrant well-being and health outcomes [2].
1.2.3. Conceptual frame work for life course modifiers for
immigrants in the U.S.
Fig. 3 Life-course modifiers for immigrants in the U.S.
(citation?)
Biological factors: Genetic and biological factors play a
fundamental role in determining health outcomes. Although
people might have less control over these factors. Regardless of
the country of birth, persons born with congenital disorders
typically experience significant health care challenges and
lower quality of life than their healthy counterparts. However,
children with special needs born in countries whose health care
systems are not as advanced as the U.S. suffer additional
challenges that can further debilitate quality and quantity of
life. Some of these challenges include stigmatization, neglect,
isolation, and poor coordination of care, resignation to fate in
cases where parents and caregivers view the situation of such
children as hopeless. This is particularly true of developing
countries [13].
Environmental influences: Multiple studies have proved that the
environment in which surrounds individuals is a major
contributor of health. Environmental influences include

8. language, lifestyle behaviors, and dietary preferences. There is
a growing body of research on the impacts of lifestyle behaviors
on individuals and public health. Some argue that new
immigrants to developed countries including the U.S. show
improved health outcomes compared to native-born populations.
Others have also stated that persons who immigrate to the U.S.
are more likely healthier and wealthier than the people who
have not migrated so that a self-selection process increases the
chance of incoming healthier immigrants [13].
Social network influences: The concept of social network
focuses on the necessity of ones’ characteristics as well as the
relationships and ties with other individuals within the network
[13]. For instance, Christakis and colleagues found that
although obesity is due to product of voluntary choices or
behaviors, the fact that people were integrated in social
networks and influenced by the evident appearance and
behaviors of those around them proved that weight gain in one
person might influence weight gain in others [14].
Environmental influences: Living in the host country,
immigrants are exposed to both positive and negative cultural
values, lifestyle and behaviors that may or may not impact their
health. Actually, higher level of acculturation does not
necessarily guarantee positive health outcomes [13].
Sociodemographic influences: The role of an individual’s social
economic status (SES) on healthcare outcomes cannot be
overemphasized. Several studies have been done to show
significant positive impacts of education, on health care
outcomes, [15,16]. Physical activity among immigrants tends to
be lower among immigrants than for most American-born
persons. Recently immigrants are typically low-to-middle
income persons dealing with multiple jobs and trying to settle
and integrate into their new environment, so they do not have
much time to engage in physical activities as American-born do
[13].
Access to healthcare: By arriving in the U.S., immigrants are

9. often confronted with a healthcare system significantly different
from what they get used to [13]. Study shows that this huge
difference might turns into the excruciating obstacle to
immigrants with low income, limited language proficiency and
education who are at higher risk of encountering both economic
and systematic barriers to care [17].
2.1. Occupational Engagement: Developing sense of Doing,
Being, Becoming and Belonging
(smith,2015) Engagement in purposeful and valued daily
occupations has the potential to promote health, well-being and
coping skills, even in excruciating conditions and the ability to
engage in daily occupations is positively linked with well-
being. Migration might be considered a complex and multi
dimential process, leading to an enormous and unpredictable
transition, with the huge loss of a familiar life and the removal
of many dignified occupations. Migrants are increasingly
acknowledged as experiencing occupational issues, from
temporary disruption to long lasting deprivation from necessary
engagement. They deal with restricted access to opportunities
and options, poor social capital, poor mental and physical
health, dwindling performance skills and wasted human
potential. There are significant predicaments to occupations,
including work, education, volunteering and networking,
excluding individuals from mainstream society, exacerbating
social exclusion and creating high levels of underemployment.
These occupational limitations have a negative impact on
individuals and communities, eroding skills, increasing
vulnerabilities, worsening the impact of poverty and ill-health,
emphasizing isolation and fostering community disharmony.
The World Federation of Occupational Therapists has identified
occupation as a human right that enables people to flourish,
fulfil their potential and experience satisfaction. World
Federation of Occupational Therapists’ (2012) position
statement on Human Displacement highlights the impact of
forced migration on occupation and the potential for occupation

10. to enable individuals to move beyond displacement. Occupation
promotes the adjustment, integration and reconstruction
necessary to manage migration, without which mastery and
competency are undermined. Occupational access and
opportunity are important feature of success in transition,
allowing individuals to renegotiate ways of doing, being,
becoming and belonging in their new context.
· Doing: the importance of being busy and having some degree
of daily structure, expressing the pleasure of getting up with a
purpose, and ending the day feeling tired. The key message
from immigrants lay in their desire not only to ‘keep busy’ but
also to ‘keep busy with a purpose’ – whilst any occupation was
better than no occupation.
· Being: the impact of migration on their sense of self, their
spiritual self and their well-being.
· Belonging: The discussions on belonging fell into two
categories, belonging associated with place and belonging
associated with people.
· Becoming: Uncertainty made their day-to-day lives very
challenging, with difficulty planning and preparing for a future
that cannot be anticipated.
Implications: For individuals facing forced migration, managing
their transition and making meaning in an unfamiliar host
country may be particularly difficult, and whilst we are
beginning to explore the potential of occupation to help people
during the process, we need to consider not only access to
occupation but the nature of that occupation. Occupation has
enormous potential for enhancing post migratory experiences,
but the choice of occupation is also important. People strive to
move beyond simply ‘keeping busy’ to find occupations of real
meaning that foster connections and purpose, and in particular
feed their need to feel valued. Occupations undertaken for the
benefit of others tap into culturally appropriate collectivist
ideals, using the desire to be altruistic to promote ‘doing, being,
belonging’ and even the elusive ‘becoming’. Occupational
therapists may be able to consider the application of desired

11. activities as effective routes to inclusion and meaningful
engagement.
2.2. Social Participation: Establishing identity
During the migration process, people may experience changes in
physical, economic, political, social and cultural aspects of
context. In turn, their occupational engagement, senses of place
and ultimately their identities may be affected. One’s
occupations and the places one engages with are shaped by
identity. It has been repeatedly proposed within the occupation-
based literature that it is not solely the doing of occupation that
contributes to identity, but also the meaning individuals attach
to, and derive from occupations that influences identity. Term
social participation refers to more than participation in goal
directed pursuits. In Wilcock’s terms, it connotes people’s
involvement in meaningful occupations “for being, becoming,
and belonging, as well as for performing or doing occupations”.
In his Eleanor Clarke Slagle lecture, Christiansen (1999)
explicitly highlighted the connection between occupation and
identity, stating, “occupations are key not just to being a
person, but to being a particular person, and thus creating and
maintaining an identity”. He based his argument, that
occupation is the primary means through which individuals both
develop and express their personal identities, on four
propositions: identity is an overarching concept that shapes and
is shaped by relationships with others; identities are closely tied
to what people do and their interpretations of those actions in
the context of their relationships with others; identities are
important to self-narratives and life stories that provide
coherence and meaning for life and everyday events; and life
meaning is an essential element for promoting wellbeing and
life-satisfaction. Social participation serves to enhance
opportunities for identity reconstruction and growth.
‘Maintaining an acceptable self-identity’ addresses people’s use
of occupation to maintain an acceptable form of personal

12. identity - understood as “the arrangement of self-perceptions
and self-evaluations that are meaningful to a person”. The
occupations people engage in influence their social and personal
identities. Likewise how they see themselves and are, or wish to
be, seen by others also influences what occupations they choose
to engage in.
Habits and routine are formed in part through occupation –
doing similar things at similar times, day after day; or as
Brockelman (2002) stated, “The ways in which humans shape
their everyday behavior towards life into predictable patterns”
which ultimately contributes to the “emergence of one’s
personal identity”. Yerxa (2002) similarly described habits as
“significant learned behaviors embedded in an ecocultural
context (of time, place, and society)” and argued that ‘positive’
habits can contribute to “personal meaning, identity,
competence, satisfaction, and self-expression”. Individuals
within a given society do not all have the same knowledge of,
and access to, the social rules and resources within which habits
are shaped and reinforced. Thus, when transitioning into a
social context that differs from that in which individuals have
been socialized and developed habits, as may occur with
international migration, they may experience a destabilization
of routine and may need to re-negotiate their habits (comfort
zone). The discussion of performance and habitus highlights the
importance of routine or noticeable lack thereof, for identity; as
it is within everyday doing, in interaction with others, located
in particular places that structure and agency interact, and that
identity is experienced and negotiated. Understanding how
identity is situated by habitus, and performed in social
interaction on a daily basis through occupation, can advance
explorations of how and why identity and its performance are
affected by international migration, as people move from one
place to another and experience changes to their engagement in
meaningful occupation and senses of place. Drawing on the
work reviewed, it is argued that routines contribute to people’s
identities, and that occupations contribute to routines by

13. enabling people to structure time and space. People engage in
similar occupations, at similar times of day, in similar places,
with similar people, day after day, on an ongoing basis, so that
the routine nature of everyday life becomes tacitly understood.
These routines both enact and reproduce habitus. The range of
occupations people engage in directly contributes to, confirms,
and re-affirms people’s identities over time as they form daily
routines and interact with others on an ongoing basis,
performing their identity in place. When people migrate
internationally, everyday interactions and routines done in
previous places may no longer enable impression management
in desired ways, thus challenging personal and social identity
and taken for-granted elements of habitus. Occupations and
places change, altering routines, affecting the meaning accorded
to and derived from familiar occupations and places, and
ultimately influencing migrants’ identities. They no longer
interact with the same people, and the ‘rules’ in which such
interactions are to occur may not be available in a non-
problematic, taken-for-granted way. They are located within
different contexts, where the people they now interact with were
socialized within a different social structure with different
social norms. Migrants may lose the ‘comfort place’ provided
by their habitus, and need to consciously search for cues
regarding how to ‘do’ in order to negotiate their personal and
social identity. They may be challenged to learn the habitus of
the dominant group or groups in their new places, leading to
alterations in occupation and, ultimately, in identity. Attending
to changes experienced by migrants at the structural macro-
scale and the agential micro-scale, and their influences on
occupational engagement and senses of place, entails
consideration of identity. Drawing together notions of
performance and habitus into an occupational perspective can
both enrich understandings of migration, as well as intersections
of occupation, place and identity, when addressing questions
such as: What is the role of, and impact upon, occupation during
the process of migration, settlement and integration? What are

14. the influences of place upon occupation throughout this
process? What are the implications of changes to migrants’
occupations and place for their identities? How do people
ultimately reaffirm or recreate identity following migration?
argue that addressing these questions require an exploration of
the issues including but not limited to migrants’ renegotiation
of routine and meaningful occupations, formation of new senses
of place, and development of performances that reflect the
aspects of identity that they seek to emphasize within changed
‘interaction fields’ shaped within a novel habitus, all of which
occur over time as migrants negotiate new routines according to
their changed contexts. An occupational perspective is valuable
for unpacking such multi-faceted human experiences, as an
individual’s occupational engagement and development of
senses of place are considered within the context in which they
are undertaken. Exploring migrants’ identities (their sense of
being within their new context); their anticipated futures (who
they seek to become); and their integration within the host
society (whether they feel they belong) can all be explored by
applying an occupational perspective that considers how people
do their identities in place.
3. Measurement
3.1. Activity Card Sort
The ACS is an occupational therapy assessment tool that
employs a q-sort methodology, requiring the subject to sort
cards depicting people engaged in real-life activities into
categories. The sorting procedure allows the subject to describe
how he or she is involved with various activities. Pictures of
people actually performing the activity prompt the subject to
recall the level of that activity in his or her life. The activities
in the pictures represent occupations from three categories of
activity: instrumental, leisure (both low-demand and high-
demand), and social. One recently developed tool is the Activity
Card Sort (ACS) (Baum, 1995), which is a standardized
assessment tool aimed at evaluating the amount and level of
involvement in various activities. Different from the few other

15. available tools, such as the Matsutsuyu interest checklist, the
ACS employs pictures of people involved in real-life activities
and thus can elicit vivid responses from participants. The ACS
provides us with the opportunity to identify the underlying
dimensions of occupational performance, as experienced by
various groups, and to better comprehend the theoretical and
practical implications of activity classification (Sachs &
Josman, 2001). ACS is the only assessment available that
measures the full range of activities that adults do and includes
20 instrumental activities, 35 low-physical-demand leisure
activities, 17 high-physical-demand leisure activities, and 17
social activities
The Activity Card Sort, 2nd Edition has three versions:
· Community Living version for community-dwelling older
adults
· Institutional version for older adults in a hospital, skilled
nursing or rehabilitation hospital
· Recovery version for older adults recovering from an injury or
disease.
The individual sorts the picture cards according to their …
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ou
tc

37. om
es
t
ha
t
co
ul
d
co
m
pr
om
is
e
th
e
ca
re
o
f p
at
ie
nt
s.

38. §4
82
.2
4
Th
e
fa
ci
lit
y
sh
ou
ld
h
av
e
an
o
rg
an
iz
at
io

39. na
l p
la
n,
w
hi
ch
sh
ow
s
th
e
re
sp
on
si
bl
e
pe
rs
on
fo
r

40. m
ed
ic
al
r
ec
or
ds
(h
ea
lth
in
fo
rm
at
io
n)
o
f e
ve
ry
in
di

41. vi
du
al
tr
ea
te
d
at
th
e
fa
ci
lit
y.
Th
e
te
rm
“
ho
sp
ita
l”

42. in
cl
ud
es
a
ll
lo
ca
tio
ns
o
f t
he
ho
sp
ita
l.
Th
e
ho
sp
ita

43. l m
us
t h
av
e
on
e
un
ifi
ed
m
ed
ic
al
r
ec
or
d
se
rv
ic
e
th
at

44. h
as
a
dm
in
is
tr
at
iv
e
re
sp
on
si
bi
lit
y
fo
r
al
l
m
ed
ic

45. al
r
ec
or
ds
, b
ot
h
in
pa
tie
nt
a
nd
o
ut
pa
tie
nt
re
co
rd
s.

46. Th
e
ho
sp
ita
l m
us
t c
re
at
e
an
d
m
ai
nt
ai
n
a
m
ed
ic
al

47. re
co
rd
fo
r
ev
er
y
in
di
vi
du
al
, b
ot
h
in
pa
tie
nt
a
nd

48. ou
tp
at
ie
nt
, e
va
lu
at
ed
o
r
tr
ea
te
d
in
th
e
ho
sp
ita
l.

49. Th
e
te
rm
“
m
ed
ic
al
r
ec
or
ds
”
in
cl
ud
es
a
t l
ea
st
w
ri

50. tt
en
do
cu
m
en
ts
, c
om
pu
te
ri
ze
d
el
ec
tr
on
ic
in
fo
rm
at

51. io
n,
ra
di
ol
og
y
fil
m
a
nd
s
ca
ns
, l
ab
or
at
or
y
re
po
rt

52. s
a n
d
pa
th
ol
og
y
sl
id
es
, v
id
eo
s,
a
ud
io
r
ec
or
di
ng
s,

53. a
nd
o
th
er
fo
rm
s
of
in
fo
rm
at
io
n
re
ga
rd
in
g
th
e
co

54. nd
iti
on
o
f a
pa
tie
nt
.
TE
XT
IN
G
CM
S
do
es
n
ot
p
er
m
it

55. t
he
t
ex
ti
ng
o
f o
rd
er
s
by
ph
ys
ic
ia
ns
o
r
ot
he
r
he

56. al
th
c
ar
e
pr
ov
id
er
s.
T
he
pr
ac
ti
ce
o
f t
ex
ti
ng
o
rd

57. er
s
fr
om
a
p
ro
vi
d e
r
to
a
m
em
be
r o
f t
he
c
ar
e
te
am

58. is
n
ot
in
c
om
pl
ia
nc
e
w
it
h
th
e
Co
nd
it
io
ns
o
f P
ar
ti

59. ci
pa
ti
on
(C
oP
s)
.
Th
e
te
xt
in
g
of
p
at
ie
nt
in
fo
rm
at
io

60. n
am
on
g
m
em
be
rs
of
th
e
he
al
th
c
ar
e
te
am
is
p
er
m

61. is
si
bl
e
if
ac
co
m
pl
is
he
d
th
ro
ug
h
a
se
cu
re
p
la
tf
or

62. m
.
D
O
CU
M
EN
T
RE
V
IE
W
A
N
D
IN
TE
RV
IE
W
1.

63. Re
vi
ew
th
e
or
ga
ni
za
tio
na
l s
tr
uc
tu
re
a
nd
po
lic
y
st
at

64. em
en
ts
.
2.
In
te
rv
ie
w
th
e
pe
rs
on
r
es
po
ns
ib
le
fo
r

65. th
e
m
ed
ic
al
r
ec
or
d
(h
ea
lth
in
fo
rm
at
io
n)
s
er
vi
ce
to

66. de
te
rm
in
e
th
at
it
is
s
tr
uc
tu
re
d
ap
pr
op
ri
at
el
y
to

67. m
ee
t t
he
n
ee
ds
o
f t
he
fa
ci
lit
y
an
d
th
e
pa
tie
nt
s.
3.

68. V
er
ify
th
e
fa
ci
lit
y
do
es
n
ot
p
er
m
it
th
e
te
xt
in
g

69. of
o
rd
er
s
by
p
hy
si
ci
an
s
or
o
th
er
h
ea
lt
h
ca
re
pr

70. ov
id
er
s.
CH
A
RT
R
EV
IE
W
Re
vi
ew
a
s
am
pl
e
of
a
ct

71. iv
e
an
d
cl
os
ed
m
ed
ic
al
re
co
rd
s
fo
r
co
m
pl
et
en
es

72. s
an
d
ac
cu
ra
cy
in
ac
co
rd
an
ce
w
ith
F
ed
er
al
a
nd
S
ta

73. te
la
w
s
an
d
re
gu
la
tio
ns
a
nd
h
os
pi
ta
l p
ol
ic
y.
Th

74. e
sa
m
pl
e
sh
ou
ld
b
e
10
p
er
ce
nt
o
f t
he
av
er
ag
e
da

75. ily
c
en
su
s
an
d
be
n
o
le
ss
th
an
3
0
re
co
rd
s.
A
dd
iti

76. on
al
ly
, s
el
ec
t a
s
am
pl
e
of
o
ut
pa
tie
nt
re
co
rd
s
in
o

77. rd
er
to
d
et
er
m
in
e
co
m
pl
ia
nc
e
in
ou
tp
at
ie
nt
d
ep

78. ar
tm
en
ts
, s
er
vi
ce
s,
a
nd
lo
ca
tio
ns
.
1
=
C
om
pl

79. ia
nt
2
=
N
ot
C
om
pl
ia
nt
Th
is
s
ta
nd
ar
d
is
n
ot

80. m
et
a
s
ev
id
en
ce
d
by
:
M
ED
IC
A
L
RE
CO
RD
S

81. (H
EA
LT
H
IN
FO
RM
A
TI
O
N
) S
ER
V
IC
ES
ST
A
N
D
A
RD

82. /
E
LE
M
EN
T
EX
PL
A
N
A
TI
O
N
SC
O
RI
N
G
P
RO
CE

83. D
U
RE
SC
O
RE
20
18
v
2
10
-2
H
FA
P
|
A
CC
RE
D

84. IT
A
TI
O
N
R
EQ
U
IR
EM
EN
TS
F
O
R
A
CU
TE
C
A
RE
H
O
SP

85. IT
A
LS
10
.0
0.
01
Fo
r
Fu
tu
re
U
se
.
10
.0
0.
02

86. O
rg
an
iz
at
io
n
&
S
ta
ff
in
g.
Th
e
or
ga
ni
za
tio
n
of

87. th
e
m
ed
ic
al
re
co
rd
se
rv
ic
e
m
us
t b
e
ap
pr
op
ria
te
to

88. th
e
sc
op
e
an
d
co
m
pl
ex
ity
o
f t
he
s
er
vi
ce
pe
rf
or
m

89. ed
.
Th
e
ho
sp
ita
l m
us
t e
m
pl
oy
a
de
qu
at
e
pe
rs
on
ne
l t
o

90. en
su
re
p
ro
m
pt
co
m
pl
et
io
n,
fi
lin
g,
a
nd
re
tr
ie
va
l o

91. f
re
co
rd
s.
§ 4
82
.2
4(
a)
Th
e
m
ed
ic
al
r
ec
or
ds
s
er

92. vi
ce
m
us
t b
e
or
ga
ni
ze
d,
eq
ui
pp
ed
, a
nd
s
ta
ff
ed
in
a

93. cc
or
da
nc
e
w
ith
th
e
sc
op
e
an
d
co
m
pl
ex
ity
o
f t
he
h
os

94. pi
ta
l’s
s
er
vi
ce
s
an
d
in
s
uc
h
a
m
an
ne
r
as
to
c
om
pl

95. y
w
ith
th
e
re
qu
ir
em
en
ts
o
f t
hi
s
re
gu
la
ti o
n
an
d
ot
he

96. r
Fe
de
ra
l a
nd
S
ta
te
la
w
s
an
d
re
gu
la
tio
ns
.
Th
er
e
m

97. us
t b
e
an
e
st
ab
lis
he
d
m
ed
ic
al
r
ec
or
d
sy
st
em
th
at

98. is
o
rg
an
iz
ed
a
nd
e
m
pl
oy
s
ad
eq
ua
te
p
er
so
nn
el
to

99. en
su
re
p
ro
m
pt
:
Co
m
pl
et
io
n
of
m
ed
ic
al
r
ec
or
ds

100. ;
Fi
lin
g
of
m
ed
ic
al
r
ec
or
ds
; a
nd
Re
tr
ie
va
l o
f m
ed
ic

101. al
r
ec
or
ds
.
Th
e
te
rm
“
em
pl
oy
s
ad
eq
ua
te
p
er
so
nn
el

102. ”
in
cl
ud
es
:
1.
Th
at
m
ed
ic
al
r
ec
or
d
pe
rs
on
ne
l a
re

103. e
m
pl
oy
ee
s
of
th
e
ho
sp
ita
l;
Th
at
th
e
ho
sp
ita
l e
m

104. pl
oy
s
an
a
de
qu
at
e
nu
m
be
r
of
m
ed
ic
al
r
ec
or
d
pe

105. rs
on
ne
l,
em
pl
oy
s
ad
eq
ua
te
ty
pe
s
of
m
ed
ic
al
r
ec
or

106. d
pe
rs
on
ne
l,
an
d
em
pl
oy
s
pe
rs
on
ne
l w
ho
po
ss
es
s
ad

107. eq
ua
te
e
du
ca
tio
n,
s
ki
lls
, q
ua
lif
ic
at
io
ns
a
nd
ex
pe
ri

108. en
ce
to
e
ns
ur
e
th
e
ho
sp
ita
l c
om
pl
ie
s
w
ith
re
qu
ir
em

109. en
ts
o
f t
hi
s
re
gu
la
tio
n
an
d
ot
he
r
Fe
de
ra
l a
nd
St
at

110. e
la
w
s
an
d
re
gu
la
tio
ns
.
IN
TE
RV
IE
W
1.
D
et
er
m

111. in
e
th
at
th
er
e
is
a
n
es
ta
bl
is
he
d
sy
st
em
in
p
la
ce

112. th
at
a
dd
re
ss
es
th
e
fo
llo
w
in
g
ac
tiv
iti
es
of
th
e
m
ed

113. ic
al
r
ec
or
d
se
rv
ic
e:
a.
tim
el
y
pr
oc
es
si
ng
o
f r
ec

114. or
ds
;
b.
co
di
ng
/i
nd
ex
in
g
of
r
ec
or
ds
;
c.
re
co
rd

115. r
et
ri
ev
al
;
d.
pr
ot
ec
tin
g
co
nf
id
en
tia
lit
y
of
m
ed
ic

116. al
in
fo
rm
at
io
n;
a
nd
e.
re
tr
ie
va
l a
nd
c
om
pi
la
tio

117. n
of
d
at
a
of
qu
al
ity
a
ss
ur
an
ce
a
ct
iv
iti
es
.
2.

118. Ve
ri
fy
th
at
th
e
sy
st
em
is
r
ev
ie
w
ed
a
nd
re
vi
se
d
as

119. n
ee
de
d.
3.
In
te
rv
ie
w
s
ta
ff
, i
f n
ee
de
d,
r
ev
ie
w
w

120. ri
tt
en
jo
b
de
sc
ri
pt
io
ns
a
nd
s
ta
ff
in
g
sc
he
du
le
s
to

121. de
te
rm
in
e
if
st
af
f i
s
ca
rr
yi
ng
o
ut
a
ll
de
si
gn
at
ed

122. r
es
po
ns
ib
ili
ti
es
.
4.
Ve
ri
fy
th
at
th
e
ho
sp
ita
l e
m

123. pl
oy
s
ad
eq
ua
te
m
ed
ic
al
r
ec
or
d
pe
rs
on
ne
l a
s
pr
ev

124. io
us
ly
de
sc
ri
be
d.
5.
A
re
m
ed
ic
al
r
ec
or
ds
p
ro

125. m
pt
ly
c
om
pl
et
ed
in
ac
co
rd
an
ce
w
ith
S
ta
te
la
w
a
nd

126. h
os
pi
ta
l
po
lic
y?
D
O
CU
M
EN
T
RE
V
IE
W
Se
le
ct
a
s

127. am
pl
e
of
p
as
t p
at
ie
nt
s
of
th
e
ho
sp
ita
l
(in
pa
tie
nt
a
nd

128. /o
r
ou
tp
at
ie
nt
).
Re
qu
es
t t
ho
se
pa
tie
nt
s’
m
ed
ic
al
r

129. ec
or
ds
.
Ca
n
th
e
ho
sp
ita
l
pr
om
pt
ly
r
et
ri
ev
e
th
os
e

130. re
co
rd
s?
1
=
C
om
pl
ia
nt
2
=
N
ot
C
om
pl
ia
nt
Th

131. is
s
ta
nd
ar
d
is
n
ot
m
et
a
s
ev
id
en
ce
d
by
:

132. M
ED
IC
A
L
RE
CO
RD
S
(H
EA
LT
H
IN
FO
RM
A
TI
O
N
) S
ER
VI
CE

133. S
ST
A
N
D
A
RD
/
E
LE
M
EN
T
EX
PL
A
N
A
TI
O
N

134. SC
O
RI
N
G
P
RO
CE
D
U
RE
SC
O
RE
20
18
10
-3

135. H
FA
P
|
AC
CR
ED
IT
AT
IO
N
R
EQ
U
IR
EM
EN
TS
F
O
R
AC
U
TE

136. C
AR
E
H
O
SP
IT
AL
S
10
.0
0.
03
Re
te
nt
io
n
of
M
ed

137. ic
al
Re
co
rd
s.
Th
e
ho
sp
ita
l m
us
t m
ai
nt
ai
n
a
m
ed
ic

138. al
re
co
rd
fo
r e
ac
h
in
pa
tie
nt
a
nd
ou
tp
at
ie
nt
.
M
ed

139. ic
al
re
co
rd
s
m
us
t b
e
ac
cu
ra
te
ly
w
rit
te
n,
p
ro
m
pt

140. ly
c
om
pl
et
ed
, p
ro
pe
rly
fil
ed
a
nd
re
ta
in
ed
, a
nd
a
cc
es

141. si
bl
e.
Th
e
ho
sp
ita
l m
us
t u
se
a
s
ys
te
m
o
f
au
th
or
id

142. en
tif
ic
at
io
n
an
d
re
co
rd
m
ai
nt
en
an
ce
th
at
e
ns
ur
es

143. th
e
in
te
gr
ity
of
th
e
au
th
en
tic
at
io
n
an
d
pr
ot
ec
ts
th

144. e
se
cu
rit
y
of
a
ll
re
co
rd
e
nt
rie
s.
§4
82
.2
4(
b)
Th
e

145. ho
sp
ita
l m
us
t m
ai
nt
ai
n
a
m
ed
ic
al
re
co
rd
fo
r e
ac
h
in
pa

146. tie
nt
a
nd
o
ut
pa
tie
nt
e
va
lu
at
ed
o
r t
re
at
ed
in
a
ny
pa

147. rt
o
r l
oc
at
io
n
of
th
e
ho
sp
ita
l.
Al
l m
ed
ic
al
re
co
rd
s

148. m
us
t b
e
ac
cu
ra
te
ly
w
rit
te
n.
T
he
ho
sp
ita
l m
us
t e
ns
ur

149. e
th
at
a
ll
m
ed
ic
al
re
co
rd
s
ac
cu
ra
te
ly
a
nd
c
om
pl
et

150. el
y
do
cu
m
en
t a
ll
or
de
rs
, t
es
t
re
su
lts
, e
va
lu
at
io
ns
, c

151. ar
e
pl
an
s,
tr
ea
tm
en
ts
,
in
te
rv
en
tio
ns
, c
ar
e
pr
ov
id
ed

152. a
nd
th
e
pa
tie
nt
’s
re
sp
on
se
to
th
os
e
tr
ea
tm
en
ts
, i
nt

153. er
ve
nt
io
ns
a
nd
c
ar
e.
Al
l m
ed
ic
al
re
co
rd
s
m
us
t b
e

154. pr
om
pt
ly
c
om
pl
et
ed
.
Ev
er
y
m
ed
ic
al
re
co
rd
m
us
t b
e

155. co
m
pl
et
e
w
ith
:
Al
l d
oc
um
en
ta
tio
n
of
o
rd
er
s,
d
ia

156. gn
os
is
,
ev
al
ua
tio
ns
, t
re
at
m
en
ts
Te
st
re
su
lts
Ca

157. re
p
la
ns
D
is
ch
ar
ge
p
la
ns
Co
ns
en
ts
In
te

158. rv
en
tio
ns
D
is
ch
ar
ge
S
um
m
ar
y
Cl
in
ic
al
e
va

159. lu
at
io
n
in
fo
rm
at
io
n
ob
ta
in
ed
fr
om
p
os
t-
di
sc
ha
rg

160. e
fo
llo
w
-u
p
te
le
ph
on
e
ca
lls
(e
xc
lu
di
ng
p
at
ie
nt
s
at

161. is
fa
ct
io
n
ca
lls
)
Ca
re
p
ro
vi
de
d
al
on
g
w
ith
th
e

162. pa
tie
nt
’s
re
sp
on
se
to
th
os
e
tr
ea
tm
en
ts
a
nd
in
te
rv

163. en
tio
ns
.
Th
e
re
co
rd
m
us
t b
e
co
m
pl
et
ed
p
ro
m
pt
ly
a

164. ft
er
di
sc
ha
rg
e
in
a
cc
or
da
nc
e
w
ith
S
ta
te
la
w
a
nd

165. h
os
pi
ta
l
po
lic
y
bu
t n
o
la
te
r t
ha
n
30
d
ay
s
af
te
r d
is

166. ch
ar
ge
.
CH
A
RT
R
EV
IE
W
, I
N
TE
RV
IE
W
, &
O
BS
ER
VA
TI
O

167. N
1.
D
et
er
m
in
e
th
e
lo
ca
tio
n(
s)
w
he
re
m
ed
ic
al

168. re
co
rd
s
ar
e
m
ai
nt
ai
ne
d.
2.
Ve
rif
y
th
at
a
m
ed

169. ic
al
re
co
rd
is
m
ai
nt
ai
ne
d
fo
r
ea
ch
p
er
so
n
tr
ea
te
d

170. or
re
ce
iv
in
g
ca
re
. T
he
ho
sp
ita
l m
ay
h
av
e
a
se
pa
ra
te

171. re
co
rd
fo
r b
ot
h
in
pa
tie
nt
s
an
d
ou
tp
at
ie
nt
s.
H
ow
ev
er

172. , w
he
n
tw
o
di
ff
er
en
t s
ys
te
m
s
ar
e
us
ed
th
ey
m
us
t b
e

173. ap
pr
op
ria
te
ly
c
ro
ss
re
fe
re
nc
ed
a
nd
ac
ce
ss
ib
le
.
3.

174. Ve
rif
y
th
at
p
ro
ce
du
re
s
en
su
re
th
e
in
te
gr
ity
o
f
au

175. th
en
tic
at
io
n
an
d
pr
ot
ec
t t
he
s
ec
ur
ity
o
f
pa
tie
nt
re
co

176. rd
s.
4.
Ve
rif
y
th
at
m
ed
ic
al
re
co
rd
s
ar
e
st
or
ed
a

177. nd
m
ai
nt
ai
ne
d
in
lo
ca
tio
ns
w
he
re
th
e
re
co
rd
s
ar
e

178. se
cu
re
, t
ha
t p
ro
te
ct
s
th
em
fr
om
d
am
ag
e,
flo
od
, f
ire
, e

179. tc
.;
ac
ce
ss
is
li
m
ite
d
to
o
nl
y
au
th
or
iz
ed
in
di
vi
du
al

180. s.
5.
Ve
rif
y
th
at
re
co
rd
s
ar
e
ac
cu
ra
te
, c
om
pl
et
ed

181. pr
om
pt
ly
, e
as
ily
re
tr
ie
ve
d
an
d
re
ad
ily
ac
ce
ss
ib
le

182. , a
s
ne
ed
ed
, i
n
al
l l
oc
at
io
ns
w
he
re
m
ed
ic
al
re
co
rd

183. s
ar
e
m
ai
nt
ai
ne
d.
1
=
C
om
pl
ia
nt
2
=
N
ot
C

184. om
pl
ia
nt
Th
is
s
ta
nd
ar
d
is
n
ot
m
et
a
s
ev
id
en
ce

185. d
by
:
M
ED
IC
A
L
RE
CO
RD
S
(H
EA
LT
H
IN
FO
RM
A

186. TI
O
N
) S
ER
VI
CE
S
ST
A
N
D
A
RD
/
E
LE
M
EN
T
EX
PL

187. A
N
A
TI
O
N
SC
O
RI
N
G
P
RO
CE
D
U
RE
SC
O
RE

188. 20
18
10
-4
H
FA
P
|
AC
CR
ED
IT
AT
IO
N
R
EQ
U
IR
EM
EN

189. TS
F
O
R
AC
U
TE
C
AR
E
H
O
SP
IT
AL
S
Th
e
m
ed
ic
al

190. re
co
rd
m
us
t b
e
pr
op
er
ly
fi
le
d
an
d
re
ta
in
ed
.
Th
e
ho

191. sp
ita
l m
us
t h
av
e
a
m
ed
ic
al
re
co
rd
s
ys
te
m
th
at
en
su

192. re
s
th
e
pr
om
pt
re
tr
ie
va
l o
f a
ny
m
ed
ic
al
re
co
rd
, o
f
an

193. y
pa
tie
nt
e
va
lu
at
ed
o
r t
re
at
ed
a
t a
ny
lo
ca
tio
n
of
th
e

194. ho
sp
ita
l w
ith
in
th
e
pa
st
5
y
ea
rs
.
N
O
TE
:
§4
82
.2
4(
b)

195. (1
) a
dd
re
ss
es
th
e
5
ye
ar
m
ed
ic
al
re
co
rd
re
te
nt
io
n

196. re
qu
ire
m
en
t.
Th
e
m
ed
ic
al
re
co
rd
m
us
t b
e
ac
ce
ss
ib
le

197. .
Th
e
ho
sp
ita
l m
us
t h
av
e
a
m
ed
ic
al
re
co
rd
s
ys
te
m
th

198. at
al
lo
w
s
th
e
m
ed
ic
al
re
co
rd
o
f a
ny
p
at
ie
nt
, i
np

199. at
ie
nt
o
r
ou
tp
at
ie
nt
, e
va
lu
at
ed
a
nd
/o
r t
re
at
ed
a
t a

200. ny
lo
ca
tio
n
of
th
e
ho
sp
ita
l w
ith
in
th
e
pa
st
5
y
ea
rs
to
b

201. e
ac
ce
ss
ib
le
by
a
pp
ro
pr
ia
te
s
ta
ff
, 2
4
ho
ur
s
a
da

202. y,
7
d
ay
s
a
w
ee
k,
w
he
ne
ve
r t
ha
t m
ed
ic
al
re
co
rd
m

203. ay
b
e
ne
ed
ed
.
M
ed
ic
al
re
co
rd
s
m
us
t b
e
pr
op
er
ly
s

204. to
re
d
in
s
ec
ur
e
lo
ca
tio
ns
w
he
re
th
ey
a
re
p
ro
te
ct
ed

205. fr
om
fi
re
, w
at
er
da
m
ag
e
an
d
ot
he
r t
hr
ea
ts
.
M
ed
ic

206. al
in
fo
rm
at
io
n
su
ch
a
s
co
ns
ul
ta
tio
ns
, o
rd
er
s,
pr
ac

207. tit
io
ne
r n
ot
es
, x
-r
ay
in
te
rp
re
ta
tio
ns
, l
ab
te
st
re
su
lts

208. , d
ia
gn
os
tic
te
st
re
su
lts
, p
at
ie
nt
a
ss
es
sm
en
ts
an
d
ot

209. he
r p
at
ie
nt
in
fo
rm
at
io
n
m
us
t b
e
ac
cu
ra
te
ly
w
rit
te

210. n,
p
ro
m
pt
ly
c
om
pl
et
ed
a
nd
p
ro
pe
rly
fi
le
d
in
th
e
pa

211. tie
nt
s’
m
ed
ic
al
re
co
rd
, a
nd
a
cc
es
si
bl
e
to
th
e
ph
ys
ic

212. ia
ns
o
r o
th
er
c
ar
e
pr
ov
id
er
s
w
he
n
ne
ed
ed
fo
r
us
e

213. in
m
ak
in
g
as
se
ss
m
en
ts
o
f t
he
p
at
ie
nt
’s
c
on
di
tio
n,

214. M
ED
IC
A
L
RE
CO
RD
S
(H
EA
LT
H
IN
FO
RM
A
TI
O
N
) S

215. ER
VI
CE
S
ST
A
N
D
A
RD
/
E
LE
M
EN
T
EX
PL
A
N
A
TI

216. O
N
SC
O
RI
N
G
P
RO
CE
D
U
RE
SC
O
RE
20
18

217. 10
-5
H
FA
P
|
AC
CR
ED
IT
AT
IO
N
R
EQ
U
IR
EM
EN
TS
F
O
R

218. AC
U
TE
C
AR
E
H
O
SP
IT
AL
S
de
ci
si
on
s
on
th
e
pr
ov

219. is
io
n
of
c
ar
e
to
th
e
pa
tie
nt
, a
nd
in
p
la
nn
in
g
th
e

220. pa
tie
nt
’s
c
ar
e.
T
hi
s
re
qu
ire
m
en
t
ap
pl
ie
s
to
th
e
m

221. ed
ic
al
re
co
rd
s
of
c
ur
re
nt
in
pa
tie
nt
s
an
d
ou
tp
at
ie
nt

222. s
of
th
e
ho
sp
ita
l.
Th
e
ho
sp
ita
l m
us
t h
av
e
a
sy
st
em
o

223. f a
ut
ho
r
id
en
tif
ic
at
io
n
an
d
re
co
rd
m
ai
nt
en
an
ce
th
at

224. e
ns
ur
es
th
e
in
te
gr
ity
o
f t
he
a
ut
he
nt
ic
at
io
n
an
d

225. pr
ot
ec
ts
th
e
se
cu
rit
y
of
a
ll
re
co
rd
e
nt
rie
s.
T
he
m
ed

226. ic
al
re
co
rd
sy
st
em
m
us
t c
or
re
ct
ly
id
en
tif
y
th
e
au
th

227. or
o
f e
ve
ry
m
ed
ic
al
re
co
rd
e
nt
ry
a
nd
m
us
t p
ro
te
ct

228. th
e
se
cu
rit
y
of
al
l m
ed
ic
al
re
co
rd
e
nt
rie
s.
Th
e
m

229. ed
ic
al
re
co
rd
s
ys
te
m
m
us
t e
ns
ur
e
th
at
m
ed
ic
al
re

230. co
rd
e
nt
rie
s
ar
e
no
t l
os
t,
st
ol
en
, d
es
tr
oy
ed
, a
lte
re
d,

231. or
re
pr
od
uc
ed
in
a
n
un
au
th
or
iz
ed
m
an
ne
r.
L
oc
at
io

232. ns
w
he
re
m
ed
ic
al
re
co
rd
s
ar
e
st
or
ed
o
r m
ai
nt
ai
ne

233. d
m
us
t
en
su
re
th
e
in
te
gr
ity
, s
ec
ur
ity
a
nd
p
ro
te
ct
io

234. n
of
th
e
re
co
rd
s.
T
he
se
re
qu
ire
m
en
ts
a
pp
ly
to
b
ot
h

235. m
an
ua
l
an
d
el
ec
tr
on
ic
m
ed
ic
al
re
co
rd
s
ys
te
m
s.

236. 10
.0
0.
04
R
ec
or
d
Se
cu
ri
ty
&
Re
te
nt
io
n
Re
qu
ir
em

237. en
ts
.
M
ed
ic
al
re
co
rd
s
m
us
t b
e
re
ta
in
ed
in
th
ei

238. r o
rig
in
al
o
r l
eg
al
ly
re
pr
od
uc
ed
fo
rm
fo
r a
p
er
io
d
of

239. a
t l
ea
st
5
y
ea
rs
.
§4
82
.2
4(
b)
(1
)
Al
l m
ed
ic
al
re
co
rd

240. s
ar
e
re
ta
in
ed
in
th
ei
r o
rig
in
al
o
r
le
ga
lly
re
pr
od
uc
ed

241. fo
rm
in
h
ar
d
co
py
, m
ic
ro
fil
m
,
co
m
pu
te
r m
em
or
y
ba
nk

242. s,
o
r o
th
er
e
le
ct
ro
ni
c
st
or
ag
e
m
ed
ia
.
Th
e
ho
sp
ita

243. l m
us
t b
e
ab
le
to
p
ro
m
pt
ly
re
tr
ie
ve
th
e
co
m
pl
et
e
m

244. ed
ic
al
re
co
rd
o
f e
ve
ry
in
di
vi
du
al
e
va
lu
at
ed
or
tr
ea

245. te
d
in
a
ny
p
ar
t o
r l
oc
at
io
n
of
th
e
ho
sp
ita
l w
ith
in
th

246. e
la
st
5
y
ea
rs
.
IN
TE
RV
IE
W
, O
BS
ER
VA
TI
O
N
, A
N
D

247. C
H
A
RT
R
EV
IE
W
1.
D
et
er
m
in
e
th
at
m
ed
ic
al
re

248. co
rd
s
ar
e
re
ta
in
ed
fo
r a
t l
ea
st
fi
ve
(5
) y
ea
rs
, o
r m
or

249. e,
a
s
re
qu
ire
d
by
s
ta
te
o
r l
oc
al
la
w
s.
2.
D
et
er

250. m
in
e
th
at
th
e
m
ed
ic
al
re
co
rd
s
ar
e
st
or
ed
in
a
s
ec

251. ur
ed
m
an
ne
r.
3.
Se
le
ct
a
s
am
pl
e
of
p
at
ie
nt
s,
b

252. ot
h
in
pa
tie
nt
an
d
ou
tp
at
ie
nt
w
ho
w
er
e
pa
tie
nt
s
of

253. th
e
1
=
C
om
pl
ia
nt
2
=
N
ot
C
om
pl
ia
nt
Th
is
s

254. ta
nd
ar
d
is
n
ot
m
et
a
s
ev
id
en
ce
d
by
:
M

255. ED
IC
A
L
RE
CO
RD
S
(H
EA
LT
H
IN
FO
RM
A
TI
O
N
) S
ER
VI
CE
S

256. ST
A
N
D
A
RD
/
E
LE
M
EN
T
EX
PL
A
N
A
TI
O
N

257. SC
O
RI
N
G
P
RO
CE
D
U
RE
SC
O
RE
20
18
10
-6
H

258. FA
P
|
AC
CR
ED
IT
AT
IO
N
R
EQ
U
IR
EM
EN
TS
F
O
R
AC
U
TE
C

259. AR
E
H
O
SP
IT
AL
S
In
a
cc
or
da
nc
e
w
ith
F
ed
er
al
a

260. nd
S
ta
te
la
w
a
nd
re
gu
la
tio
ns
, c
er
ta
in
m
ed
ic
al
re
co

261. rd
s
m
ay
h
av
e
re
te
nt
io
n
re
qu
ire
m
en
ts
th
at
e
xc
ee
d

262. 5
ye
ar
s
(f
or
ex
am
pl
e:
F
D
A,
O
SH
A,
E
PA
).
ho
sp
ita

263. l b
et
w
ee
n
th
e
pr
ev
io
us
4
8-
60
m
on
th
s.
Re
qu
es
t t
he

264. ir
m
ed
ic
al
re
co
rd
.
In
cl
ud
e
bo
th
ho
sp
ita
l c
am
pu
s
an

265. d
of
f c
am
pu
s
lo
ca
tio
ns
.
D
et
er
m
in
e
th
e
m
ed
ic
al

266. re
co
rd
:
1)
Is
p
ro
m
pt
ly
re
tr
ie
ve
d?
2)
Is
c
om
pl

267. et
e?
3)
Is
in
o
rig
in
al
o
r i
n
a
le
ga
lly
re
pr
od
uc
es

268. fo
rm
?
10
.0
0.
05
Co
di
ng
&
In
de
xi
ng
.
Th
e
ho
sp
ita
l m
us

269. t h
av
e
a
sy
st
em
o
f
co
di
ng
a
nd
in
de
xi
ng
m
ed
ic
al
re
co

270. rd
s.
Th
e
sy
st
em
m
us
t a
llo
w
fo
r t
im
el
y
re
tr
ie
va
l b
y

271. di
ag
no
si
s
an
d
pr
oc
ed
ur
e,
in
or
de
r t
o
su
pp
or
t m
ed
ic

272. al
c
ar
e
ev
al
ua
tio
n
st
ud
ie
s.
§4
82
.2
4(
b)
(2
)
Th
e

273. fa
ci
lit
y
ha
s
an
e
ff
ic
ie
nt
, o
rg
an
iz
ed
s
ys
te
m
fo
r
co

274. di
ng
a
nd
in
de
xi
ng
m
ed
ic
al
re
co
rd
s
th
at
a
llo
w
s
fo
r

275. th
e
ti
m
el
y
re
tr
ie
va
l o
f i
nf
or
m
at
io
n.
IN
TE
RV
IE
W

276. &
D
O
CU
M
EN
T
RE
VI
EW
Ve
rif
y
th
at
th
e
fa
ci
lit
y
us

277. es
a
c
od
in
g
an
d
in
de
xi
ng
s
ys
te
m
th
at
p
er
m
its
ti
m

278. el
y
re
tr
ie
va
l
of
m
ed
ic
al
re
co
rd
s
by
d
ia
gn
os
is
p
ro

279. ce
du
re
.
1
=
C
om
pl
ia
nt
2
=
N
ot
C
om
pl
ia
nt

280. Th
is
s
ta
nd
ar
d
is
n
ot
m
et
a
s
ev
id
en
ce
d
by
:

281. M
ED
IC
A
L
RE
CO
RD
S
(H
EA
LT
H
IN
FO
RM
A
TI
O
N
) S
ER

282. V
IC
ES
ST
A
N
D
A
RD
/
E
LE
M
EN
T
EX
PL
A
N
A
TI

283. O
N
SC
O
RI
N
G
P
RO
CE
D
U
RE
SC
O
RE
20
18
v
2

284. 10
-7
H
FA
P
|
A
CC
RE
D
IT
A
TI
O
N
R
EQ
U
IR
EM
EN
TS
F

285. O
R
A
CU
TE
C
A
RE
H
O
SP
IT
A
LS
10
.0
0.
06
Se
cu
ri

286. ty
o
f M
ed
ic
al
In
fo
rm
at
io
n.
Th
e
ho
sp
ita
l m
us
t h
av
e

287. a
pr
oc
ed
ur
e
fo
r
en
su
rin
g
th
e
co
nf
id
en
tia
lit
y
of
p
at

288. ie
nt
re
co
rd
s.
In
fo
rm
at
io
n
fr
om
o
r c
op
ie
s
of
re
co

289. rd
s
m
ay
b
e
re
le
as
ed
o
nl
y
to
a
ut
ho
riz
ed
in
di
vi
du

290. al
s,
a
nd
th
e
ho
sp
ita
l m
us
t
en
su
re
th
at
u
na
ut
ho
riz
ed
in

291. di
vi
du
al
s
ca
nn
ot
g
ai
n
ac
ce
ss
to
o
r a
lte
r p
at
ie
nt
re

292. co
rd
s.
O
rig
in
al
m
ed
ic
al
re
co
rd
s
m
us
t b
e
re
le
as
ed

293. b
y
th
e
ho
sp
ita
l o
nl
y
in
ac
co
rd
an
ce
w
ith
F
ed
er
al
o

294. r S
ta
te
la
w
s,
co
ur
t o
rd
er
s,
o
r s
ub
po
en
as
.
Th
e
te

295. xt
in
g
of
p
at
ie
nt
o
rd
er
s
is
pr
oh
ib
it
ed
r
eg
ar
dl
es

296. s
of
t
he
p
la
tf
or
m
ut
ili
ze
d.
Th
e
te
xt
in
g
of
p
at

297. ie
nt
in
fo
rm
at
io
n
am
on
g
m
em
be
rs
o
f t
he
h
ea
lt
h
ca
re

298. te
am
is
p
er
m
is
si
bl
e
if
ac
co
m
pl
is
he
d
th
ro
ug
h
a

299. se
cu
re
p
la
tf
or
m
.
§ 4
82
.2
4(
b)
(3
)
RE
LE
A
SE
O
F
IN

300. FO
RM
A
TI
O
N
o
r
CO
PI
ES
O
F
RE
CO
RD
S
Th
e
ho
sp
ita
l m

301. us
t h
av
e
a
pr
oc
ed
ur
e
to
e
ns
ur
e
th
e
co
nf
id
en
tia
lit
y

302. of
e
ac
h
pa
tie
nt
’s
m
ed
ic
al
r
ec
or
d,
w
he
th
er
it
is
in

303. p
ap
er
o
r
el
ec
tr
on
ic
fo
rm
at
, o
r
a
co
m
bi
na
tio
n
of
th

304. e
tw
o,
fr
om
u
na
ut
ho
ri
ze
d
di
sc
lo
su
re
.
Co
nf
id
en
tia
lit

305. y
ap
pl
ie
s
w
he
re
ve
r
th
e
re
co
rd
o
r
po
rt
io
ns
th
er
eo

306. f a
re
s
to
re
d,
in
cl
ud
in
g
bu
t n
ot
li
m
ite
d
to
c
en
tr
al
r

307. ec
or
ds
, p
at
ie
nt
c
ar
e
lo
ca
tio
ns
, r
ad
io
lo
gy
,
la
bo
ra
to

308. ri
es
, r
ec
or
d
st
or
ag
e
ar
ea
s,
e
tc
.
A
h
os
pi
ta
l i
s
pe

309. rm
itt
ed
to
d
is
cl
os
e
m
ed
ic
al
r
ec
or
d
in
fo
rm
at
io
n,
w

310. ith
ou
t a
p
at
ie
nt
’s
a
ut
ho
ri
za
tio
n,
in
or
de
r
to
p
ro
vi

311. de
p
at
ie
nt
c
ar
e
an
d
pe
rf
or
m
r
el
at
ed
ad
m
in
is
tr

312. at
iv
e
fu
nc
tio
ns
, s
uc
h
as
p
ay
m
en
t a
nd
o
th
er
ho
sp
ita

313. l o
pe
ra
tio
ns
.
1.
Pa
ym
en
t o
pe
ra
tio
ns
in
cl
ud
e
ho
sp
ita
l a

314. ct
iv
iti
es
to
ob
ta
in
p
ay
m
en
t o
r
be
r
ei
m
bu
rs
ed
fo
r

315. th
e
pr
ov
is
io
n
of
h
ea
lth
c
ar
e
to
a
n
in
di
vi
du
al
.

316. 2.
H
ea
lth
c
ar
e
op
er
at
io
ns
a
re
a
dm
in
is
tr
at
iv
e,

317. fin
an
ci
al
, l
eg
al
, a
nd
q
ua
lit
y
im
pr
ov
em
en
t a
ct
iv
iti
es

318. of
a
h
os
pi
ta
l t
ha
t a
re
n
ec
es
sa
ry
to
c
on
du
ct
bu
si
ne

319. ss
a
nd
to
s
up
po
rt
th
e
co
re
fu
nc
tio
ns
o
f
tr
ea
tm
en
t a
nd

320. p
ay
m
en
t.
T
he
se
a
ct
iv
iti
es
in
cl
ud
e,
bu
t a
re
n
ot
li

321. m
ite
d
to
:
Q
ua
lit
y
as
se
ss
m
en
t a
nd
im
pr
ov
em
en
t
ac
tiv

322. iti
es
,
Ca
se
m
an
ag
em
en
t a
nd
c
ar
e
co
or
di
na
tio
n;
Co
m

323. pe
te
nc
y
as
su
ra
nc
e
ac
tiv
it
ie
s,
c
on
du
ct
in
g
or
ar
ra

324. ng
in
g
fo
r
m
ed
ic
al
r
ev
ie
w
s,
a
ud
its
, o
r
le
ga
l
D
O

325. CU
M
EN
T
RE
V
IE
W
, I
N
TE
RV
IE
W
A
N
D
O
BS
ER
V
A
TI

326. O
N
1.
Ve
ri
fy
th
at
p
ol
ic
ie
s
ar
e
in
p
la
ce
th
at
li

327. m
its
ac
ce
ss
to
, a
nd
d
is
cl
os
ur
e
of
, m
ed
ic
al
r
ec
or
ds

328. to
p
er
m
itt
ed
u
se
rs
a
nd
u
se
s,
a
nd
th
at
r
eq
ui
re

329. w
ri
tt
en
a
ut
ho
ri
za
tio
n
fo
r
ot
he
r
di
sc
lo
su
re
s.
A

330. re
th
e
po
lic
ie
s
co
ns
is
te
nt
w
it
h
th
e
re
gu
la
to
ry
r
eq

331. ui
re
m
en
ts
?
2.
O
bs
er
ve
w
he
th
er
p
at
ie
nt
r
ec
or
ds

332. a
re
s
ec
ur
ed
fr
om
u
na
ut
ho
ri
ze
d
ac
ce
ss
a
t a
ll
tim
es

333. a
nd
in
al
l l
oc
at
io
ns
.
3.
A
sk
th
e
ho
sp
ita
l t
o
de

334. m
on
st
ra
te
w
ha
t
pr
ec
au
tio
ns
a
re
ta
ke
n
to
p
re
ve
nt
p

335. hy
si
ca
l o
r
el
ec
tr
on
ic
a
lt
er
in
g
of
c
on
te
nt
p
re
vi
ou

336. sl
y
en
te
re
d
in
to
a
p
at
ie
nt
r
ec
or
d,
o
r
to
p
re
ve
nt

337. un
au
th
or
iz
ed
d
is
po
sa
l o
f p
at
ie
nt
r
ec
or
ds
.
4.
Ve

338. ri
fy
th
at
p
at
ie
nt
m
ed
ic
al
r
ec
or
d
in
fo
rm
at
io
n
is
r

339. el
ea
se
d
on
ly
a
s
pe
rm
itt
ed
un
de
r
th
e
ho
sp
ita
l’s
p
ol

340. ic
ie
s
an
d
pr
oc
ed
ur
es
.
5.
Co
nd
uc
t o
bs
er
va
tio
ns
a
nd

341. in
te
rv
ie
w
s
ta
ff
to
de
te
rm
in
e
w
ha
t s
af
eg
ua
rd
s
ar

342. e
in
p
la
ce
o
r
pr
ec
au
tio
ns
a
re
ta
ke
n
to
p
re
ve
nt
un

343. au
th
or
iz
ed
p
er
so
ns
fr
om
g
ai
ni
ng
p
hy
si
ca
l
ac
ce
ss
o

344. r
el
ec
tr
on
ic
a
cc
es
s
to
in
fo
rm
at
io
n
in
pa
tie
nt
r
ec

345. or
ds
.
6.
If
th
e
ho
sp
ita
l u
se
s
el
ec
tr
on
ic
p
at
ie
nt

346. re
co
rd
s,
is
a
cc
es
s
to
p
at
ie
nt
r
ec
or
ds
co
nt
ro
lle
d

347. th
ro
ug
h
st
an
da
rd
m
ea
su
re
s,
s
uc
h
as
b
us
in
es
s
ru
le

348. s
de
fin
in
g
pe
rm
itt
ed
a
cc
es
s,
1
=
C
om
pl
ia
nt
2
=

349. N
ot
C
om
pl
ia
nt
Th
is
s
ta
nd
ar
d
is
n
ot
m
et
a
s
ev

350. id
en
ce
d
by
:
M
ED
IC
A
L
RE
CO
RD
S
(H
EA
LT
H
IN
FO

351. RM
A
TI
O
N
) S
ER
V
IC
ES
ST
A
N
D
A
RD
/
E
LE
M
EN
T

352. EX
PL
A
N
A
TI
O
N
SC
O
RI
N
G
P
RO
CE
D
U
RE
SC

353. O
RE
20
18
v
2
10
-8
H
FA
P
|
A
CC
RE
D
IT
A
TI
O
N
R

354. EQ
U
IR
EM
EN
TS
F
O
R
A
CU
TE
C
A
RE
H
O
SP
IT
A
LS

355. se
rv
ic
es
, i
nc
lu
di
ng
fr
au
d
an
d
ab
us
e
de
te
ct
io
n
an
d

356. co
m
pl
ia
nc
e
pr
og
ra
m
s;
Bu
si
ne
ss
p
la
nn
in
g,
d
ev
el

357. op
m
en
t,
m
an
ag
em
en
t,
an
d
ad
m
in
is
tr
at
io
n
an
d
ce

358. rt
ai
n
ho
sp
ita
l-s
pe
ci
fic
fu
nd
ra
is
in
g
ac
tiv
iti
es
.
PO
LI

359. CI
ES
A
N
D
P
RO
CE
D
U
RE
S
Th
e
ho
sp
ita
l m
us
t d
ev
el
op
p

360. ol
ic
ie
s
an
d
pr
oc
ed
ur
es
th
at
r
ea
so
na
bl
y
lim
it
di
sc

361. lo
su
re
s
of
in
fo
rm
at
io
n
co
nt
ai
ne
d
in
th
e
pa
tie
nt
’s
m

362. ed
ic
al
r
ec
or
d
to
th
e
m
in
im
um
d
is
cl
os
ur
e
ne
ce
ss
ar

363. y,
e
xc
ep
t w
he
n
th
e
di
sc
lo
su
re
is
fo
r
tr
ea
tm
en
t o
r
pa

364. ym
en
t p
ur
po
se
s,
o
r
as
ot
he
rw
is
e
re
qu
ir
ed
b
y
St
at

365. e
or
F
ed
er
al
la
w
.
W
he
n
th
e
m
in
im
um
n
ec
es
sa
ry

366. s
ta
nd
ar
d
is
a
pp
lie
d,
a
ho
sp
ita
l m
ay
n
ot
d
is
cl
os
e

367. th
e
en
tir
e
m
ed
ic
al
r
ec
or
d
fo
r …
THE LORETTO HOSPITALMEDICAL STAFF RULES AND
REGULATIONS
Adopted Medical Staff: 10/02/08
Approved by the Board of Trustees: 12/08/08
Revised and Adopted by the Medical Staff: 01/02/09
Approved by the Board of Trustees: 04/06/09

368. Revised and Adopted by the Medical Staff: 02/02/10
Approved by the Board of Trustees: 03/15/10
Revised and Adopted by the Medical Staff: 04/25/11
Approved by the Board of Trustees: 06/20/11
Revised and Adopted by the Medical Staff: 08/31/15
Approved by the Board of Trustees: 08/31/15
Revised and Adopted as by the Medical Staff: 01/08/19
Approved by the Board of Trustees: 02/27/19
Revised and Adopted by the Medical Staff: 06/19/19
Adopted by the Board of Trustees: 09/10/19
THE LORETTO HOSPITAL
MEDICAL STAFF RULES AND REGULATIONS
TABLE OF CONTENTS
Article I
Admission and Discharge of Patients
3
Section 1.1
Admissions
3
Section 1.2
Discharges
5

369. Article II
General Conduct of Care
8
Section 2.1
Responsibility for Care and Treatment
8
Section 2.2
Consultations
8
Section 2.3
Patient Encounters
10
Section 2.4
Informed Consent
10
Section 2.5
Treatment Orders
11
Section 2.6
Standing Orders
14
Section 2.7
Drugs and Medications
14
Section 2.8
Orders for Outpatient Services
15

370. Article III
Seclusion and Restraints
19
Section 3.1
Definition of Restraint
19
Section 3.2
Definition of Seclusion
19
Section 3.3
Use of Seclusion or Restraint
19
Section 3.4
Orders for Seclusion or Restraint
20
Section 3.5
Monitoring of Patients in Seclusion or Restraint
21
Section 3.6
Documentation of Seclusion and Restraint
21
Article IV
Medical Records
22
Section 4.1
Medical Records
22
Section 4.15
Medical History and Physical Examinations
25

371. Article V
Deaths and Autopsy
30
Section 5.1
Deaths
30
Section 5.2
Autopsy
31
Article VI
Surgery and Procedural Specialties
32
Section 6.1
Pre-Surgical Documentation
32
Section 6.2
Tissue Disposition
33
Section 6.3
Post-Surgical Documentation
34
Section 6.4
Oral Surgery
35
Section 6.5
Obstetrics

372. 35
Section 6.6
Special Privileges
36
Article VII
Moderate (Conscious) Sedation
36
Section 7.1
Moderate (Conscious) Sedation
36
Article VIII
Emergency Room Facilities
37
Section 8.1
General Policies
37
Section 8.2
Responsibilities of the On-Call Practitioner
38
Article IX
EMTALA Policy
38
Section 9.1
Requirements
38
Section 9.2
Medical Screening Examination (MSE)
38
Section 9.3

373. Stabilization
39
Section 9.4
Duties of On-Call Physicians
39
Section 9.5
Arrangement for Back-Up Call
40
Section 9.6
Transfers and Discharge
40
Section 9.7
Records
41
Section 9.8
Reporting
41
Article X
Patient Rights
41
Section 10.1
Exercise of Rights
41
Section 10.2
Privacy and Safety
42

374. Section 10.3
Confidentiality of Patient Records
42
Article XI
Emergency Operations Plan (EOP)
42
The Medical Staff shall adopt Rules and Regulations as may be
necessary to implement the general principles as described in
the Medical Staff Bylaws and the policies of the Hospital. Such
Rules and Regulations shall be accepted or amended on
approval by a majority of votes cast by the Medical Executive
Committee of the Medical Staff (MEC). Rules and Regulations
discussed herein shall relate to the proper conduct of Medical
Staff organizational activities in the care of all patients treated
at Loretto Hospital, as well as the quality of practice and the
standards of performance that are to be required of each
Practitioner. These Rules and Regulations shall constitute a
supplement to the Medical Staff Bylaws; and be binding on all
members of the Medical Staff.
ARTICLE I - ADMISSION AND DISCHARGE OF PATIENTS
1.1
Admissions
1.1.1 Patients are admitted to the hospital only on the
recommendation of a licensed practitioner, Doctor of Medicine
or Doctor of Osteopathy, permitted to admit patients to a
hospital, who are currently licensed and have been granted
admitting privileges by the Board of Trustees in accordance
with State of Illinois law and the Medical Staff Bylaws.
1.1.1.1 Every Medicare or Medicaid patient must be under the
care of a licensed practitioner who is a Doctor of Medicine or
Doctor of Osteopathy; or a Doctor of Dental Surgery or Dental
Medicine who is legally authorized to practice dentistry by the
State of Illinois and who is acting within the scope of his/her

375. license; or a Doctor of Podiatric Medicine, but only with respect
to functions which he or she is legally authorized by the State
of Illinois to perform; or a Doctor of Optometry who is legally
authorized to practice Optometry by the State of Illinois; or a
Chiropractor who is licensed by the State of Illinois or legally
authorized to perform the services of a chiropractor, but only
with respect to treatment by means of manual manipulation of
the spine to correct a subluxation demonstrated by x-ray to
exist; or a Clinical Psychologist but only to the extent permitted
by State of Illinois law. If a Medicare patient is admitted by a
practitioner not specified in this Section 11.1.1, that patient is
under the care of a Doctor of Medicine or a Doctor of
Osteopathy.
1.1.2
All patients shall be admitted to Loretto Hospital without
restriction based upon race, color, creed, sex, religion or ability
to pay. All patients will receive the same level of care and
treatment. Recording race, color, creed, sex, or religion of the
patient, as part of the history and physical, is permissible if it
will help facilitate statistical, spiritual or diagnostic purposes.
1.1.3
Except in an emergency, no patient shall be admitted to the
Hospital until a provisional diagnosis is made or valid reason
for hospitalization has been stated and the provisional
diagnosis/reason for hospitalization has been given to the
admission officer by the Staff Physician and assurance of bed
availability has been secured. In the case of an emergency, a
provisional diagnosis shall be recorded in the patient’s chart
within the first 24 hours of admission.
1.1.4
The patient shall be assigned to the admitting service of his
private practitioner. In the case of a patient requiring
admission who has no private practitioner, he or she shall be
assigned to the on-call attending for the service by the
Attending Physician of the emergency room. If possible,

376. patients who are without a private practitioner shall be given an
opportunity to select an appointee of the Medical Staff to be
responsible for his care while in the Hospital.
1.1.5
A Physician seeking admission of a patient shall give all such
information that may be available to him to assure the
protection of the patient from self-harm as well as the
protection of other patients and Hospital personnel from any
cause whatsoever.
1.1.6
If a patient requires custodial protection (and this includes
attempted suicide cases) the Physician shall request consultation
of a Staff psychiatrist of his choice upon admission of the
patient. The psychiatrist will evaluate the patient within
twenty-four hours of admission. Patient will be kept on suicide
precautions until evaluated by the psychiatrist.
1.1.7
As much as possible, the Physician must furnish all information
concerning cases of infection so proper isolation techniques
may be taken. The Hospital will not accept contagious cases
prohibited by the rules of the Chicago Department of Health or
Department of Public Health, State of Illinois.
1.1.8
It will be the responsibility of the Attending Physician to satisfy
all requirements of Medicare and/or Medicaid programs as
required by law.
1.1.9
Patients shall be admitted to the Hospital on the basis of the
following order of priorities when there is a shortage of
available beds: (i) Emergency; (ii) Urgent; and (iii) Elective.
1.1.10
Elective admissions to the Hospital shall occur preferably in the
morning.

377. 1.1.11
An admission assessment on each patient admitted to the
hospital must be completed and authenticated within 24 hours of
admission.
1.1.12
Multidisciplinary Plan of Care
Inpatients will have a plan of care initiated within twenty-four
(24) hours of admission. The Plan of Care includes: Provider’s
orders; Provider History and Physical Examination; Notes
(progress, consult, etc.); Conditional documentation; and other
appropriate documents that relate the Plan of Care to the
Multidisciplinary Team. All disciplines involved in the care of
a patient collaborate to develop the patient’s Plan of Care.
Each healthcare team member provides input into the Plan of
Care. The patient/family/significant other is included in the
development, implementation, maintenance, planning and
evaluation of the care provided. Patients receive care and
treatment based on an assessment of their needs, the severity of
their disease, condition, impairment, or disability. The data
obtained from the assessment is used to determine and prioritize
the patient’s Plan of Care. The patient’s progress will be
evaluated as necessary and the Plan of Care will be revised as
indicated.
1.2
Discharges
Discharge Plan:
1.2.1
A discharge plan shall be initiated within 24 hours of the
admission. The Hospital must have an effective Discharge
Planning process that applies to all patients. The Hospital must

378. identify at an early stage of hospitalization all patients who are
likely to suffer adverse health consequences upon discharge if
there is no adequate discharge planning. The Hospital must
provide a discharge planning evaluation to the patients who are
likely to suffer adverse health consequences upon discharge if
there is no adequate discharge planning, and to other patients
upon the patient’s request, the request of a person acting on the
patient’s behalf, or the request of the physician.
1.2.2
The discharge planning evaluation must include the likelihood
of a patient needing post-hospital services and the availability
of the services. The discharge planning evaluation must include
the likelihood of a patient’s capacity for self-care or the
possibility of the patient being cared for in the environment
from which he or she entered the hospital. The discharge
planning evaluation must be included in the patient’s medical
record for use in establishing an appropriate discharge plan.
1.2.3
The Hospital must transfer or refer patients, along with
necessary medical information, to appropriate facilities,
agencies, or outpatient services, as needed, for follow-up or
ancillary care.
1.2.4
The Hospital must arrange for the initial implementation of the
patient’s discharge plan. The Hospital must reassess its
discharge planning process on an on-going basis. The
reassessment must include a review of discharge plans to ensure
that they are responsive to discharge needs.
1.2.5
Referrals should be made to the Social Services Department
indicated.
Discharge Orders and Discharge Summary:
1.2.6

379. Patients shall be discharged only on written order of the
Attending Physician. The Attending Physician shall see that the
record is complete, state his final diagnosis and sign the reports.
1.2.7
The Discharge Order shall be completed 24 hours in advance of
the intended discharge date and, where indicated, the assigned
Social Worker shall be notified whenever necessary.
1.2.8
The Discharge Summary shall be completed within, or prior to
seven (7) days of discharge. The medical record must contain a
discharge summary with outcome of hospitalization, disposition
of case and provisions for follow-up care. The Discharge
Summary must include Reason for Hospitalization; Significant
Findings; Procedures and Treatment Provided; Patient’s
Discharge Condition; Patient and Family Instructions (as
appropriate); and the Attending Physician’s Signature and
should also include at least the following:
1)
Patient Demographics (Patient name; Patient Identifier/Medical
Record Number; and Gender);
2)
Visit/Encounter (Admission Date; Discharge Date; Discharge
Diagnosis; and Discharge Disposition);
3)
Diagnosis (Pre-Existing/Developed Conditions Impacting
Hospital Stay; Conditions not Impacting LOS);
4)
Course While in Hospital (Presenting Complaint(s); Summary
Course in Hospital; Investigations – Summary of Examinations
and Tests conducted while in Hospital; Interventions
(Procedures & Treatments); Documentation of complications,
hospital acquired infections, an unfavorable reactions to drugs
and anesthesia, and Final Diagnosis;
5)

380. Alert Indicators – Allergies;
6)
Discharge Plan - All Medications at Discharge; Follow-Up
Instructions for Patient; Follow-Up Plan Recommended for
Receiving Provider(s); Referrals (Referrals that have been
initiated by the sender); and Copies to be Sent To (Other
clinicians who are included in the care of patient).
1.2.9
The MD/DO or other qualified practitioner with admitting
privileges approved by the Board of Trustees, in accordance
with State of Illinois law and hospital policy, who admitted the
patient is responsible for the patient during the patient’s stay in
the hospital. This responsibility would include developing and
entering the Discharge Summary. Other MD/DOs who work
with the patient’s MD/DO and who are covering for the
patient’s MD/DO and who are knowledgeable about the
patient’s condition, the patient’s care during the hospitalization,
and the patient’s discharge plans may write the Discharge
Summary at the responsible MD/DO’s request. In accordance
with hospital policy, and 42 CFR Part 482.12(c) (1)(i), the
MD/DO may delegate writing the Discharge Summary to other
qualified health care personnel such as Nurse Practitioners and
MD/DO Assistants to the extent recognized under State of
Illinois law or a State of Illinois regulatory mechanism.
Whether delegated or non-delegated, it is expected that the
person who writes the Discharge Summary to authenticate, date,
and time their entry and additionally for delegated discharge
summaries, it is required that the MD/DO responsible for the
patient during his/her hospital stay to co-authenticate and date
the discharge summary to verify its content. The discharge
summary requirement would include outpatient records.
Medical Certification of Death:
1.2.10
Medical Certification of Death: The Attending Physician is

381. required to complete the "Cause of Death” and "Physician's
certification" portions of the certificate within twenty-four
hours after the death so that the mortician can meet the
requirements for filing. The Physician should be given
opportunity to arrange for any necessary post-mortem
examination of his patient before the body is embalmed. The
public interest requires that the cause of every death be
determined as fully and accurately as possible. The body must
not be removed to a mortuary until the Attending Physician has
agreed to its removal from the place of death. To facilitate this,
the Physician should, when notified of the death, and if no
autopsy has been secured, give the cause of death so that the
mortician may call the Department of Health and secure
permission for the removal of the body. All deaths shall be
reviewed at the next meeting of the respective clinical
Department of the Medical Staff.
ARTICLE II - GENERAL CONDUCT OF CARE
2.1
Responsibility for Care and Treatment
2.1.1
A Doctor of Medicine or Doctor of Osteopathy is on duty or on
call at all times in the hospital to provide medical care and
onsite supervision when necessary. The patient is under the
care of a doctor of medicine, a doctor of osteopathy, a doctor of
dental surgery, a doctor of podiatric medicine, a doctor of
optometry, a chiropractor or a clinical psychologist, each
practicing within the extent of state and federal law and as
privileged and credentialed under the Medical Staff Bylaws.
Further, a doctor of medicine or osteopathy shall be responsible
for the care of each patient with respect to any medical or
psychiatric condition that is present on admission or develops
during hospitalization and is not specifically within the scope of
practice of a Doctor of Dental Surgery, Dental Medicine,

382. Podiatric Medicine, or Optometry, a Chiropractor, or Clinical
Psychologist, as that scope is: A) Defined by the Medical
Staff; B) Permitted by State of Illinois law; and C) Limited
under CMS paragraph 482.12 (c )(1)(v) with respect to
Chiropractors.
2.1.2
Whenever the responsibilities of the patient’s Attending
Physician are permanently transferred to another Medical Staff
member qualified to act as the patient’s Attending Physician,
the outgoing Attending Physician shall clearly note the transfer
of responsibility to the new Attending Physician in the patient’s
Medical Record.
2.2
Consultations
2.2.1
The good conduct of medical practice includes the proper and
timely use of consultation. Judgment as to the seriousness of
the illness and the resolution of any doubt regarding the
diagnosis and treatments rests with the Practitioner responsible
for the care of the patient. On the other hand, it is the duty of
the organized Medical Staff, through the Department
Chairmenand the Medical Executive Committee, to see that
those Practitioners practicing in the Hospital do not fail to call
consultants as needed.
2.2.2
When the clinical presentation of a patient is not within the
scope and expertise of the primary Physician, consultation with
an appropriate Physician is recommended.
2.2.3
The consultation must be performed by a Physician who is
credentialed in the field in which his opinion is sought.
2.2.4
Applicants for active membership must agree to provide care

383. and consultation for any patients admitted to the Hospital or
arrange for alternative consultation if the initial consult is
refused in accordance with these bylaws and rules and
regulations.
2.2.5
Requests for consultation should be made by direct personal
communication from the Attending Practitioner to the
Consulting Practitioner.
2.2.6
Upon notification, it is expected that consultations will be
provided by the end of the following day. Any delay is to be
promptly discussed with the Attending Practitioners. When
operative procedures are involved, the consultation note, except
in an emergency, shall be record prior to operation.
2.2.7
For each patient on whose case a Consultant agrees to consult,
the Consultant shall review the patient's medical record,
conduct an appropriate history and physical examination of the
patient, and prepare a written or dictated Consultation Report
signed by the Consultant that reflects an actual examination of
the patient and the patient's medical record.
2.2.8
A Consultant who agrees to assume any portion of a patient’s
care or treatment shall be responsible for that portion of the
patient’s care or treatment until the Consultant informs the
Attending Physician that the Consultant is returning such
responsibility to the Attending Physician and records a written
notation of such in the patient’s Medical Record.
2.2.9
Consultation is recommended in major surgical cases in which
the patient is not a good risk; in all cases in which the diagnosis
is obscure, or when there is doubt as to the best therapeutic
measure to be utilized; and in all cases where a patient is
suicidal. Judgment as to the serious nature of the illness and

384. the question of doubt as to diagnosis and treatment rests with
the Physician responsible for the care of the patient. It is the
duty of the Hospital Staff through the clinical Departments and
the Medical Executive Committee to see that members of the
Staff do not fail in the matter of calling Consultants as needed.
2.2.10
In circumstances of grave urgency, the President & CEO and
Medical Staff President or their respective designee, shall at all
times have the right to call in a Consultant after conferring with
the appropriate departmental chairperson.
2.2.11
If the Attending Physician and consultant disagree, a second
Consultant should be called for an opinion.
2.2.12
Children under age twelve (12) who need special treatment
procedures and/or adolescents who need psychiatric or
substance abuse services are referred to other specialty
hospitals.
2.2.13
Joint Admissions: When requested by the attending
psychiatrist, a Physician who does not have consultative
privileges may follow and treat the patient on the Psychiatry
Unit subject to the limits of his privileges and as permitted by
the respective Department policies.
2.2.14
The patient or the patient's surrogate decision-maker must be
advised of the requested consultations and the name of the
Consultant by the Attending Physician.
2.3
Patient Encounters
2.3.1

385. Each Attending Physician and each Consultant who has assumed
any portion of a patient’s care or treatment, or another member
covering for them in their absence, shall personally assess their
patients at least once per day while admitted to the Hospital or
Special Unit. At the time of each such assessment, or as soon
as possible thereafter, the Attending Physician or Consultant
shall record a Progress Note in the patient’s Medical Record.
2.4
Informed Consent
2.4.1
Written Consent: The treating Physician is responsible for
obtaining a valid consent in accordance with Hospital policy
before initiating treatment. The medical records shall contain
evidence of informed consent for procedures and treatments for
which it is required by Hospital policy. Consent forms must be
signed by the patient or his authorized designee. The name of
the Physician who is to perform the procedure or treatment
should be written on the consent form in the space provided for
this information. There are to be no additions, modifications or
deletions to the Informed Consent once it has been signed by
the patient or his legal representative. Written consents
obtained more than thirty (30) days prior to the initiation of
care or treatment will not be valid. Informed Consent will be
written in simple sentences and in the primary language of the
patient.
2.4.2
No autopsy shall be performed without a properly completed
written Informed Consent by the authorized next of kin or the
legal representative.
2.4.3
Except in emergencies, patients are entitled to receive, in terms
or language that they can understand as much information about
the proposed procedure or treatment as may be needed to make
an informed decision.
2.4.4

386. Telephone Consent: When a patient is unable to consent for his
treatment and when it is impossible for the individuals listed in
the applicable Hospital policy to come to the Hospital to sign
for the patient's treatment, it is permissible to accept consent
from these individuals over the telephone. In such cases, two
individuals, other than the Physician who is to perform the
procedure, must witness the consent over the phone. The chart
must indicate that telephone consent was received, the name of
the witnesses, time, date, and phone number of the person
providing the consent, and relationship to patient.
2.4.5
Emergency Consent: In the case of an emergency, and when no
consent is able to be obtained from the patient or next of kin
(life-threatening situation when death, loss of limb or function
of a major organ would probably ensue if medical intervention
is not immediately implemented), administrative review is not
required. The Physician documents the emergency in the medial
record and proceeds with appropriate treatment.
2.5
Treatment Orders
2.5.1
With the exception of influenza and pneumococcal
polysaccharide vaccines, which may be administered per
Physician-approved Hospital policy after an assessment of
contraindications, orders for drugs and biologicals must be
documented and signed by a Practitioner who is authorized to
write orders by Hospital policy and in accordance with State
law, and who is responsible for the care of the patient.
2.5.2
Initiation of Medical Staff approved written protocols and/or
standing orders for drugs or biological requires an order from a
Practitioner responsible for the patient's care.
2.5.3
Except as specifically provided herein, all orders for treatment
shall be in writing. All orders, including verbal orders, shall be

387. dated and timed, and authenticated promptly within forty-eight
(48) hours, by the ordering Practitioner or another Practitioner
who is responsible for the care of the patient and authorized to
write orders by Hospital policy in accordance with Federal and
State Law.
2.5.4
In accordance with standard practice, elements that must be
present in orders for all drugs and biologicals to ensure safe
preparation and administration include: (i) Name of patient
(present on order sheet or prescription); (ii) Age and weight of
patient, when applicable; (iii) Date and time of the order; (iv)
Drug name; (v) Exact strength or concentration, when
applicable; (vi) Dose, frequency, and route; (vii) Quantity
and/or duration, when applicable; (viii) Specific instructions for
use, when applicable; and (ix) Name of prescriber.
2.5.5
If verbal orders are used, they are to be used infrequently.
Verbal and telephone orders should relate only to the immediate
needs of the patient. Verbal communication of orders should
only be used if the circumstances are such that an immediate
order is required and it would be impossible or impractical for
the ordering Practitioner to write the order without delaying
treatment. Verbal orders are not to be used for the convenience
of the Practitioner.
2.5.5.1
A Physician may give verbal or telephone orders which can be
accepted only by persons who are authorized to do so by
Hospital policy and procedures consistent with Federal and
State law, such as a house physician, resident, registered
professional nurse, advanced practice nurse, physician assistant,
registered dietician, registered pharmacist, registered or
certified respiratory therapist, licensed clinical psychologist,
registered speech therapist, registered physical therapist or
certified social worker. Verbal orders must be authenticated
within forty-eight (48) hours by the ordering Practitioner,
especially any order for narcotics, intravenous medications,

388. restraints, anticoagulants, suicide precaution, pre-operative and
postoperative orders and CCU orders.
2.5.5.2
The content of verbal orders must be clearly communicated. All
verbal orders must be immediately documented in the patient's
medical record and signed by the individual receiving the order.
Verbal orders should be recorded directly onto an order sheet in
the patient's medical record or entered into the computerized
order entry system, if applicable.
2.5.5.3
The transcriber of the verbal or telephone order will read back
the order and the ordering Practitioner then will confirm the
accuracy of the order to conform to patient safety initiatives.
Each verbal order shall be dated and timed and identify the
name of the individual who gave it and who received it and the
record shall indicate who implemented it. Verbal and telephone
orders will be flagged for the Practitioner's signature by the
registered nurse or other authorized person who received it.
2.5.5.4
A qualified non-physician practitioner, such as a physician
assistant (PA) or nurse practitioner (NP), who is responsible for
the care of the patient may authenticate a physician’s or other
qualified non-physician’s order only if the order is within
his/her scope of practice. If State law requires that the ordering
practitioner authenticate his/her own orders, or his/her own
verbal orders, then a practitioner other than the prescribing
practitioner would not be permitted to authenticate the verbal
order.
2.5.6
The Practitioner's orders must be written clearly, legibly and
completely. Orders which are illegible or improperly written
will not be carried out until rewritten or understood by the
nurse. The use of "Renew", "Repeat", and "Continue Orders"
are not acceptable.
2.5.7
Patient orders may be written by a House Staff Physician.

389. House Staff Physician orders do not require countersignature by
the Attending Physician. This shall not prohibit the Attending
Practitioner from writing orders on those patients. The refusal
of a Medical Staff member to allow House Physicians to write
orders on his private patients shall not be the basis for any
sanction or loss of privileges or prerogative.
2.5.8
All requests for treatment, restraints and/or medications shall be
in writing and documented on the Order Sheet and shall be
signed, dated and timed by the prescribing Practitioner.
Seclusion and Restraint orders must be episode-specific, time-
limited with specific starting and end times as outlined in the
Hospital Seclusion and Restraint Policy and Procedures and in
conformance with Article III of these Rules and Regulations.
2.5.9
Orders for anticoagulants, narcotics, antibiotics, hypnotic,
tranquilizers, sedatives and steroids shall be cancelled
automatically according to Hospital policy unless specifically
ordered by a Physician for a longer definite period. All orders
for patients shall be reviewed by the Attending Physician at
least every third day. The prescribing Practitioner must be
notified within twenty-four (24) hours before an order is
automatically stopped. If the order expires during the night, the
prescribing Practitioner should be so informed the following
morning. In no event shall the drug or treatment indicated be
given for the maximum duration indicated if the last effective
order specifies a shorter interval.
2.5.10
A surgical operation, except ECT, shall automatically cancel all
orders, except DNR Orders, which are rescinded during surgery
and reinstated after surgery.
2.5.11
Do Not Resuscitate (“DNR”) Orders
2.5.11.1
It is the …