Director of Health Information and Staff support member for the Medical Records Committee.

THE LORETTO HOSPITAL

MEDICAL 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

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

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

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

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 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 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

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 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, 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.

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 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 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) 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 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, 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 Chairmen and 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 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 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 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 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 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, 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. 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 responsibility of the Medical Staff member to initiate DNR Orders to comply with the Hospital’s Policy on Advance Directives and Patient Rights.

2.5.11.2 If a conflict arises with a DNR order, the issue may be directed to the Hospital Ethics Committee.

2.6 Standing Orders

2.6.1 Each Department of the Medical Staff will determine which, if any, standing orders or screening of patients will be done on patients admitted to the Hospital. Standing orders may be formulated for each clinical department by that Department. Standing orders are orders for tests and/or procedures which the Department has decided are to be performed in the absence of or without individual orders in specific groups of patients and are directly related to the diagnosis or conditions. Initiation of Medical Staff approved written protocols and/or standing orders for drugs or biologicals require an order from a Practitioner responsible for the patient's care.

2.6.2 Standing orders shall be followed insofar as proper treatment of the patient will allow. When specific orders are not written by the Practitioner, the standing orders shall constitute the orders for treatment and the Practitioner shall sign such orders at the time of his next visit on the following day.

2.6.3 Standing orders are to be reviewed and approved at least annually by the medical staff and the hospital’s nursing and pharmacy leadership and shall be revised as necessary. The sponsoring practitioner authenticates the “Master Copy” as evidenced by his/her signature to ensure current practice is accurate and maintained.

2.6.4 Standing orders must be dated, timed, and authenticated promptly in the patient’s medical record by the ordering practitioner or another practitioner responsible for the care of the patient only if such practitioner is acting in accordance with State of Illinois law, including scope of practice laws, hospital policies, and Medical Staff Bylaws, Rules and Regulations.

2.7 Drugs and Medications

2.7.1 Except as may otherwise specifically be provided herein, all drugs and medications administered to patients shall be those listed in the latest edition of United States Pharmacopoeia, National Formulary, American Hospital Formulary Services, A.M.A. Drug Evaluations, or the Loretto Hospital Formulary.

2.7.2 An order for medication must comply with the Hospital’s Policies and Procedures which govern the content of, and nomenclature and abbreviations permitted in medication orders, both generally and for specific types of medications.

2.7.3 Proprietary remedies whose composition is unknown to the Physicians, to the pharmacist or to the Pharmacy and Therapeutics Committee, shall neither be prescribed nor administered to patients.

2.8 Orders For Outpatient Services

The hospital’s outpatient services must meet the needs of the patients in accordance with acceptable standards of practice. Outpatient services must be appropriately organized and integrated with inpatient services. The hospital must assign one or more individuals to be responsible for outpatient services. The hospital must have appropriate professional and non-professional personnel available at each location where outpatient services are offered, based on the scope and complexity of outpatient services. Orders for outpatient services (as well as patient referrals for hospital outpatient services) must be ordered by a practitioner who meets the following conditions:

● Responsible for the care of the patient;

● Licensed in, or holds a license recognized in the jurisdiction (State of Illinois) where he/she provides care to the patient;

● Is acting within his or her scope of practice under State of Illinois law; and

● Is authorized in accordance with State of Illinois law and policies adopted by the Medical Staff and approved by the Governing Board to order applicable outpatient services. This applies to the following:

(i) All practitioners who are appointed to the hospital’s Medical Staff and who have been granted privileges to order the applicable outpatient services.

(ii) All practitioners not appointed to the Medical Staff, but who satisfy the above criteria for authorization by the Medical Staff and the hospital for ordering the applicable outpatient services for their patients.

2.8.1 Policy

The hospital’s Medical Staff policy for authorizing practitioners to refer patients for outpatient services must address how the hospital verifies that the referring practitioner who is responsible for the patient’s care is appropriately licensed and acting within his/her scope of practice. The policy must also make clear whether the policy applies to all hospital outpatient services, or whether there are specific services for which orders may only be accepted from practitioners with Medical Staff privileges. The hospital‘s policy must make any exceptions to the general authorization for referring practitioners clear.

1. Each department performing Outpatient Services for practitioners not on the Medical Staff shall be responsible for verifying current valid licensure and that the ordering practitioner is free from sanctions or exclusions which are imposed by the OIG.

2. Signed, handwritten or electronic prescriptions or orders on prescription or standardized authorization forms known to the department shall be accepted as verification.

3. Verbal orders shall not be accepted from practitioners without clinical privileges.

2.8.2 Procedure

1. Practitioners, defined as any Physician (Doctor of Medicine or Doctor of Osteopathic Medicine), Doctor of Dental Surgery or Dental Medicine, Doctor of Podiatric Medicine, Doctor of Optometry; or a Chiropractor, or a Non-Physician Practitioner, who provide services within the authorized scope of their practice/license. who has been awarded an appropriate degree from an accredited institution and who holds a valid and unsuspended license, issued by the Illinois Department of Financial Professional Regulation to practice his/her respective profession within the authorized scope of his practice/license issued by the Illinois Department of Financial Professional Regulation, with clinical privileges at the hospital may order hospital outpatient services that are within the scope of their privileges granted by the hospital.

2. Departments may also accept orders from non-privileged practitioners for the following outpatient services:

a. Laboratory (Orders for Blood Transfusions require a recent H & P from the ordering provider);

b. Medical Imaging

c. Nuclear Medicine services must be ordered only by practitioners whose scope of Federal or State licensure and whose defined staff privileges allow such referrals. There must be a Director who is a Doctor of Medicine or Osteopathy qualified in Nuclear Medicine,

d. Nutrition Counseling

e. Rehabilitation (Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Rehabilitation, and Audiology). The Director of Services must have the necessary knowledge, experience, and capabilities to properly supervise and administer the services.

f. Respiratory Care Services. There must be a Director of Respiratory Care Services who is a Doctor of Medicine or Osteopathy with the knowledge, experience, and capabilities to supervise and administer the service properly. The Director may serve on either a full-time or part-time basis.

g. Sleep Studies

h. Infusion Therapy (Note: Infusion Therapy requires a recent H & P from the ordering provider)

i. Blood Transfusions (Note: Blood Transfusions require a recent H & P from the provider).

3. Orders from non-privileged practitioners (Non-Medical Staff or Non-Physician Practitioner Staff members) may be carried out only if:

a. The practitioner ordering the service is responsible for the care of the patient; and

b. The hospital has verified all of the following:

(i) That the practitioner holds a current and valid license as follows:

1). If the patient was seen in Illinois, verify that the practitioner holds a current and valid license (and/or certification, as appropriate) to practice his or her profession. Such verification shall be made through the Illinois Department of Financial and Professional Regulation (IDFPR) License Lookup OR

2. If the patient was seen outside of the State of Illinois, verify that the practitioner holds a valid license (and/or certification, as appropriate) in the state or jurisdiction where he or she saw the patient. Such verification shall be made in accordance with that state or jurisdiction’s process for verifying practitioner licensure or certification. Licensure in other states are verified by the respective State Medical or other professional Board.

(ii) That the practitioner is acting within the scope of his or her practice in ordering the hospital outpatient services. In some cases, the practitioner’s license or certification may be sufficient evidence of an order being within his or her scope of practice (e.g., a physician referring a patient for a basic blood test). In cases where additional information may be required regarding the practitioner’s scope of practice, the hospital shall confirm with a hospital or other health care facility at which the practitioner practices that the order is within the scope of the practitioner’s privileges or other authority to provide care at such health care facility.

iii) That the practitioner has not been excluded from federally funded health care programs by the Office of Inspector General of the U.S. Department of Health and Human Services. Such verifications shall be made through the OIG’s List of Excluded Individuals/Entities (http://oig,hhs.gov/exclusions/).

iv) That the practitioner has not been excluded by the U.S. General Services Administration from receiving federal contracts, certain subcontracts, and certain financial and non-financial assistance and benefits. Such verification shall be made through the GSA’s Excluded Parties List System (http://www.sam.gov/portal/SAM/).

4. Practitioners included in the EMR dictionary have had verifications completed.

5. Practitioners not included in the EMR dictionary will need verifications completed.

ARTICLE III - SECLUSION AND RESTRAINTS

Seclusion or Restraint may only be imposed to insure the immediate physical safety of the patient, a Staff member, or others and must be discontinued at the earliest possible time.

3.1 Definition of Restraint

A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmet, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort). A physical escort would include a “light” grasp to escort the patient to a desired location. If the patient can easily remove or escape the grasp, this would not be considered physical restraint. However, if the patient cannot easily remove or escape the grasp, this would be considered physical restraint and all the requirements would apply.

3.1.1 Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or

3.1.2 A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

3.2 Definition of Seclusion: Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.

3.3 Use of Seclusion or Restraint

3.3.1 Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a Staff member, or others from harm.

3.3.2 The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a Staff member, or others from harm.

3.3.3 Seclusion may only be used for the management of violent or self-destructive behavior.

3.3.4 The use of seclusion or restraint must be in accordance with a written modification to the patient's plan of care.

3.3.5 All use of seclusion or restraint must be implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by Hospital policy in accordance with the law of the State of Illinois.

3.4 Orders for Seclusion or Restraint

3.4.1 The use of seclusion or restraint must be in accordance with the order of a Physician or other licensed independent Practitioner, who is responsible for the care of the patient and who is authorized to order seclusion or restraints by Hospital policy in accordance with the law of the State of Illinois.

3.4.2 Orders for the use of seclusion or restraint must never be written as a standing order or on an as needed basis (PRN).

3.4.3 The Attending Physician must be consulted as soon as possible if the Attending Physician did not order the seclusion or restraint.

3.4.4 Unless superseded by the law of the State of Illinois, if more restrictive:

3.4.4.1 Each order for seclusion or restraint used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a Staff member, or others may only be renewed in accordance with the following limits for a total of 24 hours:

3.4.4.1.1 Four (4) hours for adults 18 years of age or older;

3.4.4.1.2 Two (2) hours for children and adolescents 9 to 17 years of age; or

3.4.4.1.3 One (1) hour for children under 9 years of age.

3.4.5 After 24 hours, before writing a new order for the use of seclusion or restraint for the management of violent or self-destructive behavior, a Physician or other licensed independent Practitioner who is responsible for the care of the patient and who is authorized to order seclusion and restraint by Hospital policy in accordance with the law of the State of Illinois, must see and assess the patient.

3.4.6 Each order for restraint used to insure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by Hospital policy.

3.4.7 Seclusion or restraint must be discontinued at the earliest possible time, regardless of the length of time identified in the order.

3.5 Monitoring of Patients in Seclusion or Restraint

3.5.1 The condition of the patient who is restrained or secluded must be monitored by a Physician; other licensed independent Practitioner or trained Staff that have completed the training criteria outlined in Hospital policy.

3.5.2 When seclusion or restraint is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a Staff member, or others, the patient must be seen face-to-face within one (1) hour after the initiation of the intervention by a Physician or other licensed independent Practitioner; or registered nurse or physician assistant who has been trained in seclusion and restraint in accordance with Hospital policy, to evaluate the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the seclusion or restraint. If the face-to-face evaluation is conducted by a trained registered nurse or physician assistant, the trained registered nurse or physician assistant must consult the Attending Physician or other licensed independent Practitioner who is responsible for the care of the patient as soon as possible after the completion of the one (1) hour face-to-face evaluation.

3.5.3 Simultaneous seclusion and restraint use is only permitted if the patient is continually monitored face-to-face by an assigned, trained Staff member; or by trained Staff using both video and audio equipment, which must be in close proximity to the patient.

3.6 Documentation of Seclusion and Restraint

3.6.1 When seclusion or restraints is used there must be documentation in the patient's medical record of the following:

3.6.1.1 The 1 hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior;

3.6.1.2 A description of the patient's behavior and the intervention used;

3.6.1.3 Alternatives or other less restrictive interventions attempted (as applicable);

3.6.1.4 The patient's condition or symptom(s) that warranted the use of the seclusion or restraint; and

3.6.1.5 The patient's response to the intervention(s) used, including the rationale for continued use of the intervention.

3.6.1.6 The patient has the right to safe implementation of restraint or seclusion by trained staff.

3.6.1.7 Deaths associated with the use of seclusion or restraints must be reported to CMS by telephone, facsimile, or electronically as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death. Reporting includes each death that occurs while a patient is in restraint or seclusion; each death that occurs within 24 hours after the patient has been removed from restraint of seclusion; and each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume the use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint or seclusion used on the patient during this time.

ARTICLE IV - MEDICAL RECORDS

4.1 Medical Records

4.1.1 A medical record must be maintained for every individual evaluated or treated (inpatient and outpatient) in the hospital. Medical Records must be accurately written, promptly completed, properly filed and retained and accessible. The Hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. The Hospital must have a procedure for ensuring the confidentiality of patient records.

Content of the Medical Record:

The medical record must include evidence of informed consent for procedures, interventions, care plans, diagnosis, orders, medical history, progress notes, treatments, test results and documentation that justifies admission, and supports the diagnosis, describes the patient’s response to treatment and provides a discharge summary. Include clinical evaluation information obtained from post-discharge follow-up telephone calls; care provided and the patient’s response to treatments and interventions. The term “medical record” includes at least written documents, computerized electronic information, radiology film and scans, laboratory reports and pathology slides, videos, audio recordings, final diagnosis and other forms of information regarding the condition of the patient. The Medical Record must reflect the patient’s entire care during his or her inpatient or outpatient treatment. The Medical Record must contain information to justify admission, continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and treatment services.

Responsibility for Preparation of the Medical Record:

The Attending Physician shall be responsible for the preparation of a medical record for each patient according to regulatory guidelines. All patient medical record entries must be accurate, legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided, consistent with Hospital policies and procedures. Advanced Practice Nurses (Nurse Practitioners, CRNA’s and APN Nurse Midwife) do not require medical record entries to be countersigned with the exception of the Discharge Order. All Certified Physician Assistants who are employed by a medical staff member must have any and all medical record entries, including but not limited to Progress Notes; History and Physical Examinations; and any and all orders such as pharmaceutical orders; laboratory orders; and diagnostic imaging orders, countersigned by their sponsoring physician. All Certified Physician Assistants who are employed by the hospital must have any and all medical record entries, including but not limited to Progress Notes; History and Physical Examinations; and any and all orders such as pharmaceutical orders; laboratory orders; and diagnostic imaging orders, countersigned by a physician member of the Medical Staff with comparable clinical privileges. Symbols and abbreviations may be used only when the have been approved by the Medical Staff. An official record of the annually approved abbreviations and explanations will be on file in the Medical Records Department.

4.1.2 All medical records must document the following, as appropriate:

Evidence of:

(i) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration. Documentation of the updated examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services;

(ii) Admitting diagnosis;

(iii) Results of consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient;

(iv) Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia;

(v) Properly executed informed consent forms for procedures and treatments specified by the Medical Staff, or by Federal or State of Illinois law if applicable, to require written patient consent;

(vi) All practitioners’ orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition;

(vii) Discharge Summary with outcome of hospitalization, disposition of case, and provisions for follow-up care;

(viii) Final diagnosis with completion of medical records within 30 days following discharge.

(ix) If an autopsy is performed, provisional anatomic diagnoses are recorded in the medical record within three (3) days, and the complete protocol is included in the record within sixty (60) days.

4.1.3 Each medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and responses to medications and services. The medical record should contain, at a minimum, information as it relates to the patient’s admission or episode of care: identification data; date; name of any legally authorized representative; the patient's communication needs, including preferred language; complaint, personal history; family history; history of illness; history of allergies, current medication, physical examination findings; treating or admitting diagnosis; laboratory and radiological data; hospital acquired infections; and unfavorable reactions to drugs and anesthesia; medical and surgical treatment; anesthesia record; pathological findings; progress notes; final diagnosis; condition on discharge, discharge summary and care plan; discharge instructions to patient; and when performed, results of autopsy. When an autopsy is performed, provisional anatomic diagnoses are recorded in the medical record within three (3) days, and the complete protocol is included in the record within sixty (60) days.

4.1.4 The medical record shall contain evidence of the patient's Informed Consent for any procedure or treatment, including the use of investigational drugs, or any special diagnostic or therapeutic radiology procedure and any special ambulatory care or emergency care. It should also include the following: (i) identity of individual(s) performing procedures or administering treatment; (ii) authorization for anesthesia and/or administration of blood or blood components; (iii) indications that alternate means of therapy and possible risks or complications have been explained to the patient; (iv) authorization for disposition of any tissue or body parts; and (v) authorization for photographs and/or videotaping.

4.1.5 Each medical record shall contain evidence of a critical review of the patient’s written record by the Attending Practitioner.

4.1.6 Medical History and Physical Examinations. A medical history and physical examination must be completed and documented for each patient no more than 30 days prior to or 24 hours after hospital admission or registration, but prior to surgery or a procedure requiring anesthesia services. The Medical History and Physical Examination must be completed and documented by a physician (as defined in Section 1861(r) of the Act (Social Security Act), oral maxillofacial surgeon, or other qualified licensed individual in accordance with State of Illinois Scope of Practice law and hospital policy and who are formally authorized by the hospital to conduct an H & P and who have been credentialed and granted clinical privileges by the Board of Trustees to perform an H & P. Other qualified licensed individuals are those licensed practitioners who are authorized in accordance with their State of Illinois scope of practice laws or regulations to perform an H & P and who are formally authorized by the hospital to conduct and H & P and have been credentialed and granted clinical privileges by the Board of Trustees to perform an H & P. Other qualified licensed practitioners would include Nurse Practitioners and Physician Assistants. The medical history and physical examination must be placed in the patient's medical record within 24 hours after admission or registration. The Medical Staff is responsible for specifying the minimal content of medical histories and physical examinations, which may vary by setting or level of care, treatment and services and defines when a medical history and physical examination must be validated and countersigned by a Practitioner with appropriate privileges. The quality of all medical and physical examinations are monitored by the Medical Staff.

An Advanced Practice Nurse (APN) or a Physician Assistant (PA) may perform the history and physical examination if they have been credentialed and privileged to do so by the Board of Trustees. If the performance of the H&P is delegated to an APN or PA, the APN or PA must have delegated authority from their collaborating physician or their supervising physician respectively, and this must be located in written form in APN or PA’s credentialing file located in the Medical Staff Office.

History and physical examinations completed by medical students are for educational purposes only and do not meet the required H&P standards, even if authenticated by a medical staff or house staff physician.

4.1.6.1 H & P Medical Record Update: When the medical history and physical examination are completed within 30 days before admission or registration, an updated examination of the patient, including any changes in the patient's condition, must be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The updated examination of the patient, including any changes in the patient's condition, must be completed and documented by a Physician, an oral maxillofacial surgeon, or other qualified licensed individual in accordance with State of Illinois law and hospital policy. Other qualified licensed individuals are those licensed practitioners who are authorized in accordance with their State of Illinois scope of practice laws or regulations to perform an H & P and who are formally authorized by the hospital to conduct and H & P and have been credentialed and granted clinical privileges by the Board of Trustees to perform an H & P. Other qualified licensed practitioners would include Nurse Practitioners and Physician Assistants.

4.1.6.2 Additional Requirements Related to Surgery or Invasive Procedures. The complete history and physical examination described in this section must be documented in the chart of every patient prior to either inpatient or outpatient surgery or any invasive or diagnostic or therapeutic procedure in any setting in which anesthesia services are required. Indicated preoperative diagnostic tests and the preoperative diagnosis shall also be completed and recorded in the patient's medical record. A pre-anesthesia evaluation must be completed and documented by an individual qualified to administer anesthesia, within 48 hours prior to any inpatient or outpatient surgery or a procedure requiring anesthesia services. At a minimum, the pre-operative anesthetic evaluation of the patient should include: (i) notation of anesthesia risks; (ii) anesthesia, drug and allergy history; (iii) any potential anesthesia problems identified; and (iv) patient's condition prior to the induction of anesthesia. In addition, a history and physical examination where anesthesia is involved shall include at a minimum: (a) indications for the procedure; (b) known allergies and adverse medication reactions; (c) a list of current medication and dosages; and (d) a statement of general health, vital signs and mental status.

4.1.7.3 Emergency Situations. In emergency situations where there is inadequate time to record the history and physical examination before surgery, a brief note, including the pre-operative diagnosis, shall be made in the patient’s record prior to surgery. An "emergency situation" is defined as one in which the patient presents with a life-threatening, critical condition that requires immediate transport to the operating room, bypassing the routine assessment process. A physician must, however, document the emergency nature of the procedure and condition for which it is being applied.

4.1.7 The operating surgeon and anesthesiologist shall see and examine all patients preoperatively. It is also their duty to see that the records show evidence of adequate preoperative study and documentation of patient reevaluation immediately before deep sedation use and before anesthesia induction. Both operating surgeon and anesthesiologist are responsible for writing preoperative and postoperative orders and the appropriate progress notes of the patient's condition.

4.1.8 In surgical cases, the preoperative diagnosis shall be given to the surgical supervisor as far in advance as circumstances permit. Except in emergencies, a complete history and physical examination must be written before any surgery is started.

4.1.9 Operative reports shall be dictated immediately after surgery. In addition, a brief operative note must be written in the record immediately after surgery which shall include: (i) Primary surgeon and assistants; (ii) Findings; (iii) Procedures performed and description of the procedures; (iv) Estimated blood loss; (v) As indicated, specimens removed; and (vi) Postoperative diagnosis.

4.1.10 The medical records of dental patients should contain documentation of pertinent instructions particularly concerning oral care given to the patient and/or family at the time of discharge.

4.1.11 The medical records of podiatry patients should contain documentation of pertinent instructions particularly concerning foot care given to the patient and/or family at the time of discharge.

4.1.12 The medical record of patients admitted to psychiatric or substance abuse services must contain documentation for the use of special treatment procedures including but not limited to the following: (i) restraint or seclusion; (ii) electroconvulsive therapy; (iii) aversive conditioning in behavior modification disorder; and (iv) special treatment procedures for children or adolescents.

4.1.13 Progress notes shall be legibly recorded with date, time and signatures in a manner that gives a chronological report of the patient's condition in the Hospital, a reflection of any change in the patient's condition and results of tests and treatment, and a continuous update and modification of the treatment plan stating the reasons for continuous hospitalization.

4.1.14 Visitations by Physicians or licensed independent Practitioners will be documented in progress notes. A progress note shall be written each time the treating Physician, or licensed independent Practitioner visits the patient. If issues have been raised in the medical record by other disciplines, the treating Physician shall provide an appropriate response.

4.1.15 The medical record may include entries that are transmitted by facsimile machine provided that the faxed copies will be maintained on non-thermal paper and that the faxed copies will be dated and authenticated in accordance with Hospital policy

4.1.16 The discharge summary may be written no more than 24 hours before hospitalization ends and shall include the reason for admission, findings, treatment, condition on discharge, medication on discharge, final diagnosis, and, in the case of death, the events leading to death and the cause of death. The discharge note includes at least the patient's condition on discharge, diagnosis on discharge, medications on discharge, and discharge instructions.

4.1.17 If the patient is transferred to another health care facility, that facility must have an accepting Physician. A transfer note shall be made by the patient's treating Physician to reflect the patient's immediate needs. A copy of the entire medical record along with this transfer note shall accompany the patient, of which the details shall include: (i) Diagnosis, including history of any serious physical condition unrelated to the proposed treatment which might require special attention to keep the patient safe; (ii) Physician orders in effect at the time of discharge and the last time each medication was administered; (iii) The patient's nursing needs; and (iv) Drug and other allergies.

4.1.18 All entries in the medical record must be dated, timed and authenticated, in written or electronic form by the person responsible for providing or evaluating the service provided. No medical record shall be permanently filed until it is legible and completed or otherwise ordered by the Medical Executive committee. Medical records of discharged patients are to be completed no later than thirty days following the date of discharge. If a chart is not completed within 30 days, after it is made available to the Medical Staff member, the charts are considered delinquent. The Medical Records Department shall make the record available to the Physician for completion within 7 days of the patient's discharge. The Medical Records Department will notify the Physician of incomplete charts on the 14th day incomplete, on the 21st day incomplete, and if on the 30th day the record is incomplete it may result in automatic suspension of admitting, consulting and surgical privileges

4.1.19 The Attending Physician who fails or refuses to complete or maintain medical records as described in these Rules and Regulations and the Medical Staff Bylaws shall be subject to disciplinary action in accordance with Article VII of the Medical Staff Bylaws.

4.1.20 All original records are the property of the Hospital and may not be removed from the Hospital without a court order, subpoena or in accordance with relevant statute. This includes all radiographic studies. Unauthorized removal of charts from the Hospital is grounds for suspension of the Practitioner for a period to be determined by the Medical Executive Committee.

4.1.21 In case of readmission of a patient, all previous records shall be available for the use of the current Attending Practitioner. This shall apply whether the patient is attended by the same Practitioner or by another. Free access to all medical records of all patients shall be afforded to members of the Medical Staff for bona fide study and research consistent with preserving the confidentiality of personal information concerning the individual patients. All such projects shall be approved by the Medical Executive Committee before records can be studied. Subject to the discretion of the President and Chief Executive Officer, former members of the Medical Staff shall be permitted free access to information from the medical records of their patients covering all periods during which they attended such patients in the Hospital.

4.1.22 Countersignature Requirements

In accordance with State of Illinois law and Hospital policy, the following individuals require countersignatures on certain portions of the patient’s medical record as identified below:

1) Licensed Advanced Practice Nurses – APN (Nurse Practitioner; CRNA; & Nurse Midwives): Countersignature required for Discharge Summary.

2) Licensed Certified Physician Assistants (PA): Countersignature required for all orders including treatment orders; progress notes; Medical History and Physical Examinations; and Discharge Summary.

3) Residents: Countersignature required by supervisory or attending Medical Staff members for all orders; progress notes; Medical History and Physical Examinations; and Discharge Summary.

4) Medical Students: Medical Students are not licensed practitioners but may, for educational purposes, document in the medical record. A member of the medical or house staff shall evaluate, verify and authenticate (countersign) all documentation by medical students within twenty-four (24) hours of its entry. The teaching physician must verify in the medical record all medical student documentation or findings, including history, physical exam and/or medical decision making. History and physical examinations completed by medical students are for educational purposes only and do not meet the required H&P standards, even if authenticated by a medical staff or house staff physician. The teaching physician must personally perform (or re-perform) the Medical History and Physical examination and medical decision making activities of the medical student. Each documentation by a medical student must be reviewed and evaluated by the teaching physician and authenticated by the physician. The physician who authenticates any portion of the medical record is responsible for its content.

ARTICLE V - DEATHS AND AUTOPSY

5.1 Deaths

5.1.1 Pronouncement of Death

5.1.1.1 If a patient arrived at the Hospital dead or dies in the Hospital, a Physician shall pronounce the patient dead within a reasonable time. The patient's remains may not be released until the Physician has made an authenticated entry of the pronouncement of death in the patient's medical record.

5.1.1.2 If the patient has suffered "brain death", (i.e. the total and irreversible cessation of all functions of the entire brain, including the brain stem), death may be pronounced only after a second, independent Physician has confirmed the "brain death" and both Physicians have documented their findings supporting the determination of "brain death" in the patient's record.

5.1.1.3 Medical treatment shall be continued only if the family contests the accuracy of the diagnosis.

5.1.1.4 Contested cases shall be referred to Administration for review before further action is taken.

5.1.1.5 The patient's family, next-of-kin or legal guardian must be informed of the patient's death.

5.1.2 Death Reporting Requirements: Hospitals must report the following information to CMS:

5.1.2.1 Each death that occurs while a patient is in restraint or seclusion.

5.1.2.2 Each death that occurs within 24 hours after a patient has been removed from restraint or seclusion.

5.1.2.3 Each death known to the Hospital that occurs within one week after restraint or seclusion where it is reasonable to assume that the use of restraint or placement in seclusion contributed directly or indirectly to a patient's death. "Reasonable to assume" in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing, or asphyxiation.

5.1.2.4 Each death must be reported to CMS by telephone no later than the close of business the next CMS business day following knowledge of the patient's death.

5.1.2.5 The Hospital Staff must document in the patient's medical record the date and time the death was reported to CMS.

5.2 Autopsy

5.2.1 Every member of the Medical Staff should attempt to secure consent to meaningful autopsies in all cases of unusual deaths and of medical-legal and educational interest. The Medical Staff (specifically the attending physician) is informed of autopsies that the hospital intends to perform.

5.2.2 Autopsies are encouraged in situations identified by the College of American Pathologists:

5.2.2.1 Deaths in which an autopsy would explain unknown or unanticipated medical complications.

5.2.2.2 All deaths in which the cause of death or a major diagnosis is not known with reasonable certainty on clinical grounds.

5.2.2.3 Deaths in which an autopsy would allay concerns of and/or reassure the family and/or the public regarding the death.

5.2.2.4 Unexplained or unexpected deaths during or following any dental, medical or surgical diagnostic procedures and/or therapies.

5.2.2.5 Deaths of patients participating in clinical investigations.

5.2.2.6 Unexpected or unexplained deaths which are apparently natural and not subject to forensic medical jurisdiction.

5.2.2.7 Natural deaths which are subject to, but waived by, a forensic medical jurisdiction such as (i) persons dead on arrival at hospitals, (ii) deaths occurring in hospitals within 24 hours of admission, and (iii) deaths in which the patient sustained or apparently sustained an injury while hospitalized.

5.2.2.8 Deaths resulting from high risk infectious and contagious diseases.

5.2.2.9 All obstetric deaths.

5.2.2.10 All perinatal and pediatric deaths.

5.2.2.11 Deaths at any age in which it is believed that autopsy would disclose a known or suspected illness which also may have a bearing on survivors or recipients of transplant organs.

5.2.2.12 Deaths known or suspected to have resulted from environmental or occupational hazards.

5.2.3 No autopsies will be performed, however, without the written consent of the next of kin or a personal representative of the deceased patient as defined by Illinois law. The Physician should document in the progress notes the actions regarding attempts to obtain consent for an autopsy. All autopsies, except where otherwise required by law, shall be performed by the Hospital's pathologist or a Physician to whom he or she may delegate the responsibility. The responsibility of the Hospital's pathologist shall include: (i) assuring and documenting that the Attending Physician is notified that the autopsy is being or has been performed; and (ii) notifying the Medical Staff routinely and in writing of all autopsies which will be or have been performed.

ARTICLE VI - SURGERY AND PROCEDURAL SPECIALTIES

6.1 Pre-Surgical Documentation

6.1.1 With the exception of emergency surgeries, no Member shall perform a major surgical operation on any patient until all of the requirements under Section 4.1.5 are satisfied, including a written History and Physical Examination and the results of appropriate studies, as indicated by the patient’s illness or condition.

6.1.2 With the exception of emergency surgeries, if a Consultant is to perform a surgery, the Consultant shall enter either a Consultation Report or a Preoperative Note in the patient’s Medical Record prior to performing the surgery.

6.1.3 The patient must be informed of the name of the Physician who will be the surgeon and the patient must consent specifically to be operated on by him.

6.1.4 Consistent with Section 4.1.5, no Member shall perform a surgical operation on any patient until an anesthesiologist or other qualified anesthetist has performed a pre-anesthesia evaluation of the patient and placed a written record of such evaluation in the patient’s Medical Record.

6.1.5 On his own cases, the surgeon shall examine the patient pre-operatively and include, in his admission notes, his findings, the preoperative diagnosis and give preoperative orders.

6.1.6 Surgery shall be performed by surgeons according to Clinical Privileges granted to them by the Board of Trustees as recorded on the current surgical privilege record.

6.1.7 Every surgeon performing hazardous surgery (as identified by the MEC) shall have a licensed Physician as an assistant in accord with the requirements as determined by the Department of Surgery of the Medical Staff.

6.1.8 Surgeons shall be in the operating room and ready to commence the operation at the time scheduled. In no case will the operating room be held longer than thirty minutes after the time scheduled.

6.1.9 Except in cases of emergency where the operation is necessary the save the patient's life or limb, no operation will be performed unless written consent has been obtained.

6.2 Tissue Disposition

6.2.1 All tissues, including teeth and all specimens of exudates, removed at surgery or during any procedure shall be sent to the Department of Pathology for examination by a pathologist

6.2.2 The pathologist will make such examination or any test as he may consider necessary to arrive at a diagnosis and the pathologist will submit a signed and dated report for the record. In the case of pathological findings, especially neoplasms, when no organ or major portion is removed, every effort should be made to obtain a biopsy at the time of surgery.

6.3 Post-Surgical Documentation

6.3.1 Post-Anesthesia Evaluation: A post-anesthesia evaluation must be completed and documented by an individual qualified to administer anesthesia, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation is required any time general, regional or monitored anesthesia has been administered to the patient. The post-anesthesia recovery must be completed in accordance with State law and with Hospital policies and procedures that have been approved by the Medical Staff and that reflect current standards of anesthesia care. The American Society of Anesthesiology (ASA) guidelines do not define moderate or conscious sedation as anesthesia. However, the patient receiving conscious or moderate sedation must be monitored and evaluated before, during and after the procedure by trained Practitioners providing the moderate or conscious sedation. A post anesthesia evaluation is not required for moderate or conscious sedation.

Any Practitioner who performs surgery or a procedure on any patient shall prepare or dictate an Operative Report or Procedure Note immediately following such surgery or procedure, whether the surgery or procedure was performed on an inpatient or outpatient basis. When the Operative Report or Procedure Note is not placed in the record immediately after the surgery or procedure, the Member who performed the surgery or procedure shall record a Progress Note in the patient’s Medical Record immediately following the surgery or procedure.

6.3.2 The anesthesiologist or qualified anesthetist who managed the patient’s anesthesia during surgery shall record a complete written anesthesia record. A post-anesthesia evaluation must be completed by the anesthesiologist or qualified anesthetist within 48 hours after surgery and documented in the patient's medical record.

6.3.3 The surgeon is responsible for postoperative orders, daily appraisal of the patient (in person or by telephone) and for progress notes on the surgical convalescence.

6.3.4 The anesthesiologist is responsible for ordering the patient from recovery room to patient room. He shall be responsible for adequate visits to the patient, written progress notes and post-anesthetic orders.

6.3.5 All infections of clean surgical cases shall be reported to the infection surveillance officer, the departmental chairman, and the Infection Control Committee shall investigate these cases.

6.4 Oral Surgery

6.4.1 The care of a patient admitted for oral surgery is a dual responsibility involving the oral surgeon or dentist and the Physician member of the Medical Staff.

6.4.2 The Oral Surgeon's or Dentist's responsibility shall include:

6.4.2.1 A detailed dental history justifying hospital admission;

6.4.2.2 A detailed description of the examination of the oral cavity and a preoperative diagnosis;

6.4.2.3 A complete operative record describing the findings and technique. In case of extraction of teeth, the oral surgeon or dentist shall clearly state the number of teeth and fragments removed. All tissue including teeth and fragments shall be sent to the Hospital pathologist for examinations;

6.4.2.4 Progress notes as are pertinent to the oral condition;

6.4.2.5 Discharge of the patient shall be on written order of the oral surgeon or dentist member of the Medical Staff; and

6.4.2.6 Clinical Resume or Summary.

6.4.3 The Physician's responsibility shall include:

6.4.3.1 Medical history pertinent to the patient's general health;

6.4.3.2 Physical examination to determine the patient's condition prior to anesthesia and surgery; and

6.4.3.3 Supervision of the patient's general health status while hospitalized.

6.5 Obstetrics

6.5.1 The recommended Rules and Regulations promulgated by the Chicago Department of Health shall govern all obstetric procedures and all problems of newborns in the Hospital.

6.6 Special Privileges

6.6.1 Official readings of electrocardiograms, electroencephalograms or other types of analogues as well as the privilege to use radioisotopes shall be assigned to members of the Staff qualified to carry out these studies, upon recommendations of the Medical Executive Committee of the Staff and concurrence with the Governing Board.

6.6.2 Privileges to perform angiograms, and other such procedures, shall be assigned as other privileges.

ARTICLE VII - MODERATE (CONSCIOUS) SEDATION

7.1 Moderate (Conscious) Sedation

7.1.1 M.D.'s or D.O.'s administering moderate (conscious) sedation will be specifically credentialed and privileged through the Medical Staff credentialing process and privileges for administering Moderate Sedation will be approved by the Board of Trustees. Included in the qualifications of individuals providing moderate (conscious) sedation is competency based education, training and experience in:

7.1.1.1 Evaluating the patient prior to performing moderate sedation;

7.1.1.2 Performing moderate sedation to include methods and techniques required to rescue those patients who unavoidably, unintentionally slip into a deeper than desired level of sedation or analgesia. Specifically, M.D.’s or D.O.’s who have appropriate credentials and privileges approved by the Board of Trustees and are permitted to administer moderate sedation are qualified to rescue patients from deep sedation, meaning they are competent in managing a compromised airway to include providing adequate oxygenation and ventilation.

7.1.2 Privilege requirements for M.D.’s and D.O.’s wishing to administer moderate sedation include one or more of the following criteria:

1. Board Certification in Anesthesiology; Board Certification in Emergency Medicine; Board Certification in Critical Care Medicine; Board Certification in Interventional Cardiology; or Board Certification in Interventional Radiology. With the exception of Board Certified Anesthesiologists, each of the above Board Certified specialists must successfully pass a Moderate Sedation Competency Test developed and approved by the Chair of the Department of Anesthesiology. All Board Certified Anesthesiologists; Emergency Medicine Physicians; Critical Care Medicine Physicians; Interventional Cardiology Physicians; and Interventional Radiologists requesting privileges to administer Moderate Sedation must have current ACLS Certification

2. Non Boarded Anesthesiologists; Non Boarded Emergency Medicine Physicians; Non Boarded Critical Care Physicians; Non Boarded Interventional Cardiologists; or Non-Boarded Interventional Radiologists must have current ACLS Certification and must successfully pass a Moderate Sedation Competency Test developed and approved by the Chair of the Department of Anesthesiology.

3. All other M.D.’s or D.O.’s who are non-anesthesiologists requesting privileges for Moderate Sedation privileges must have current certification in ACLS and must successfully pass a Moderate Sedation Competency Test developed and approved by the Chair of the Department of Anesthesiology.

7.1.3 The American Society of Anesthesiology (ASA) guidelines do not define moderate or conscious sedation as anesthesia. However, the patient receiving conscious or moderate sedation must be monitored and evaluated before, during and after the procedure by trained Practitioners providing the moderate or conscious sedation. A post-anesthesia evaluation is not required for moderate or conscious sedation.

7.1.4 Advanced Practice Nurses and Registered Nurses administering medications for Moderate Sedation must have current ACLS and do so only on the order of the M.D. or D.O. who is privileged and credentialed for Moderate Sedation. The MD/DO who is credentialed and privileged for Moderate Sedation must be in attendance during the drug administration.

ARTICLE VIII - EMERGENCY ROOM FACILITIES

8.1 General Policies

8.1.1 Emergency room facilities shall be provided by the Hospital for the service of the community.

8.1.2 The Hospital agrees to provide facilities and equipment, adequate medical (licensed house physician) and nursing personnel. The Hospital requires adequate records which are retained as permanent records of the Hospital.

8.1.3 The medical screening exam will be performed by a Physician, an APN or a PA, who has been granted clinical privileges by the Board of Trustees to do so within the scope of their practice.

8.1.4 If consultation is necessary, he/she may call the member of the indicated Department assigned for emergency call during the day as listed in the schedule formulated by the Chairman of the Department at the beginning of the month.

8.1.5 If an emergency case requires hospitalization, the Physician on call should assume this responsibility if the patient's Attending Physician is not available.

8. 2 Responsibilities of the On-Call Practitioner

8.2.1 Responsibilities for Care in the Emergency Department: The Medical Staff members on call shall be required to respond to calls from the Emergency Department in accordance with the EMTALA Policy.

8.2.2 Responsibilities for Follow-Up Care: Emergency Department On-Call not only covers admissions to the Hospital but also includes patients who are discharged from the Emergency Department and require follow-up care. Members of the Medical Staff are expected to provide follow-up care as needed.

8.2.3 Responsibilities for In-Hospital Coverage: On-call also includes in-Hospital coverage. The respective Department chairperson/vice chairperson has the authority to require that a Physician on Emergency Department On-Call coverage provide consultation to patients when deemed necessary.

ARTICLE IX - EMTALA POLICY

9.1 Requirements

9.1.1 The Medical Staff of the Hospital is required by law to comply with the medical screening, stabilization, transfer and on-call requirements of the Emergency Medical Treatment and Labor Act ("EMTALA") with regard to patients coming to the Hospital Emergency Department and those who may need to receive care elsewhere. Physicians must comply with this policy and any other Hospital policies regarding EMTALA, including ED Policy 1406, to fulfill these obligations.

9.2 Medical Screening Examination (“MSE”)

9.2.1 MSE means a process applied in a nondiscriminatory manner by a Qualified Medical Person, to reach, with a reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. A nondiscriminatory manner means that the MSE is provided regardless of diagnosis, financial status, race, color, national origin and/or disability. Screenings include vital signs, oral history, and physical examination of affected or potentially affected systems. Consideration of unknown chronic conditions requires testing needed to determine the presence of an emergency medical condition, including use of Hospital personnel and on-call Physicians; documentation on designated logs; triage and the Emergency Department records of the above, as well as final patient disposition. Screenings shall be performed by a Qualified Medical Person, which means an Emergency Physician, On-Call Specialty Physician, or Primary Care Physician or an Advanced Practice Nurse or Licensed Certified Physician Assistant who has been granted privileges to do so by the Board of Trustees. Patient's Attending Physician may perform an MSE as long as that Physician is appropriately credentialed and meets and sees the patient in the Emergency Department within the timeframe mandated by ED Policy 1406 as approved by the Medical Executive Committee. Triage is not a medical screening examination.

9.3 Stabilization

9.3.1 If the medical screening examination indicates that the person has an emergency medical condition, then that patient must be stabilized within the capabilities of the Hospital Staff and facilities. An individual will be considered stabilized if the treating physician has determined, within reasonable clinical confidence, that the emergency medical condition has been resolved even if the underlying medical condition still persists. With respect to a non-labor related emergency medical condition, stabilization requires the provision of such medical treatment as necessary to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from, or occur during the transfer or discharge of the individual from the Hospital. With respect to a labor related emergency, stabilization occurs if the woman has delivered the baby, including the placenta. With respect to a psychiatric condition, stabilization occurs if the patient is protected and prevented from injuring self or others by adequate chemical or physical restraint.

9.4 Duties of On-Call Physicians

9.4.1 The respective Clinical Department Chairperson shall determine the on-call list for the Emergency Room on a monthly basis. The on-call schedule will be posted in the Medical Staff office and in the Department of Emergency Medicine on a monthly basis. If a Medical Staff member is on-call and is contacted by a Physician or other qualified designated person, that Physician must respond in the timeframes established by ED Policy 1406 as determined by the Chairman of the Emergency Department in conjunction with the respective Clinical Department Chairperson. On-call Physicians may be asked merely to consult by phone or to come to the Hospital and complete the medical screening examination or stabilizing treatment. The Emergency Room Physician shall determine what type of response is required by the on-call Physician and if the physical presence of the on-call Physician is required at the Hospital.

9.5 Arrangement for Back-Up Call

9.5.1 The on-call Physician may perform elective surgery during the period he is on-call and may accept simultaneous call coverage. The Hospital must be notified, however, of all potential conflicts and the on-call Physician is responsible for ensuring that an alternate on-call coverage Physician is available in the event he is unavailable. Failure to respond within the timeframe established by ED Policy 1406 to a request for on-call coverage by the emergency room Physician or to inform the Hospital of illness, vacation, competing coverage or other obligations, such as elective surgery, or to arrange for an alternate to respond if the Physician is unavailable may result in corrective action under the Medical Staff Bylaws. In the event a Physician or alternate fails to provide on-call coverage, the emergency room Physician shall affect an "Appropriate Transfer" in accordance with ED Policy 1406 if an emergency medical condition exists which cannot be stabilized due to the lack of such coverage. To the extent the failure to respond violates this Policy and results in the need to transfer a patient to another facility for care which could have been provided by the on-call Physician, by law, the name and address of the Physician must be forwarded to the receiving hospital with the patient and the patient's record. This report could trigger an investigation by federal agencies and could result in a finding that the Physician has violated EMTALA.

9.6 Transfers and Discharge

9.6.1 Patients for whom the emergency medical condition has been stabilized may be discharged with appropriate follow-up instructions or transferred to other facilities as provided in ED Policy 1406.

9.6.2 Patients who have not been stabilized for any reason may also be transferred as provided in the ED Policy 1406 regarding transfers of unstable patients and "Appropriate Transfers."

9.6.3 Members of the Medical Staff must participate in the transfer process with regard to identifying and discussing with the patient the risks and benefits of a transfer, contacting Physicians at the receiving hospital and issuing appropriate transfer orders.

9.6.4 Unstable patients from other hospitals may need admission to Hospital if medical screening and/or stabilizing treatment is unavailable at the transferring hospital. Members of the Medical Staff shall participate in the acceptance of transferring patients by taking calls from referring Physicians, providing medical screening examinations and stabilizing these patients.

9.7 Records

9.7.1 Physician shall keep records of the time and nature of the medical screening examination and any stabilizing treatment provided and all other documentation as required by Hospital policies for patients with emergency medicine conditions and ED Policy 1406.

9.8 Reporting

9.8.1 Failure of any Physician to satisfy his on-call responsibilities shall be reported to the Chairman of the Emergency Department, the respective Clinical Department or his designee and the President and CEO or his designee.

ARTICLE X - PATIENT RIGHTS

10.1 Exercise of Rights

The Hospital must protect and promote each patient’s rights as follows:

10.1.1 The patient has the right to participate in the development and implementation of his or her plan of care.

10.1.2 The patient or his or her representative (as allowed under the law of the State of Illinois) has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate.

10.1.3 The Hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State of Illinois law), of the patient’s rights in advance of furnishing or discontinuing patient care whenever possible.

10.1.4 The patient has the right to formulate advance directives and to have Hospital Staff and Practitioners who provide care in the Hospital comply with these directives.

10.1.5 The patient has the right to have a family member or representative of his or her choice and his or her own Physician notified promptly of his or her admission to the Hospital.

10.1.6 The patient must have the right to a prompt resolution of patient grievances and each patient must be informed as whom to contact to file a grievance. The patient must be informed of the time frames for review of the grievance and the provision of a response. In its resolution of the grievance, the Hospital must provide the patient with written notice of its decision that contains the names of the Hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

10.2 Privacy and Safety

10.2.1 The patient has a right to personal privacy.

10.2.2 The patient has the right to receive care in a safe setting

10.2.3 The patient has the right to be free from all forms of abuse or harassment. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

10.3 Confidentiality of Patient Records

10.3.1 The patient has the right to the confidentiality of her or her clinical records.

10.3.2 The patient has the right to access information contained in his or her clinical records within a reasonable time frame. The Hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits.

ARTICLE XI - EMERGENCY OPERATIONS PLAN (EOP)

11.1 An Emergency Operations Plan (EOP) for The Loretto Hospital has been formulated by the Medical Staff and Administration and approved by the Board of Trustees. The EOP is developed, maintained, and available to the staff for crisis preparation and response. The EOP is based on the priorities established in the bi-annual Hazard Vulnerability Analysis (HVA).