Confidentiality Procedures

The Health Information Management Department recognizes the vital role of information in all aspects of today’s society, and especially in the healthcare professions. We are committed to providing the highest quality of service to our patients, physicians, staff and other healthcare information users by ensuring the accurate, dependable and secure collection, maintenance, and appropriate dissemination of information.

As professionals, we are dedicated to unfailing reliability in meeting each request and duty asked of us. We pledge to empower our staff through continuous education and upgrading of our skills and thus enhance the quality of our communication, participation and interaction with physicians and others in meeting the health information needs of this hospital and the communities it serves.

SUBJECT: CONFIDENTIALITY

POLICY:

It is the policy of RMC to maintain an individual’s right to privacy and confidentiality of information. Information known or contained in the patient's medical record (known as protected health information) shall be treated as confidential and will be released in appropriate circumstances only with the written consent of the patient or legal guardian. Information concerning patients, visitors and staff shall be managed with the highest degree of appropriateness and confidentiality, pursuant to organization-wide policies and procedures.

PROCEDURE:

· All persons employed at RMC having access to information concerning patients, such as volunteers, hospital staff members and physicians must hold all information in strict confidence, and shall abide by the Health Insurance Portability and Accountability Act (HIPAA) regulations.

· Information concerning patients which may be considered ordinary facts and necessary for planning of specific care and services, will be handled with professional discretion and on a "need to know” basis.

· Information regarding physicians, staff members or volunteers is to be relayed to others as appropriate to the related job function or task and/or to facilitate patient care and services only. Information regarding physicians, staff members or volunteers is to be kept on a professional level, and only discussed in relationship to the individual’s purpose and function within the institution.

· Requests for patient information will be directed to the Health Information Management Department. Disposition of such requests will be in accordance with the hospital's established policy and procedure for Release of Information and pursuant to the HIPAA regulations.

· Advances in technology will be reviewed as these are made available to the institution, to determine if these advances can be employed to improve privacy and confidentiality practices.

· Personal opinions as to the competence of hospital staff members or any staff members, are not to be expressed in a public environment and should always be addressed to the staff member's supervisor, hospital Chief Executive Officer or the Chief of Staff for resolution.

· At no time shall physicians, staff members, volunteers or others associated with RMC engage in discussions of a personal nature which are unrelated to the organization’s mission, values and purpose (i.e., gossip).

· At no time shall staff members, volunteers, or others associated with SSMH, who have access to confidential patient or hospital information, speak with the news media, or others outside the hospital, without prior approval from hospital administration. All encounters with the news media should be directed to administration.

· All staff will be educated and trained about the requirements for information privacy and confidentiality appropriate for each level of employee to carry out his/her healthcare function within the hospital. Education and training includes orientation, initial education and any ongoing education and training necessary related to changes with this organization’s information confidentiality and privacy practices.

· Enforcement of the principles of this policy will be monitored through the combined efforts of the Information Services Director and the Risk Management Department. Monthly monitoring of violations of this policy will be conducted with quarterly reports submitted to the Performance Improvement Committee and Governing Body.

· Outcomes from monitoring activities will be analyzed to determine if improvements can be made in privacy and confidentiality practices.

SUBJECT: JOB DESCRIPTIONS

POLICY

It is the our policy that every staff member be provided and sign an acknowledgement of receipt for their specific job description.

PROCEDURE

· All newly hired personnel shall be shall be provided with a copy of his/her specific job description.

· All personnel shall have a copy of their signed specific job description in their official personnel file.

· Should any changes be made to the job description, an updated copy of the job description will be provided to the employee and a new signature will be required acknowledging the changes made.

SUBJECT: ATTENDANCE

POLICY

It is the policy of the Health Information Management Department to provide quality and timely services to our patients, visitors and other staff members. It is essential that employees work their scheduled hours.

PROCEDURE

· The Health Information Management Department staff member shall request time off either verbally or in writing at least 24 hours in advance of requested time off, not including sick time.

· Requested time off may be granted or denied depending on department’s need by the immediate supervisor or division head.

· Should an employee not give the proper notification for requests (not including sick time), he/she will be subject to disciplinary actions as specified in personnel manual.

SUBJECT: ABSENTEEISM AND TARDINESS

POLICY

It is the policy of the Health Information Management Department to ensure the delivery of quality services through the provision of adequate staffing levels as defined by budgeted staffing parameters. The maintenance of the planning work schedule by each staff member is of paramount importance in meeting such a covenant.

POLICY GUIDELINES

· Absenteeism:

· A staff member who needs to report off ill for a scheduled shift must notify the director or supervisor no less than two (2) hours prior to the beginning of the scheduled shift.

· An absence occurrence is defined as one (1) or more consecutive days of unscheduled time off taken for any reason including illness, personal business or family-related business.

· The Health Information Management Department Director may request that the staff member present a physician’s certification of illness following any occurrence of illness. A staff member who is sick for three (3) days or more must present a physician certification of illness upon returning to work.

· Excessive absenteeism is defined as:

· Three (3) absence occurrences in a three (3) month period

· Six (6) absence occurrences in a six (6) month period

· Twelve (12) absence occurrences in a 12-month period

· Excessive absenteeism will result in progressively disciplinary action up to and including termination, at the discretion of the HIM Department Director.

· An absence occurrence which is coupled with schedule days off, holiday time or vacation time will be subject to progressive disciplinary action.

· Three (3) consecutive days of failure to report without notification will be viewed as the voluntary termination of employment as per policy of Samuel Simmonds Memorial Hospital.

· Scheduled time off is defined as:

· A holiday approved by the supervisor

· A vacation approved by the supervisor

· A personal or medical leave of absence approved by the supervisor

· A bereavement leave

· Tardiness:

· Each member of the department is expected to be present in proper attire and to be ready to work at the start of the scheduled shift (i.e., 0830, 1230).

· A staff member who does not arrive on time to work will be considered tardy.

· The staff member must take responsibility for notifying the director or supervisor if he/she is to be late for any reason.

· A staff member may not elect to stay past the scheduled end of the shift in order to compensate for the missed time due to tardiness.

· The extension of break or meal time periods beyond authorized time limits will be subject to progressive disciplinary action.

· Tardiness will be monitored by the director or supervisor

· Excessive tardiness which occurs twice within one (1) month will be defined as excessive.

· Failure to Report:

· It is the responsibility of each staff member in the Health Information Management Department to follow the agreed schedule.

· The failure to report as scheduled without notification of the director or supervisor will result in a plan of improvement.:

· An Absence Request for paid time off as a result of the failure to report will not be approved.

· Holidays:

· The Health Information Management Department Director will not authorize paid days off including holidays if the staff member fails to work the last scheduled day before and the first scheduled day after a holiday that is taken off.

For additional information please refer to the Personnel Manual section 2.2

SUBJECT: ESTABLISHING A MEDICAL RECORD

POLICY

A written patient record shall be maintained for each patient presenting for care at the medical center, this includes those patients presenting for admission, newborns and those requiring outpatient or emergency care for the first time.

PROCEDURE

· The Health Information Department initiates the medical record:

· Issues hospital number

· EHR is started when demographic data is entered

· Record is grown as providers enter data

· The Information Systems Department initiates the census, discharge, transfer and admission registers and forwards the reports to the Health Information Management Department.

· The Health Information Management Department scans documents that are not created electronically

· Any discrepancies in existing medical records (name, birthdate, etc.) that are identified will be brought to the attention of the Director of HIS or designee for clarification/correction.

SUBJECT: MEDICAL RECORD CONTENT

POLICY

It is the policy of the medical center is that the medical record shall contain sufficient information to identify the patient, support the diagnosis, to justify the treatment and document the results accurately.

PROCEDURE

· The Nursing Department is responsible for collecting sufficient information to identify the patient. The information is documented on the face sheet, which is a permanent part of the patient's record.

· Emergency care, treatment and services received by the patient before his/her arrival at the hospital are documented.

· The history and physical examination is recorded in the medical record at the time of the patient's admission. It shall be obtained from the patient when possible and include:

· Chief complaint

· History of present illness

· Relevant past medical history, family and social history

· Allergies to medications and foods

· Review of systems, including a minimum review of the cardiovascular, respiratory, genitourinary and gastrointestinal systems

· For a child or adolescent, there is mention of developmental age factors, consideration of educational needs and daily activities, height, weight, as appropriate, patient's immunization status, family's and/or guardian's expectations for, and involvement in, the assessment of, treatment and continuous care of the patient

· Obstetrical records including all prenatal information, which may be a copy from the physician's office

· A report of the physical examination, which must include all body systems, pelvic, rectal and breast exams, when applicable. If these are deferred, there must be statement by the physician as to the plans for follow-up or results of a recent exam

· A statement of the impression

· Treatment plan

· Signature of the physician(which authenticates the history and physical exam)

· If a completed physical examination has been performed within 30 days prior to admission, by a member of the Medical Staff , a durable legible copy for this report may be used in the patient's hospital medical record, provided there have been no changes subsequent to the original examination or the changes have been documented at the time of admission.

· There is evidence of informed consent in the patient's medical record.

· There is evidence of known advance directives in the patient’s medical record.

· Clinical observations are made daily in the progress notes by the physician. Other persons making observations, report on designated forms. These progress notes give a pertinent chronological report of the patient's course in the hospital and reflect any change in condition, the results of treatment and plan of care revisions when indicated.

· Consultation reports contain a written or dictated opinion by the consultant that reflect an actual examination of the patient, when applicable, and the patient's medical record.

· Nurses’ notes and entries by nonphysicians, contain pertinent and meaningful information and observations. This information is documented on the respective forms as approved by the Medical Records Committee.

· Opinions requiring medical judgment are written and authenticated only by the medical staff members in the progress notes or on consultation reports.

· All reports of diagnostic and therapeutic procedures, tests and their results are documented and authenticated in the medical record.

· All medications ordered are documented in the medical record.

· Medication administration is documented in the patient’s medication record to include:

· Strength

· Dose, rate of administration

· Route

· Administration devices used

· Any adverse drug reaction

· Response/results of administration if appropriate

· For those patients who are receiving continuing outpatient (ambulatory) services, a list of the following will be made upon initial presentation, if possible; however, no later than the third visit (when more complete information can be listed due to continuing care):

· Known diagnoses (significant and secondary)

· Known or observed conditions

· Prior operative and invasive procedures

· Drug allergies

· Known adverse drug reactions

· Medication:

· Current prescriptions

· Over-the-counter medications

· Herbal supplements

· Reports of Pathology and Clinical Laboratory examinations, Imaging/Radiology, and any other diagnostic or therapeutic procedure are filed in the medical record within 24 hours of completion.

· Patient and family education is documented by all disciplines, as applicable, in the patient’s medical record.

· Communication with the patient, verbally or via e-mail or telephone, is documented in the patient’s medical record.

· The discharge summary or final summary shall include:

· Admitting diagnosis/reason for admission

· Final diagnosis and any associated diagnosis

· Consultants

· History

· Pertinent physical findings

· Pertinent Clinical Laboratory findings

· All procedures performed

· Hospital course

· Discharge medications

· The condition of the patient on discharge

· Discharge instructions, which include activity, diet, medications and follow-up appointments

· A copy of the discharge instructions given to the patient is filed in the medical record.

SUBJECT: DOCUMENTATION GUIDELINES FOR PHYSICIANS

POLICY

The quality of the medical record depends in part on the timeliness, meaningfulness, authentication and legibility of the information it contains.

PROCEDURE

· General Outlines:

· All entries must be timed, dated and authenticated. (JCAHO)

· Records shall be completed and authenticated within two (2) weeks following patient discharge as outlined in the Medical Staff Bylaws.

· In no event shall the completion of chart exceed 30 days following patient discharge. (JCAHO)

· Records will be considered complete when all entries are authenticated.

· Final diagnosis and complications must be recorded without abbreviations or symbols.

· History and Physical Examinations:

· Shall be completed within the first 24 hours of admission.

· Must include the following:

· Chief complaint

· Details of the present illness

· Relevant past, social and family history

· Allergies

· Review of systems

· Physical examination to include inventory of body systems and vital signs

· Pelvic, rectal, breast and for diabetic patients, funduscopic examination or reason for deferral, along with results if done in the hospital

· Conclusions or impressions

· Course of action or plan

· Progress Notes:

· Must be written on a daily basis. (JCAHO)

· Should give a pertinent chronological report of patient’s course.

· Should reflect any change in condition.

· Should reflect the results of treatment.

· Must be timed and dated.

· Consultation:

· Should contain written opinions reflecting actual examination of the patient and the patient’s medical record.

· Clinical Summary Reports:

· Must contain the principal and associated diagnosis.

· Must list all procedures performed.

· Must be dated and authenticated.

· Cannot contain any abbreviations or symbols.

· In the event of death, a summation statement shall be made as to the immediate cause of death.

· Discharge Summary:

· Should be completed within 24 hours following patient’s discharge except in unusual situations where pathology or autopsy findings are awaited.

· Must recapitulate the reason for the hospitalization.

· Must include significant lab/history and physical findings.

· Must include procedures performed and treatment rendered.

· Must include the condition of the patient on discharge.

· Must include any instruction relating to physical activity, medication, diet and follow-up care.

· Must include final diagnosis.

· Must be completed for all deaths.

· Final progress may be substituted for a discharge summary if:

· The patient was hospitalized less than 24 hours for a minor problem (does not include deaths).

· The patient had an uncomplicated obstetrical stay.

· The patient was a normal newborn infant.

Final progress note should include instructions to the patient and/or famil

SUBJECT: SCOPE OF SERVICE

· he Health Information Management Department is responsible for overseeing the timely processing, completeness and when necessary, the retrieval of all patient medical records.

· The scope of services provided by the Health Information Management Department is based upon a collaboration and information sharing format to enhance patient care. Health Information Management services are provided to all areas of the facility, as appropriate to need and security levels. Health Information Management services include provision of an accurate patient record, with emphasis on the following:

· Record processing

· Data entry

· Correspondence

· Record retrieval, filing and storage

· Birth certificate function

· The scope of services also encompasses efforts made to provide:

· More timely and easier access to complete information throughout the organization;

· Improved data accuracy;

· Demonstrated balance of proper levels of security versus ease of access;

· Use of aggregate data, to assist all healthcare providers with information that allows for identification of opportunities to improve performance;

· Accessibility of the medical record at all times to those authorized persons requesting their use for patient care;

· Prepare a birth certificate for each child born. Provide proof of birth and proof of age verifications when requested.

SUBJECT: OWNERSHIP OF MEDICAL RECORDS

POLICY

The medical record is the property of RMC and is maintained for the benefit of the patient, the medical staff and the hospital. The medical center is responsible for safeguarding both the record and its informational content against loss, defacement, tampering and from the use by unauthorized individuals.

CHANGE OF OWNERSHIP

· In the event the ownership of the hospital changes, both the previous licensee and the new licensee will provide the Department of Health, prior to change of ownership, written documentation that:

· The new licensee will have custody of the patients’ records upon transfer of the hospital and that the records are available to both new and former licensee and other authorized persons.

· Arrangements have been made for the safekeeping of patients’ records, as required, and that the records are available to both the new and former licensees and other authorized persons.

CESSATION OF OPERATION

· In the event the hospital ceases operation, arrangement will be made for safe preservation of patients’ records.

· The Department of Health shall be notified within 48 hours of cessation and arrangements will be made for the safe preservation of the medical records.

SUBJECT: REMOVAL OF RECORDS

POLICY

Any information of a medical nature in the possession of Samuel Simmonds Memorial Hospital must not be revealed by any staff member of the hospital or the chart removed from the premises except as outlined in the procedure below.

PROCEDURE

· Medical records shall not be taken outside of the hospital, except upon receipt of a subpoena, court order, statute or specific written authorization of the administrative offices except as otherwise provided by law.

· The medical records shall not be used in any manner that may jeopardize the interest of the patient, except that the hospital’s interests are priority when necessary to defend itself, or its agents, against accusations made by patients or others.

SUBJECT: INCOMPLETE RECORDS

POLICY

· Medical records shall be completed within 14 days of the patient’s discharge.

· Medical records shall be completed promptly and authenticated or signed by a physician, within two (2) weeks following a patient’s discharge.

· The records of discharged patients are completed within a period of time that in no event exceeds 30 days following discharge.

PROCEDURE

· When a discharged patient’s chart is analyzed, it will be considered delinquent 14 days after it is properly processed by the Health Information.

· A deficiency slip is printed from chart deficiency system. The yellow slip is placed on the right side of the patient’s chart. A letter is sent to the physician by the chart deficiency clerk.

· All charts remaining incomplete on the 15th day following discharge will be processed accordingly. Please refer to Delinquent Medical Records policy of this manual.

SUBJECT: DELINQUENT MEDICAL RECORDS

POLICY

It is the policy of the Health Information Management Department to notify a practitioner of suspension when he/she has delinquent medical records.

PROCEDURE

· Physicians will be notified on a weekly basis of their number of incomplete charts through a letter until the charts are complete or the physician is on suspension.

· All deficiencies are noted, by responsible physician, on the chart deficiency log. Deficient records are then placed in the Physician’s Dictation Room in the Health Information Management Department.

· Should the Health Information Management Department not receive a physician response to complete his/her medical records within seven (7) days of the first notice, the physician will be notified via telephone call and a second reminder letter.

· Should the medical record(s) remain incomplete on the 15th day after patient discharge, the Health Information Management Department will notify the physician, and submit his/her name to administration, and the Medical Executive Board.

· A copy of all letters are placed in the physician’s peer review file housed in the Medical Staff Office.

SUBJECT: ABBREVIATIONS

POLICY

It is the policy of Samuel Simmonds Memorial Hospital that to avoid misinterpretation, certain abbreviations and symbols may not be used in the medical record. The list of unacceptable abbreviations and symbols published by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will be utilized. Additionally, a list of commonly used and recognizable abbreviations is available for reference.

PROCEDURE

· It is the responsibility of the Medical Staff to monitor the use of unacceptable abbreviations in the medical record.

· The Health Information Management Department will perform first level review of the medical record for use of unacceptable abbreviations and report their finding to the Hospital Quality Assurance Committee, who will then take any necessary action.

· No abbreviations may be used in the final diagnosis recorded in the discharge, transfer or final summary. The Health Information Management Department will monitor this area of the medical record and notify physicians not in compliance.

· A printed list of the unacceptable abbreviations is made available to all individuals documenting in the medical record and those who must interpret information in the medical record. The original copy will be kept in the Health Information Management Department.

UNACCEPTABLE ABBREVIATION AND SYMBOL LIST

Do Not Use any of the Following When Ordering or Prescribing:

* JCAHO recommended unacceptable abbreviations. The JCAHO recommends a “do not use” list of a minimum of eight (8) items.

Medically Related Abbreviations - DO NOT USE IN MEDICAL RECORD This includes abbreviations found to be dangerous by the National Coordinating Council for Medication Error Reporting and Prevention. This list of abbreviations which should NEVER be used was approved by the Medical Records committee and will be reviewed for further additions, as needed.

SUBJECT: MEDICAL RECORD REVIEW

POLICY

The Medical Record Review Function is designed to assure the appropriateness of clinical information, timely entry, timely completion and legibility of medical records. The focus of medical record review is on the quality of documentation in the medical record.

PROCEDURE

The medical record will be reviewed to determine if the record clearly, completely and accurately reflects the diagnosis, results of diagnostic test, therapy rendered, conditions, inhospital progress of the patient and the condition of the patient at discharge.

· A random sample of medical records (at least 20% of monthly hospital discharges) will be reviewed for the Medical Record Review Function on a monthly basis.

· Records will be retrieved by the Health Information Management Department personnel with sample size proportionate to utilization patterns.

· Sample size will be representative of the full scope of services provided in the hospital and all physicians utilizing the facility, over time.

· Medical record review will be performed to determine if the record clearly, completely and accurately reflects the diagnosis, results of diagnostic tests, therapy rendered, condition, in-hospital progress of the patient and condition of patient at discharge.

· Entries into, and completion of medical records will be reviewed for timeliness.

· Medical record review includes, but is not limited to, analysis of:

· Identification data

· Medical history, including the chief complaint, details of present illness, relevant past, social and family histories and an inventory by body systems

· A summary of the patient's psychosocial needs, as appropriate to the age of the patient

· Statement of the conclusions or impressions drawn from the admission and physical examination

· Statement of the course of action planned for the patient while in the hospital and of its periodic review as appropriate

· Diagnostic and therapeutic orders

· Evidence of appropriate informed consent

· Clinical observations, including the results of therapy

· Progress notes made by the medical staff and other authorized staff

· Consultation reports

· Reports of any diagnostic and therapeutic procedures, such as pathology and clinical laboratory examinations, radiology and examinations or treatments

· Records of donation and receipt of transplants or implants

· Final diagnosis or diagnoses

· Conclusions at termination of hospitalization

· Clinical resumes and discharge summaries

· Discharge instructions to the patient or family

· Autopsy result, when performed

· The Medical Record Review Function is performed by the medical staff in cooperation with the Nursing Department, the Health Information Management Department, management and administrative services and representatives of other department/services as appropriate.

· Records will be reviewed for special issues such as compliance with abbreviation and unacceptable abbreviation lists, authentication of data and other information that is used to monitor data content to ensure timely and economical data collection with the degree of accuracy, completeness and discrimination necessary for the record’s intended use.

· All records which fail to meet completing, timeliness or pertinence criteria will be forwarded to the Medical Records Committee on a monthly basis for discussion.

· Conclusions, recommendations, actions and evaluation of action effectiveness of the Medical Record Review Function will be documented in the monthly minutes of the Information Management Committee.

· Individual practitioner review outcome will be included in the practitioner’s performance improvement profile for consideration at time of reappointment. Data will be trended to allow for comparison of individual practitioner’s performance against the norm.

SUBJECT: PERFORMANCE IMPROVEMENT

PURPOSE/OBJECTIVE

· The Health Information Management Department participates in an organization-wide performance improvement (PI) program designed to monitor, evaluate and improve the quality and appropriateness of clinical services by:

· Planning, designing, measuring, assessing, improving new or revised processes of patient care and service,

· Identifying opportunities through continuous assessment of systems and processes of care through a collaborative, interdisciplinary focus, and

· Implementing solutions and actions which will bring about the desired changes, to

· Facilitate a positive patient outcome, while

· Maintaining a safe environment for personnel, patients and visitors.

· Information Management:

· Performance improvement activities throughout the organization are dependent upon the management of information function. This function is performed in an interdisciplinary collaborative approach throughout the facility. As the management of information is a function that is comprehensive, impacting all services within the facility, the review of this function is performed as a collaborative process when medical staff and departmental performance improvement activities are conducted. Outcomes are reflected in the specific departments and hospital-wide through the auspices of the Quality Council's review and analysis of performance improvement data.

· This function is performed to obtain, manage and use information to enhance and improve individual and organizational performance in effective communication, patient care and safety, governance, management and support processes. The quality of the medical record is reviewed for accuracy, timeliness, completeness and legibility.

RESPONSIBILITY

· The Health Information Management Department Director is responsible for establishing and implementing a Health Information Management Department performance improvement plan. The plan shall integrate medical record performance improvement activities into a system that will foster improvement in systems and processes associated with care. The Health Information Management Department Director also shall delegate responsibilities for monitoring, action, evaluation and reporting.

· The Health Information Management Department Director will report all Health Information Management Department performance improvement activities to the organization-wide Quality Council and the Information Management Committee for their review and recommendations. The organization-wide Quality Council and the Information Management Committee will in turn report their evaluations to the Medical Executive Committee.

GOALS OF PERFORMANCE IMPROVEMENT

· The primary goals of the Health Information Management Department performance improvement plan are to continually and systematically plan, design, measure, assess and improve performance of priority focus areas, improve healthcare outcomes and reduce and prevent medical/health care errors. To achieve these goals the plan strives to:

· Incorporate quality planning;

· Provide a systematic mechanism that assures the Health Information Management Department designs processes (with special emphasis on design of new or revisions of established services) well and systematically measures, assesses and improves its performance to achieve optimal patient health outcomes in a collaborative, cross-departmental, interdisciplinary approach. These processes include mechanisms to assess the needs and expectations of the patients and their families, staff and others. Process design contains the following focus elements:

· Consistency with the organization’s mission, vision, values, goals and objectives and plans

· Meets the needs of the individuals served, staff and others

· Use of sound and current data sources (for instance, information from relevant literature and standards)

· Is based upon sound business practices

· Incorporates available information from internal sources and other organizations about the occurrence of medical errors and sentinel events to reduce the risk of similar events in this institution

· Utilizes the results of performance improvement, patient safety and risk reduction activities

· The Health Information Management Department incorporates information related to these elements, when available and relevant, in the design or redesign of processes, functions or services.

· Necessary information is communicated between departments/services when problems or opportunities to improve services and practices involve more than one department.

· The status of identified problems is tracked to assure improvement or problem resolution.

· Information and the findings of discrete performance improvement activities and adverse patient events are used to detect trends, patterns of performance or potential problems that affect more than one (1) department/service.

· The objectives, scope, organization and mechanisms for overseeing the effectiveness of monitoring, assessing, evaluating and problem-solving activities in the performance improvement program are evaluated annually and revised as necessary.

· Treatment and services affecting the health and safety of patients are identified. Included are those that occur frequently or affect large numbers of patients; place patients at risk of serious consequences or deprivation of substantial benefit if care is not provided correctly or not provided when indicated; or care provided is not indicated, or those tending to produce problems for patients, their families or staff.

SCOPE OF CARE

· The Health Information Management Department services are provided to all areas of the facility, as appropriate to need and security levels and includes for the provision of an accurate patient record and is based on collaboration and information sharing format that enhances patient care.

· The Health Information Management Department provides to both the inpatient and outpatient population and include:

· Adequate supervision and qualifications of Health Information Management Department personnel

· Documentation that facilitates the continuity of care and the evaluation of services

· Protection of the legal interest of the patient, hospital and the responsible practitioner

· Accuracy and security of record storage, with records kept in a risk-free environment

· Readily accessible and easily retrievable information balanced with appropriate levels of security

· Medical record review function with results submitted to medical staff committees as appropriate.

· Data management

· The hours of operation are 8:30 am to 9:00 pm. The Health Information Management Department Director is responsible for the condition and direction of the performance improvement plan. A quarterly report is submitted to the organization-wide Quality Council.

PERFORMANCE ACTIVITIES

· The performance improvement program for the Health Information Management Department shall monitor processes, which are felt to be high-risk, high volume or have demonstrated a trend toward potential negative outcomes (problem-prone) and/or that involve risks or may result in sentinel events. Those processes that have been identified through the continuous quality improvement (CQI) process as an area where a system or process may be improved and additional indicators will be identified and chosen for monitoring through a collaborative effort utilizing information obtained from all areas of Nursing Services, medical staff, departmental representatives, administration, Risk Management and other services throughout the facility, as appropriate.

· Proposed focus areas for assessment include, but are not limited to:

· Needs, expectations and satisfaction of patient and staff

· Staff view regarding performance improvement activities

· Education of clerical personnel for optimum data retrieval of medical information

· Retrieval of relevant data for medical staff committee review

· Analysis of the medical record for completeness and accuracy

· Selection and design of forms for inclusion in the medical record

· Adequacy of medical record content

· Aggregation of information for medical record review function

· Confidentiality of the medical record

· Protection of the medical record

· Accuracy of statistical data gathering of medical information

· Accuracy of medical record abstracting for reporting purposes performed by an outside vendor

· Conducting education self improvement programs to enhance performance, moral and loyalty

· Patient confidentiality

· Hazard awareness, prevention and control

· Sentinel event reduction and elimination

· Performance monitoring of focus areas are subject to change due to the collaborative processes outlined above

PERFORMANCE MEASURES

Performance measures with related performance outcomes will be established as a means to systematically monitor the focus areas in an ongoing manner, and to provide operational linkages between the risk management functions related to the clinical aspects of patient care and safety and the performance improvement functions. Performance expectations will be established for any new or revised processes undertaken by the Health Information Management Department staff. Performance measures will be specific and measurable. Performance measures will be structured to relate to both the processes and outcomes of patient care. Performance measures will pertain directly to the Health Information Management Department practices and will use objective criteria that reflects current knowledge and experience.

· The following criteria will be utilized to assure that the indicator chosen for data collection is the most appropriate for monitoring the performance of a patient care or service process, system or function:

· The measure can identify the events it was intended to identify.

· The measure has a documented numerator and denominator statement or description of the population to which the measure is applicable.

· The measure has defined data elements and allowable values.

· The measure can detect changes in performance over time.

· The measure allows for comparison over time within the organization or between the organization and other entities.

· The data intended for collection is available and attainable.

· Results can be aggregated and reported in a way that is useful to the organization and other related interested parties.

THRESHOLDS

Measurement of performance measures will be structured to focus on an improvement in patient care. Thresholds will represent either pre-established levels, that when reached trigger an intensive evaluation of the measure under review, or benchmarks that have been identified by facility experience, that requires an in-depth evaluation of the proposed performance aspect and related performance measures. Thresholds will also serve as a means to identify targeted areas for further study.

METHODOLOGY

The Health Information Management Department utilizes the FOCUS PDCA, methodology to plan, design, measure, assess and improve functions and processes related to major patient care related activities.

· F—Find a process to improve

· O—Organize to improve the process

· C—Clarify current knowledge of the process

· U—Understand sources of process variation

· S—Select the process improvement

· Plan:

· Performance measures are based on current knowledge and experience and are structured to represent cross-departmental, interdisciplinary processes, as appropriate.

· The following data sources will be reviewed for use in the development of performance measures:

· Staff opinion and needs

· Staff perceptions of risks to patients and suggestions for improving patient safety

· Staff willingness to report medical/health care errors

· Outcomes of processes or services, including adverse events

· Performance measures from organization approved internal and external databases

· Satisfaction surveys

· Risk management

· Utilization management

· Quality control

· Customer demographics and diagnoses

· Benchmarks or thresholds that trigger intensive assessment and evaluation are established.

· Do:

· Data is collected to determine:

· Whether the design specification for new processes were met

· The level of performance and stability of existing processes

· Priorities for possible improvement of existing processes

· Check:

· The Health Information Management Department Director and the department as a whole shall review and evaluate the data presented for analysis of outcome. Appropriate statistical methodology will be employed to analyze and display data. Evaluation shall focus on identifying opportunities to improve both the processes of patient care and actual identified problem areas that effectuate a negative outcome, as well as the reduction and/or elimination of real or potential sentinel events. Comparisons with both internal, department specific historical data and external data will be performed in the evaluation process, with undesirable patterns or trends in performance and sentinel events requiring intensive analysis. Conclusions will be drawn regarding the evaluation of data presented with recommendations considered.

· Act:

· Upon review of the data presentation, conclusions and recommendations, the Health Information Management Department will take actions to resolve identified problems and will direct efforts to those areas which have the greatest potential for improving patient care and reducing the risk of sentinel events. The Health Information Management Department shall utilize existing hospital resources, committees and problem-solving techniques to resolve identified problems and improve patient care and safety. The Health Information Management Department will perform follow-up monitoring to assure that actions taken are effective and that any progress achieved is sustained. The criteria used for follow-up monitoring should be the same or similar to those used in the initial identification of the problem/opportunity for improvement, however, the sample size may vary or focused monitoring may be utilized for effectiveness.

COMMUNICATION/INTEGRATION OF INFORMATION

The Health Information Management Department Director shall ensure that documentation of the results of the outcomes of performance improvement and patient safety activities are maintained and that reports are forwarded as prescribed by the organization-wide performance improvement plan. Committees reviewing the outcomes of the Health Information Management Department’s ongoing performance improvement activities include: the Information Management Committee, organization-wide Quality Council and the Medical Executive Committee. Other medical staff and clinical department committees may also receive performance improvement related information as appropriate. The frequency of reporting will be as defined in the organization-wide performance improvement plan, on a monthly/bimonthly/quarterly basis as designated. Documentation and reports shall include:

· Findings from monitoring activities

· Conclusions regarding identified opportunities for improvement

· Recommendations concerning potential actions

· Actions taken to effectuate change

· Outcome of action effectiveness (results of follow-up monitoring performed to determine extent of effectiveness and that improvement made are sustained)

ANNUAL EVALUATION OF PERFORMANCE IMPROVEMENT PROGRAM

The Health Information Management Department shall evaluate the effectiveness of the performance improvement monitoring and evaluation program at least annually and revise as necessary. Other sources that interact with the Health Information Management Department during the course of services will be encouraged to participate in the evaluation of the effectiveness of the program. The evaluations shall be documented and forwarded through the appropriate medical staff reporting structure to the Governing Body.

CONFIDENTIALITY

· All information related to performance improvement activities performed by the medical staff or hospital personnel in accordance with the plan are confidential.

· Confidential information may include but is not limited to: the medical staff committee minutes, Performance Improvement Executive Report, electronic data gathering and reporting, untoward incident reporting and clinical profiling.

· Some information may be disseminated on a “need to know basis” as required by agencies such as federal review agencies, regulatory bodies, the National Practitioners Data Bank or any individual or agency that proved a “need to know basis” as approved by the Medical Executive Committee, hospital administration and/or Governing Body.

SUBJECT: RECORD RETENTION

POLICY

· A medical record shall be retained on all patients admitted or accepted for treatment to the medical center.

· The patient record shall be preserved safely for a minimum of 10 years following the most recent discharge date. The exception is the record of an unemancipated minor. Such records shall be kept at least one (1) year after his/her date of majority (18), but in any case, not less than 10 years from the date of the most recent discharge date.

· The medical record is the property of the hospital and is maintained for the benefit of the patient, the professional staff and the hospital.

PROCEDURE

· Upon discharge, the medical record shall be reviewed for the patient's date of birth.

· If a minor, the medical record shall be reviewed to conclude if patient is an emancipated minor.

· All records of "death" patients treated within the past five (5) years are filed in the Health Information Management Department storage room.

· Any patient's medical record with a "letter of intent" shall be housed in the Health Information Management Department litigation file. This chart shall remain in this area until all legal matters have been concluded.

· Records on patients not treated within the last five (5) years are sent to an outside storage facility.

SUBJECT: INTERNET AND EHR ACCESS

POLICY

It is the policy of the medical center to provide access to the patient care data base to appropriate individuals.

PROCEDURE:

· The Information Systems is responsible for providing access to and maintaining all electronic forms of communication.

· EHR access is restricted to clinical staff and appropriate administrative staff. Use by other departmental staff must be approved on a case by case basis.

· It is a violation of RMC policies to use someone else’s password or to log into someone else’s account without their authorization.

· No patient specific information is to be sent over unsecured data lines.

· No hospital proprietary information may be used or sent without written administrative approval.

· All Internet access will be directed through the hospital’s Internet Service Provider from designated terminals only.

· Use of the hospital’s computer resources for non-business related purposes is prohibited.

· Staff are prohibited from using computer games on company owned equipment.

· Internet paid subscriptions must be budgeted through individual departments.

SUBJECT: GENERAL SAFETY INFORMATION

POLICY

· The Health Information Management Department Director is responsible for maintaining safety standards, developing safety rules, supervising and training personnel in departmental standards.

· The Health Information Management Department Director is responsible for notifying the Safety Officer in case of any safety hazard.

· All department employees shall report defective equipment, unsafe conditions, acts or safety hazards to supervisor.

· Keep electrical cords clear of passageways. Do not use electrical extension cords without written approval of the Safety Officer.

· All equipment and supplies must be properly stored. Do not store heavy items on top shelves.

· Use step stools or ladders for elevated items, not chairs or furniture.

· All personal electric appliances shall be inspected by the Safety Officer or Maintenance for safe use prior to operation in the facility.

· Scissors, knives, pins, razor blades and other sharp instruments must be safely stored and used.

· Use of sharp spindles is prohibited.

· All electric machines with heat producing elements must be turned off when not in use.

· Smoking is prohibited in the hospital.

· Do not permit rubbish to accumulate.

· Notify the Maintenance immediately of improper illumination and ventilation.

· Furniture and equipment must be arranged to allow passage and access to exits at all times.

· Minor spills, i.e., water, will be cleaned by the employee who discovers the spill. This will be done immediately. Major spills will be cleaned by Housekeeping.

· Report faulty equipment to Maintenance or vendor as per policy.

· Obey warning signs.

· File drawers and cabinet doors shall be closed when not in use. Open only one drawer at a time. Evenly distribute material to prevent the file cabinet from being unbalanced and tipping over.

· Wear suitable clothing. (Avoid high heels or jewelry that may catch in machinery.)

· Always place machines on sturdy desks and stands. If possible, machines shall be fastened to prevent falling.

· Understand and practice good body mechanics.

· Keep to right when going down corridors. Approach intersections carefully. Be sure traffic on other side is clear when opening swinging doors. Do not push doors open with equipment. Use push panel or door knob.

· Do not leave equipment standing in traffic lanes. Return equipment to its proper location when not in use.

· Do not obstruct fire equipment. Know location of fire fighting equipment and how to use it. Know evacuation routes and what to do in case of fire

SUBJECT: ERGONOMICS

PROPER STANDING POSTURE

· Supports musculature of back

· Increases comfort

· Conserves body energy

· Decreases fatigue

· Enhances appearance

MAINTAINING PROPER ALIGNMENT

· Head - Hold straight, not bending forward

· Shoulders - Keep shoulders straight, not slumped

· Abdomen - Hold in mid-position with slight hollow in the low back

· Knees - Do not lock straight

· Feet - Hold a few inches apart, with the weight evenly distributed over the foot and the outside edge of the sole

PROPER SITTING POSTURE

Do not sit with legs extended in front of you. This places undue stress on your back and will increase fatigue.

PREVENT BODY DISCOMFORTS AND INJURIES BY

· Keeping in shape and active.

· Try to maintain optimal weight. Extra weight equals extra burden for your back and body.

· When lifting, lift with the legs with knees slightly bent. Do not reach and lift at the same time. Do not attempt to lift a load that is too heavy for your size and build.

· If you are required to sit for long periods of time, stand and walk erect for several minutes once an hour. Consider obtaining lumbar support device.

· Do not lift any object over 10 pounds if you have a condition that prohibits this.

· When Lifting Remember:

· Lift weight with your legs, never your back.

· Place your feet in a position to give you a wide base.

· Your toes should be facing the object you intend to lift.

· Your toes should be facing the object as you set it down.

· Always keep the load close to your body.

· Most importantly, get help for loads that are awkward or appear too heavy.

SUBJECT: FIRE SAFETY

PROCEDURE:

The proper response to fire or smoke is R.A.C.E.

R = Rescue patients immediately from fire or smoke area.

A = Pull fire alarm station and call emergency number give exact location.

C = Contain the smoke or fire by closing all doors to rooms and corridors.

E = Extinguish the fire (when safe to do so).

· Rescue individuals from the immediate fire or smoke area. Always rescue people before pulling the fire alarm.

· Pull the fire alarm and call emergency number to report the fire. Be sure to take this step immediately after rescuing, so that the appropriate emergency response personnel are notified and can start to the scene of the fire.

· Contain the fire and smoke by closing all doors in the area.

· After all doors are closed in the fire area, attempt to extinguish the fire if it is safe to do so. All employees shall be familiar with the location and operation of fire extinguishers through the fire safety education program.

· If fire or water threatens your area, initiate the following procedures:

· Turn off all equipment, however leave the lights on.

· Remove all records (identified for removal) from building or area.

· Place all other records in file and storage cabinets as space provides.

· Keep telephone lines clear.

· Close all doors and windows.

· Use the fire extinguisher to suppress the fire only if you are trained and it is safe to do so.

· If the fire is not in your area, be alert, be guided by the instructions of your area fire marshal, or department director.

· Assign personnel to take fire extinguishers and report to scene of the fire.

· Assign personnel to close all doors, file cabinets, etc.

· Turn off all equipment.

· Close all doors and windows.

· Stand by for further orders.

· Evacuation:

· Doors in the area must be closed before evacuation to prevent the circulation of air and to contain the fire. In such an instance, the action must be well supervised to see that traffic moves quickly, properly and calmly to prevent panic.

· The Health Information Management Department staff members may be asked to assist the nursing staff in removing any patients from the patient rooms. Any staff members involved in this action must notify their supervisor.

· All personnel are reminded never to run. They should remain as calm as possible and in control during the emergency.

· Refer to Hospital Safety Manual

· Fire Prevention:

· Staff members must be alert to possible ignition sources in the hospital. Preventing fires is a part of our professional obligation to our patients and others in the facility. Fire prevention is the interruption of the sequence of events that can cause a fire.

· Equipment:

· Any defective piece of electrical equipment is a potential source of ignition for a fire. You are responsible to REPORT any malfunctioning piece of equipment AT ONCE, tag it and TAKE IT OUT OF SERVICE IMMEDIATELY to prevent an accident or fire.

· Extension cords must be used on a temporary basis only and must be of hospital approved type.

· Wire may NEVER BE NAILED OR STAPLED to the wall, floor or ceiling.

· Sprinklers must be free and clear so they can be activated in case of fire.

· Air vents must never be blocked, nor air vent fans, and they must be cleaned on a frequent basis.

· Liquids, coffee cups, etc., may never be placed on top of electrical equipment. Items could spill and cause a fire or equipment could overheat.

· All electrical equipment brought in from the outside, such as fans, Christmas lights, radios, etc., MUST BE CHECKED by the Safety Officer or the Maintenance Department before they may be used in the department.

· Portable heaters are not allowed under any circumstances.

SUBJECT: CONTINGENCY PLAN FOR WATER DAMAGED CHARTS

POLICY

It is the policy of medical center to provide a contingency plan in the event records are damaged due to water damage. Any type of damage is destructive. Water damage from broken pipes fire can be most devastating.

PROCEDURE

· The following procedures should be implemented as soon as the water is removed and the amount of damage is assessed.

· Determine what documents should be rescued using the retention requirements.

· Prioritize which records should be removed first in order to keep the hospital functioning.

· Records are to be removed within 48 hours of damage to prevent mold, mildew and bacteria growth.

· Depending on the degree of damage, the records can be restored by:

· Air drying the records by placing absorbent material between each document and then fans are used for increased air circulation.

· Freezing the records and keeping them in cold storage. This process stops the deterioration of handwritten data on paper records.

· Freeze-drying is the quickest and most expensive method. Only for optimal preservation of original records that are totally irreplaceable.

· Remember time is a critical factor. Move as quickly as possible to recover damaged information.

SUBJECT: COMPUTER INTERRUPTION / MALFUNCTION / DESTRUCTION PLAN

POLICY

It is the policy of this medical center to protect the electronic data media source and equipment from damage or loss.

POLICIES FOR REDUCING RISKS

· Preventive Maintenance of Hardware will be Performed on the Following:

· Peripheral Hardware:

· Bimonthly by Information Systems personnel or on an “as needed basis”

· Protection of Computer Data will be Performed by "Back-up" Storage of Information:

· Backup Policy:

· Entire system will be copied onto magnetic tapes each evening as part of the nightly system shutdown procedure. There are no exceptions to this policy.

· Backup Storage Policy:

· Tape Rotation and Storage:

· Nightly backup tapes are to be rotated on a daily basis, seven (7) days per week, 365 days per year.

· Protection of Data Center Operation:

· Power Loss:

· Computer room is protected by a backup generator and a line conditioning system.

· The back-up generator will be tested quarterly to assure back-up techniques are effective.

· Fire Protection:

· Computer Room:

· Equipped with smoke and heat detectors

· Equipped with a hand-held halon fire extinguisher

· Fire alarm pull station located in hallway outside of computer room

· An emergency shutoff switch is located directly outside the Computer Room

· Physical Security:

· The Information Systems Department is locked at all times.

· Computer Access Security:

· Modem Security:

· Only return calls to predetermined numbers

· Only allow access to calls with proper security clearance

· Passwords-Financial and Clinical Systems:

· User defined

· Security Systems:

· Accessibility authorized in accordance with policies and procedures

COMPUTER INTERRUPTION OR FAILURE

· Partial Interruption of Computer Services:

· Notify Information Systems Director immediately.

· Hospital personnel on duty are to be notified as soon as deemed necessary via the hospital paging system.

· If situation occurs during off hours, Information Systems Director or alternate is to be notified if services have not been restored within one (1) hour, unless earlier notification is deemed necessary.

· Information Systems Director or alternate will attempt to identify:

· The nature of the problem

· An estimated timeframe for resolution of the problem

· Information Systems Director will notify all other department directors/managers or their alternates of affected departments if services have not or will not be restored within one hour.

· Major Failure But Computer Room Intact:

· Notify Information Systems Director immediately.

· If situation occurs during off hours, Information Systems Director or alternate is to be notified immediately.

· Information Systems Director or alternate will notify all other personnel of affected departments as soon as possible.

· When service is restored, orders will be entered into the computer by the receiving department, thus generating the charge.

· Routine orders are held until services are restored and then entered into the computer by the ordering department, thus generating the charge.

· Services Interrupted Over Two (2) Hours:

· Registrations are completed manually.

· When service is restored, registrars will enter all registrations in chronological order.

· "STAT" orders are called to the departments and manual requests are sent via courier to the department. "STAT" order telephone calls are to be followed with manual requests.

· Exception: Pharmacy must enter all orders on the computer, thus generating the charge.

RECOVERY PROCEDURES

· Loading Backup Tapes:

· Backup tapes will be loaded as instructed by Information Systems Director or alternate.

· Daily reports will be printed from backup microfiche tapes and data entry will be keyed at this time.

SUBJECT: HAZARD COMMUNICATION PROGRAM

INTRODUCTION

· The Occupational Safety and Health Administration (OSHA) wrote the Hazard Communication Standard so that illnesses and injuries that may be caused by working with chemicals can be prevented and/or reduced. The purpose of the standard is to inform you of the risks associated with working with chemicals and to show you what you can do to protect yourself from possible illness or injury while on the job.

· Rasmussen Medical Center (RMC) has developed a Hazard Communications Program to enhance our employee’s health and safety. It is the requirement of the Federal Occupational Safety and Health Administration (OSHA) that all employees be educated on the Hazards Communication Program. This program provides information about hazardous substances as well as the control of the substance. It includes product labeling, a material safety data sheet and educational and communication processes.

· There is a written policy and procedure for the Hazards Communication Program in the Safety Policy and Procedure Manual. A policy and procedure specific to the Health Information Management Department may be found in the MSDS manual in the Health Information Management Department. Please read this policy and procedure, which outlines your rights as an employee as well as management’s responsibilities regarding hazardous substances

· Health hazards are substances which can have acute or chronic effects on exposed persons.

· The Material Safety Data Sheet (MSDS) is written material prepared by a manufacturer concerning the physical and chemical properties of a substance that may be a health hazard. It contains information on safe handling, emergency and first-aid procedures and the safe disposal of waste.

PRODUCT LABELING

· All containers involving hazardous substances will have:

· The identity of the hazardous substances

· Hazard warnings

· Name and address of the manufacturer

· It is important for your safety that you read the hazard warning and use the substance(s) within the guidelines written on the label. If there is no label do not use the substance and report to your supervisor.

· Ask your supervisor if you are unsure about correct use of a product.

MATERIAL SAFETY DATA SHEET (MSDS)

· The MSDS is the means by which you can find additional information regarding the hazardous substances to which employees of the department may be exposed. The MSDS contains all the information you need to know regarding safety.

· Information about MSDS is contained in a binder located in your department.

· If you have questions regarding any hazardous substances your resource person is the Safety Officer.

· When new hazardous substances are introduced into your work areas, your supervisor will review them with you.

INTERPRETING THE MSDS

· Each MSDS is broken down into nine (9) sections:

· Section I Header - Product identity

· Trade and Generic Names

· Manufacturer date-name

· Address and emergency phone number

· Section II Header - Names and amounts of hazardous ingredients listed by classification

· Section III Header - Physical characteristics of the substance including boiling point, solubility and other such data

· Section IV Header - Fire and explosion hazards

· Fire fighting procedures

· Storage and other relevant precautions to prevent fire/explosion

· Section V Header - Health Hazard Information

· Recommended limits for human exposure and effect of over exposure

· First aid/emergency treatment to cover common protocols of entry into the body i.e., what to do if the product gets into eyes or is inhaled

· Section VI Header - Chemical reactions of the substance

· Stability, incompatibility with other products

· Hazardous by products

· Section VII Header - Spill or leak precautions

· Clean up procedures

· Waste disposal

· Section VIII Header - Special Protection Information

· Look here to determine if protective clothing, eyewear or other special precautions are necessary to avoid direct contact with the substance

· Section IX Header - Special Precautions

· Handling and storage of the product

CATEGORIES OF HAZARDOUS SUBSTANCES

The most commonly used hazardous substances in the hospital have been identified.

· Flammables:

· Example: Alcohol, Acetone

· Flammable liquids represent fire and explosion hazards if not handled correctly.

· Irritants:

· Example: Cytology Fixative, Tincture of Benzoin Spray

· Contents may be in pressurized containers and are highly flammable.

· Cleaning Agents:

· Example: HI-TOR PLUS, Cidex/Glutarex, Germacare

· Many of the products used in the hospital are similar to those used at home. The chemical ingredients may cause skin burns if products are handled carelessly. These products are intended to be diluted prior to use.

· Physical Hazards:

· Examples: Pressurized cylinders such as: Oxygen, Acetylene, compressed air tanks

· Fire and explosion can occur

· Specific Hazardous Chemicals:

· Example: Formaldehyde, oxygen oxide, suspected carcinogens, nitrous oxide.

FIRST AID PROCEDURES

· Consult the MSDS for instructions pertaining to specific hazardous substances if exposure occurs.

· The following first aid procedures are provided for general information only:

· Eye Contact:

· If splashed into eyes, flush with water for 15 minutes or until irritation subsides. If irritation continues, see a physician.

· Skin Contact:

· In case of skin contact, remove any contaminated clothing and wash skin thoroughly with water and soap.

· Inhalation:

· If overcome by vapors, remove from exposure and call a physician immediately. If breathing is irregular or has stopped, start resuscitation.

· Ingestion:

· If ingested, DO NOT induce vomiting, call emergency medical aid immediately.

HAZARDOUS MATERIALS IN THE HEALTH INFORMATION MANAGEMENT DEPARTMENT

In the hospitalwide MSDS Manual is a list of hazardous materials used in the Health Information Management Department. Read it and pay special attention to the following information:

· Storage

· Handling procedures

· Special precautions for spills or exposure

· Emergency care

EMERGENCY MANAGEMENT PLAN

Upon hearing the announcement, "CODE YELLOW, EXTERNAL," personnel shall respond and participate according to the following:

· The Health Information Management Department Director, or designee, will contact Administration/Nursing Supervisor to determine if there is adequate staff available for the Operations Center. In the event there is not, the following will occur:

· The director/designee will send at least one (1) employee, maximum of three (3) if possible, to assist in setting up and staffing the Operations Center. The employee(s) will perform the following responsibilities:

· Obtain the blackboard for the listing of the victims and take it to the Operations Center.

· Assist in answering the telephone.

· Update the Patient Flow Sheet as necessary.

· Perform other duties as assigned in the Operations Center.

· In the event that adequate personnel are available to staff the Operations Center, the following will occur:

· The director/designee will send the available employee(s) to the Labor Pool.

Note: The following will occur if either plan is in effect:

· At least one (1) person will remain in Health Information Management Department.

· One (1) employee will report to the Triage Area. Upon release of the patients, employee will collect the multi-casualty incident patient charts. (Completion of treatment rendered and discharged from the hospital).

· The Health Information Management Department Director will be responsible for notifying the off-duty Health Information Management Department personnel. A list of the department employees for call-back shall be kept in the department in the front of the Department Policy and Procedure Manual. Upon being contacted, they will be told where to report upon arrival to the hospital. All employees will sign in before reporting to duty.

Note: Identification cards are necessary to gain entry into the hospital.

· The Health Information Management Department Director is responsible for ensuring the security and preventing the loss of hardcopy medical records.

INTERNAL EMERGENCY MANAGEMENT PLAN

Upon hearing the announcement, "CODE YELLOW, INTERNAL," the Health Information Management Department Director, or designee, will:

· Outside the department:

· Keep two (2) people in the Health Information Management Department.

· One (1) person to remain in the department.

· One (1) person to report to the Holding Area if activated.

· All other personnel to the Labor Pool.

· Within the department:

· Notify the operator by phone if possible, or by runner if the phone is not in operation. Report the location, nature and extent of emergency.

· The Director/Designee:

· Directs the department personnel and others until someone more qualified arrives.

· Determines the necessity to evacuate the Health Information Management Department due to the emergency or an imminent emergency in the department.

· Evacuation:

· If additional help is needed, contact Labor Pool.

· To transport the injured, wheelchairs and gurneys shall be obtained from the nursing units and storage.

POLICY

· Patient Rights: The medical center and medical staff have adopted the following statement of patient rights. This list shall include but not be limited to the patient's right to:

· Become informed of his or her rights as a patient in advance of, or when discontinuing, the provision of care. The patient may appoint a representative to receive this information should he or she so desire.

· Exercise these rights without regard to sex or cultural, economic, educational or religious background or the source of payment for care.

· Considerate and respectful care, provided in a safe environment, free from all forms of abuse, neglect, harassment and/or exploitation.

· Access protective and advocacy services or have these services accessed on the patient’s behalf.

· Appropriate assessment and management of pain.

· Remain free from seclusion or restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff.

· Knowledge of the name of the physician who has primary responsibility for coordinating his/her care and the names and professional relationships of other physicians and healthcare providers who will see him/her.

· Receive information from his/her physician about his/her illness, course of treatment, outcomes of care (including unanticipated outcomes) and his/her prospects for recovery in terms that he/she can understand.

· Receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse the course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved in the treatment, alternate course of treatment or non-treatment and the risks involved in each and to know the name of the person who will carry out the procedure or treatment.

· Participate in the development and implementation of his or her plan of care and actively participate in decisions regarding his/her medical care. To the extent permitted by law, this includes the right to request and/or refuse treatment.

· Formulate advance directives regarding his or her healthcare, and have hospital staff and practitioners who provide care in the hospital comply with these directives (to the extent provided by state laws and regulations).

· Have a family member or representative of his or her choice notified promptly of his or her admission to the hospital.

· Have his or her personal physician notified promptly of his or her admission to the hospital.

· Full consideration of privacy concerning his/her medical care program. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. The patient has the right to be advised as to the reason for the presence of any individual involved in his or her healthcare.

· Confidential treatment of all communications and records pertaining to his/her care and his/her stay in the hospital. His/her written permission will be obtained before his/her medical records can be made available to anyone not directly concerned with his/her care.

· Receive information in a manner that he/she understands. Communications with the patient will be effective and provided in a manner that facilitates understanding by the patient. Written information provided will be appropriate to the age, understanding and, as appropriate, the language of the patient. As appropriate, communications specific to the vision, speech, hearing cognitive and language-impaired patient will be appropriate to the impairment.

· Access information contained in his or her medical record within a reasonable time frame (usually within 48 hours of request).

· Reasonable responses to any reasonable request he/she may make for service.

· Leave the hospital even against the advice of his/her physician.

· Reasonable continuity of care.

· Be advised of the hospital grievance process, should he or she wish to communicate a concern regarding the quality of the care he or she receives or if he or she feels determined discharge date is premature. Notification of the grievance process includes: whom to contact to file a grievance, and that he or she will be provided with a written notice of the grievance determination that contains the name of the hospital contact person, the steps taken on his or her behalf to investigate the grievance, the results of the grievance and the grievance completion date.

· Be advised if hospital/personal physician proposes to engage in or perform human experimentation affecting his/her care or treatment. The patient has the right to refuse to participate in such research projects. Refusal to participate or discontinuation of participation will not compromise the patient’s right to access care, treatment or services.

· Full support and respect of all patient rights should the patient choose to participate in research, investigation and/or clinical trials. This includes the patient’s right to a full informed consent process as it relates to the research, investigation and/or clinical trial. All information provided to subjects will be contained in the medical record or research file, along with the consent form(s).

· Be informed by his/her physician or a delegate of his/her physician of the continuing healthcare requirements following his/her discharge from the hospital.

· Examine and receive an explanation of his/her bill regardless of source of payment.

· Know which hospital rules and policies apply to his/her conduct while a patient.

· Have all patient's rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient.

All hospital personnel, medical staff members and contracted agency personnel performing patient care activities shall observe these patients' rights.

· Patient Responsibilities:

· The care a patient receives depends partially on the patient himself. Therefore, in addition to these rights, a patient has certain responsibilities as well. These responsibilities should be presented to the patient in the spirit of mutual trust and respect:

· The patient has the responsibility to provide accurate and complete information concerning his/her present complaints, past illnesses, hospitalizations, medications and other matters relating to his/her health.

· The patient is responsible for reporting perceived risks in their care and unexpected changes in their condition to their responsible practitioner.

· The patient and family are responsible for asking questions when they do not understand what they have been told about the patient’s care or what they are expected to do.

· The patient is responsible for following the treatment plan established by his/her physician, including the instructions of nurses and other health professionals as they carry out the physician's orders.

· The patient is responsible for keeping appointments and for notifying the hospital or physician when he/she is unable to do so.

· The patient is responsible for his/her actions should he/she refuse treatment or not follow his/her physician's orders.

· The patient is responsible for assuring that the financial obligations of his/her hospital care are fulfilled as promptly as possible.

· The patient is responsible for following hospital policies and procedures.

· The patient is responsible for being considerate of the rights of other patients and hospital personnel.

· The patient is responsible for being respectful of his/her personal property and that of other persons in the hospital.

SUBJECT: ADVANCE DIRECTIVES

PURPOSE

The purpose of this policy is to provide an atmosphere of respect and caring and to ensure that each patient's ability and right to participate in medical decision making is maximized and not compromised as a result of admission for care through the medical center. Additionally, the purpose of this policy is to assure compliance with the Patient Self-Determination Act (PSDA) in such a manner as to expand the patient, personnel and community knowledge base regarding advance directives and the process by which patient participation in medical decision making is carried out at this facility.

POLICY

It is the policy of RMC to respect and encourage patient self-determination. Patients will be encouraged and assisted to be active participants in the decision making process regarding their care through education, inquiry and assistance as requested. Patients will be encouraged to communicate their desires in regard to advance directives to their significant others, to allow for guidance of significant others and healthcare providers in following the patient's wishes should the patient become incapacitated, rendering them unable to make decisions. The existence of an advance directive, or lack thereof, will not determine the patient’s access to care, treatment and services.

PROCEDURE

· An inquiry will be made by the nurse during the admissions process of the patient, or if the patient is incapacitated, to the patient's significant other, as to whether or not the patient has completed an advance directive. RMC shall not condition the provision of care or otherwise discriminate against any individual based on whether or not the individual has executed an advance directive.

· A request of the patient/significant other to provide a copy of the advance directive for medical record entry will be made by the nurse during the admission process.

· As part of the admission process the patient/significant other will be provided with an information packet outlining the individual's rights to make decisions concerning medical care. The information packet provided will include:

· The right to accept or refuse medical treatment, even if the treatment is lifesustaining;

· Information concerning the Patient Self-Determination Act;

· RMC’s mission and value statements and policies regarding refusal of medical treatment, including life-sustaining measures;

· That the existence of an advance directive, or lack thereof, will not determine the patient’s right to care, treatment or services;

· Definitions of pertinent healthcare terminology as they apply to the Patient SelfDetermination Act;

· Policy regarding the patient's right to voice a complaint related to advance directive requirements to the State Department of Health Services;

· Contact personnel available to assist those interested in pursuing the advance directive issue.

· Information regarding the PSDA will be provided to the patient upon each admission to RMC.

· Nursing personnel will document in the medical record whether the patient has completed an advance directive and that information concerning advance directives has been given to the patient/significant other during the admission process.

· Should the patient present as a repeat admission, with prior information obtained indicating there is an advance directive in the previous medical record, the nursing staff will have the responsibility to review the existing advance directive with the patient/significant other to validate its current status. The medical record from the previous admission containing the advance directive will be identified with a red divider labeled "advance directive".

· In the event the patient/significant other indicates that the previous advance directive does not accurately reflect the patient's wishes, a revised advance directive must be submitted and must meet all advance directive regulations. Any expression by the patient of a revision in previous advance directive desires will be documented by the nursing personnel in the nursing progress notes.

· To the extent that the patient/significant other requests additional information or further explanation regarding the PSDA or advance directives, follow-up interaction between the physician and the patient and significant others, as appropriate, is required.

· Should the patient wish to formulate an advance directive while receiving services in this institution, a member of the Medical staff will be contacted to assist the patient or refer the patient as necessary to accomplish the desire to formulate the directives.

· There will be availability of the Ethics Committee to discuss patient rights issues as needed, through the Medical Staff Office. All requests from patients/significant others, hospital personnel and/or medical staff members to institute the Ethics Committee process will be honored.

· All follow-up education and interaction with the patient/significant other will be documented in the medical record by the individual designated to interact with the patient/significant other regarding their concerns surrounding advance directives.

· In order to ensure that an opportunity for patient participation in medical decision making is maximized, and that care provided is consistent with patient values and directives, educational information about advance directives will be provided. RMC's policies, mission and value statements regarding advance directives and withholding of life-sustaining measures will be provided to the medical, allied health professional and hospital staff on a periodic basis and as necessary. Information will be provided through a collaborative effort with all disciplines via inservice format as well as written newsletters, memorandums, orientation processes, and annual personnel reviews.

· In order to assure that the community is served by this organization, education concerning advance directives and the PSDA shall be provided through community forums or written material made available at RMC.

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