rules and regulations.doc

Children’s Hospital of Wisconsin – KenoshaMedical-Dental Staff

Rules and Regulations

Effective August 21, 2008

Medical-Dental Staff Rules and Regulations Children’s Hospital of Wisconsin - Kenosha

TABLE OF CONTENTS

GENERAL OBLIGATIONS__________________________________________________________4

COMMUNICATION AND SERVICE STANDARDS______________________________________4

Physician Roles_________________________________________________________________________4

Inpatients______________________________________________________________________________4

Medical-Dental Staff Code of Professionalism________________________________________________4Fundamental Principles__________________________________________________________________5Professional Responsibilities_____________________________________________________________5Technical Quality of Care________________________________________________________________5Patient Safety__________________________________________________________________________5Quality of Service______________________________________________________________________6Resource Utilization____________________________________________________________________6Peer and Co-Worker Relationships_________________________________________________________6Citizenship____________________________________________________________________________7

INPATIENT MANAGEMENT: ADMISSION, TREATMENT AND DISCHARGE____________7

General Responsibilities__________________________________________________________________7

General Medical and Surgical Patients_____________________________________________________8

Critically Ill Patients or Patients with Significant Deterioration_________________________________8

CARE OF PATIENTS UNDER GOING INVASIVE PROCEDURES________________________8

Consent to Surgery at KHMC, or for a Special Procedure_____________________________________8

Pre-operative and Pre-procedural Histories and Physicals_____________________________________8

The Surgeon is Responsible for____________________________________________________________9

The Anesthesiologist is Responsible for____________________________________________________10

CARE OF DENTAL AND PODIATRY PATIENTS_____________________________________10

The Dentist is Responsible for____________________________________________________________10

MEDICAL/SURGICAL CONSULTATION AND TRANSFER OF SERVICE_______________12

Consultation___________________________________________________________________________12

Expectations/Responsibilities of the Attending Physician to the Consultant______________________12

Expectations/Responsibilities of the Consultant_____________________________________________12

CARE OF OUTPATIENTS_________________________________________________________12

MEDICAL ORDERS______________________________________________________________12

General Rules_________________________________________________________________________13

Inpatient Orders_______________________________________________________________________13

Approved: CHW-K MEC 2/11/02; CHW Board of Directors 4/10/02Revised: CHW-K MEC 9/8/03; CHW Board of Directors 11/20/03Revised: CHW-K MEC 8/8/05; CHW Board of Directors 11/29/05Revised: CHW-K MEC 12/9/05; CHW Board of Directors 2/1/06Revised: CHW-K MEC: 6/11/07; 7/9/07; CHW Board of Directors: 8/16/2007Revised: CHW-K MEC: 8/13/07; PAC: 10/25/07; BOD: 11/28/07Revised: CHW-K MEC: 3/19/08; PAC: 3/25/08; BOD: 4/30/08Revised: CHW-K MEC: 7/16/08; PAC: 8/11/08; BOD: 8/21/08

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Peri-operative Orders___________________________________________________________________13

Restraint Orders_______________________________________________________________________13

Medication Orders_____________________________________________________________________13

Investigational Drugs___________________________________________________________________13

Verbal Orders_________________________________________________________________________13

Telephone Orders______________________________________________________________________14

Recording and Authenticating Verbal or Telephone Orders___________________________________15

Order Sets____________________________________________________________________________15

Delegated Medical Orders_______________________________________________________________15

Physician Signature for Delegated Medical Orders__________________________________________15

Collaborative Practice Orders____________________________________________________________15

CARE OF PATIENTS RECEIVING TELEHEALTH SERVICES__________________________16

PROCESS FOR DELINQUENT MEDICAL RECORDS_________________________________16

Suspension Process for Delinquent Inpatient Records________________________________________16

Suspension Process for Undictated Operative Reports________________________________________16

PATIENT DEATH, TISSUE AND ORGAN DONATION, AND AUTOPSY__________________17

Reporting of Deaths____________________________________________________________________17

Documenting a Death___________________________________________________________________17

Organ/Tissue Donations_________________________________________________________________17

Autopsies_____________________________________________________________________________17

CLINICAL RESEARCH AND PUBLICATION_________________________________________18

Research on Human Subjects____________________________________________________________18

MEDICAL EDUCATION___________________________________________________________18

Medical-Dental Staff Members are Responsible for__________________________________________18

PHYSICIANS’ MEMBERSHIP REQUIREMENTS_____________________________________18

ACCEPTED ABBREVIATIONS_____________________________________________________18

AMENDMENTS TO RULES AND REGULATIONS____________________________________19

APPROVAL OF RULES AND REGULATIONS________________________________________19


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GENERAL OBLIGATIONSUpon accepting an appointment to practice at Children's Hospital of Wisconsin – Kenosha (CHW-K), 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 STANDARDSA. Physician Roles1. The Attending Physician has the primary patient care responsibility of patient care for each

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-K for care.

B. Inpatients1. The attending physician is responsible for communicating with the patient and/or family

regarding the condition, prognosis and plan of care. 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. When the attending physician is not the primary care physician, the attending physician is

expected to communicate with the primary care physician. At a minimum, this needs to occur at admission and discharge. For long-term patients, Interim progress reports to the primary care physician are also expected to occur weekly and more often as determined by clinical circumstances.

5. When there is a referring physician, the attending physician is responsible for assuring that there is communication with the referring physician.

6. The attending physician is expected to communicate with other physicians who are involved in the care of patients.

C. Medical-Dental Staff Code of ProfessionalismThis code describes the expectations that the 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 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.


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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.

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 enter 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 appropriate identification and identify yourself to patients and families.


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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.

o For hospital-based inpatients this means: Immediate response to all calls deemed emergent by the

requesting caregiver Response as soon as possible 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 member-to-member contact providing a clear reason for consultation.

Initiate patient consultation (see patient or make appropriate arrangements for follow-up) within 24 hours of request.

Provide non-emergent hospital-based outpatient consultation in a timely manner. 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 (including advance directives and patient and family support) when

appropriate to a patient’s condition and honor patient and family desires. 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 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 and the Hospital staff, patients and their families, including but not limited to the following:

o Impulsive, disruptive, sexually harassing or disrespectful behavior


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o Documentation in the medical record that does not relate to the clinical status of the patient and plan of care

o 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 care-givers.

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.

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 Responsibilities1. 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 or part of the history and physical examination and or update assessment and note to an appropriately privileged allied health professional 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 completed history and physical, within 24 hours of admission which

includes: (1) Chief complaint, symptoms, duration;(2) Pertinent family and social history;(3) Home medications;(4) Pertinent inventory of systems with positive and negative

findings; and


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(5) Physical examination.

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, a

brief discharge note 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. General Medical and Surgical Patients1. The attending physician or designee will evaluate newly admitted patients who

are stable within 24 hours of hospital admission. If the patient is transferred from the KHMC Surgery Department, the patient must be evaluated by the surgeon within 24 hours of the transfer.

C. Critically Ill Patients or Patients with Significant Deterioration1. The attending physician or designee must evaluate patients who become

physiologically unstable after admission to the hospital within 4 hours.2. The attending physician is responsible for determining if a patient’s medical

needs exceed the scope of service at Children’s Hospital of Wisconsin – Kenosha, and is responsible for arranging for transport to an appropriate facility for definitive care.

Ref: Patient Care Policies & Procedures: “Admission of a Patient to the Hospital”

III. CARE OF PATIENTS UNDER GOING INVASIVE PROCEDURESA. Consent to Surgery at KHMC, or for a 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 Children’s Hospital Of Wisconsin and CHW Affiliates.

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,


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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.

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-put 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.


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*Note: Surgical Services are performed at KHMC. It is expected that for continuity of surgical care, these responsibilities are fulfilled.

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.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: Scope of Service Operating Room Ref: Patient Care Policies & Procedures: ”Medical Records”

IV. CARE OF DENTAL AND PODIATRY PATIENTS1 A patient admitted for dental care may be admitted to the service of any member

of the dental staff performing the procedure. . A co-attending physician member should be involved in the ongoing medical care of inpatients.

2 Dentists and Podiatrists 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.

3 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 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.

A. 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. .


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9. Providing a discharge order.10. Providing a discharge diagnosis.

Ref: Patient Care Policies & Procedures: “Medical Records”

V. MEDICAL/SURGICAL CONSULTATION AND TRANSFER OF SERVICEA. Consultation: A medical/surgical consultation is a formalized deliberation between

Medical/Dental staff members regarding a particular patient’s care and/or the treatment of the patient.

1. A consultation must occur when:a) patient care needs exceed the expertise, clinical privileges or availability of the attending physician;

b) there is a need for further evaluation or treatment of the patient; or b) there is a patient or family request for a consultation.

B. Expectations and Responsibilities of the Requesting Attending Physician to the

Consultanta) The requesting attending physician or designee should: b) Discuss the purpose and need for the consult with the patient and family;c) Follow the current process for ordering consults (reference); andd) Communicate to the consultant:

The specific patient care issues that need to be addressed The urgency – (routine, urgent and emergent); and The level of involvement requested:- One time opinion only- Evaluate for procedure- Treatment of condition- Co-management- Transfer of care Whether diagnostic test treatments may be ordered or scheduled by the

consultant service; How and whom to contact to discuss findings and consultant

recommendations.

C. Expectations and Responsibilities of the Consultant: The consultant or designee should:

a) Acknowledge receipt of the consult requestedb) Confirm the level of service requested and the urgency of the consult

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.

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.


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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.

c) Communicate to the requesting attending physician any specific requirements or prerequisites (e.g., NPO status, diagnostic evaluations

d) Perform the consult within the established timeline (reference) Emergent consults should be done as expeditiously given the specific

patient care needs. Urgent consults should be done within 4 hours of receiving the initial

page request. Routine consults should be done within 24 hours of receiving the initial

page request unless other arrangements are made between the requesting physician and the consult.

e) Verbally communicate with the requesting provider or his or her designee, the initial findings or recommendations.

f) Document in the patient’s chart initial findings and recommendations.g) Provide a full written/dictated consult in the patient record within 24 hours of

evaluation of the patient.h) Communicate the information to the patient or family only after discussing

with the requesting provider or his or her designee.i) Specify which service will be responsible for follow-up pending tests during

the hospital stay and after discharge.j) 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.

VI. CARE OF OUTPATIENTSA. 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. MEDICAL ORDERS

A. General Rules1. When possible, medical orders should be written.2. All medical orders should be legibly written, dated, timed and signed.3. There are no standing orders that apply universally to all patients admitted to the

hospital.


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4. A facsimile transmitted order and signature is as acceptable as a written order.5. 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 Orders1. 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. Peri-operative Orders

1. The following applies to all situations where a patient receives anesthesia:a) The surgeon or designee is responsible for reviewing all pre-operative

orders prior to entering post-operative orders.b) Post-operative orders must be written immediately following the

procedure.

D. Restraint Orders1. Guidelines for patient restraint are outlined in Patient Care Policies & Procedures:

“Restraints”

E. Medication Orders1. 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 KHMC hospital

formulary except in unusual situations. A non-formulary drug may be requested by contacting the KHMC hospital pharmacist.

3. Certain medications are restricted. These must be ordered by the knowledgeable specialist. This information is available from the KHMC hospital pharmacy.

F. Investigational Drugs1. Drugs for investigational or experimental purposes may be used only with

permission of the Research and Publications Committee/Human Rights Review Board.

G Verbal Orders1. Verbal orders are orders for medications, treatments, interventions or other patient

care that are communicated as oral, spoken communications between senders and receivers face to face or by telephone. 42 CFR482.23 (C) (2)

2 Verbal orders are acceptable in emergency situations or when the ordering physician is performing a procedure, except in situations where verbal orders are restricted by hospital policy (e.g. Digitalis orders).

3 Verbal orders may be accepted by a registered nurse, advance practice nurse, or physician’s assistant.


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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 radiology technicians.

H. Telephone Orders1. 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, except in situations where verbal orders are restricted by hospital policy (e.g. Digitalis orders).

2. Telephone orders may be accepted by a registered nurse, advance practice nurse, or physician’s 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 radiology technicians.

I. Recording and Authenticating Verbal or Telephone Orders1. A verbal order for medication should contain the name of the patient, age and

weight of the patient when appropriate, date and time of the order, drug name, dosage form, exact strength or concentration, dose, frequency and route, quantity and duration, purpose or indication, specific instructions for use and name of the prescriber.

2. All verbal orders should be legible.3. 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 the accuracy.

4. All verbal and telephone orders shall be authenticated by the prescribing member of the Medical-Dental staff within 48 hours of receipt.

5. Verbal or telephone orders can be authenticated by either the prescribing physician or another physician who is responsible for the care of the patient as long as such physician has knowledge of the patient’s hospital course, medical plan of care, condition and current status. A physician who does not possess this knowledge about a patient should not be authenticating verbal or telephone orders for this patient.

6. Authentication includes the date, time and signature. (42CFR 482.23 (c) (2) (ii) and HFS 124.12 (5) (b) (11).


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J. Order Sets1. 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.

K. Delegated Medical Orders1. Delegated medical orders are medical interventions (orders) that are:

a) Ordered and/or carried out by a physician’s 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.

c) An initiation order to invoke 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 is required prior to use.

L. Physician Signature for Delegated Medical Orders1. An initiation order to invoke the use of a delegated order medical order or protocol

must be legible, in writing and authenticated by the prescribing member of the Medical-Dental staff promptly or within 48 hours of receipt for drugs and biologicals. 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.

M. Collaborative Practice Orders1. Collaborative Practice results from Protocols that are jointly developed by physicians

and other health care professionals including registered nurses, respiratory care practitioners, dieticians or pharmacists. These protocols allow the identified professional to write an order when a previously defined set of conditions exist.

Ref: Patient Care Policies & Procedures: “Medical Orders”

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


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Ref: WI Statutes 441.16(2)

VIII. CARE OF PATIENTS RECEIVING TELEHEALTH SERVICESA. “Telehealth Services” involve the use of medical information exchanged 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 Patient Safety Committee and approved by 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 in an attending physician or consulting physician role. The provider of Telehealth Services is responsible for the care provided. Documentation must occur at the time of service. At 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 and sent to the originating site.

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. PROCESS FOR DELINQUENT MEDICAL RECORDS

A. Suspension Process for Delinquent Inpatient Records1. 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, 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 medical records remain incomplete by ninety (90) days, a certified letter will be sent to the suspended staff member notifying them of automatic resignation 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 Executive Committee review. A copy of this letter shall also be sent to the appropriate Medical or Surgical Section Chief.

B. Suspension Process for Undictated Operative Reports1. Operative reports must be dictated immediately after the operative procedure, prior to the

patient’s transfer to the next level of care. Requirements include the completion by the


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surgeon or his/her designee(s) of both the brief post-operative note and a dictation of the procedure describing techniques, finding 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.

1. 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 Executive Committee review. A copy of this letter will also be sent to the appropriate Surgical Section Chief and/or Medical/Program Director.

2. 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”

X. PATIENT DEATH, TISSUE AND ORGAN DONATION, AND AUTOPSYA. Reporting of Deaths1. All deaths which occur at Children’s Hospital of Wisconsin – Kenosha must be reported to

the Medical Examiner.B. Documenting a Death1. 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 Donations1. The attending physician 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.

Ref: Patient Care Policies & Procedures: “Death - Care of the Dying Child”

D. Autopsies1. It is the responsibility of the attending physician or designee to request an autopsy.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.


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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.

Ref: Patient Care Policies & Procedures: “Death - Care of the Dying Child”

XI. CLINICAL RESEARCH AND PUBLICATION A. Research on Human Subjects1. 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-K”

XII. MEDICAL EDUCATION

A. Medical-Dental Staff Members are Responsible for:

1. Teaching colleagues and other health care professionals

2. Assuring that the patient and family’s well being will be taken into consideration.

3. Being available in person or by telephone and able to be present within a reasonable period of time, appropriate to the patient care need

XIII. PHYSICIANS’ MEMBERSHIP REQUIREMENTSA. Vigilance in maintaining an environment that minimizes infections, including the use of

hand cleansing techniques.B. Continuing Medical Education relevant to the member’s practiceC. Timely return of re-appointment information D. Compliance with Hospital policies regarding TB skin testing and follow-upE. Compliance with required immunizations:

1. All Medical-Dental Staff born after 1956 must furnish documentation of either a positive rubeola antibody titer or evidence of rubeola immunization since January 1, 1980. Rubeola immunization prior to 1980 or a previous clinical history of rubeola is not acceptable for evidence of sufficient immunity to rubeola.

2. All Medical-Dental Staff members must show evidence of immunity to rubella. 3. 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.

XIV. ACCEPTED ABBREVIATIONS


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A. Use of abbreviations should be kept to a minimum. Clinical abbreviations, acronyms and symbols may be used only if found in Stedman’s Abbreviations, Acronyms, and Symbols, and will be taken in the context of the relevant body system being referenced in the documentation. Use of any unapproved abbreviations, acronyms and symbols is prohibited in the patient’s medical record.

Ref: Patient Care Policies & Procedures: “Documentation: Patient Care” Abbreviations

XV. AMENDMENTS TO RULES AND REGULATIONS A. These Rules may be amended at any regular meeting of the Medical Executive Committee.

Such amendment shall become effective when reviewed and approved by the Medical Executive Committee and by the Board of Directors of the Hospital.

XVI. APPROVAL OF RULES AND REGULATIONSA. These Rules and Regulations shall become effective when adopted by the Medical

Executive Committee and approved by the Board of Directors.

Approved: CHW-K MEC 2/11/02; CHW Board of Directors 4/10/02Revised: CHW-K MEC 9/8/03; CHW Board of Directors 11/20/03Revised: CHW-K MEC 8/8/05; CHW Board of Directors 11/29/05Revised: CHW-K MEC 12/9/05; CHW Board of Directors 2/1/06Revised: CHW-K MEC: 6/11/07; 7/9/07; BOD: 8/16/2007Revised: CHW-K MEC: 8/13/07; PAC: 10/25/07; BOD: 11/28/07Revised: CHW-K MEC: 3/19/08; PAC: 3/25/08; BOD: 4/9/08Revised: CHW-K MEC: 7/16/08; PAC: 8/11/08; BOD: 8/21/08

Adopted by the Medical Executive Committee of Children's Hospital of Wisconsin - Kenosha

____________________________________Date Chief Medical Officer

Approved by the Board of Directors

____________________________________Date President, Board of Directors


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