A. Except in an emergency, no patient shall be admitted to the hospital without a provisional diagnosis. In case of an emergency, the provisional diagnosis shall be stated as soon after admission as possible.
B. Physicians or oral surgeons admitting patients shall be responsible for giving such information as is available to the physician or surgeon or as may be necessary to assist in protecting other patients, staff or other persons on the premises from those who are or may be a source of danger including protection from self harm.
C. Any patient needing care who has no attending physician or oral surgeon shall be assigned to the member of the Medical Staff attending on service call at that time.
D. Members of the Medical Staff shall be free to exercise independent judgment in clinical decisions about patient care without regard to the patient’s source of payment or reimbursement, or any compensation or risk sharing arrangement in which the physician or hospital may participate. Nothing in the preceding sentence is intended to limit the authority of appropriate medical staff or hospital officers or committees to intervene when necessary in the interest of protecting a patient or ensuring quality care, or otherwise to enforce the Medical Staff Bylaws, Rules and Regulations, and hospital policies.
II. Tissue Submissions to Pathology
A. The following delineates those surgical specimens which may be exempt from submission for pathologic examination and those specimens for which a microscopic examination may not in all cases be necessary.
B. All tissues removed from a patient in any operating suite shall be forwarded to the Department of Pathology with the exception of the following:
1. Cataracts removed by phycoemulsification (cataracts removed by other techniques shall be forwarded for examination)
2. Orthopedic hardware (hardware not returned to the manufacturer shall be submitted for examination)
3. Foreign bodies
4. Therapeutic radioactive sources
5. Teeth
6. Toenails and fingernails that are grossly unremarkable
7. Intrauterine devices (IUD's) without soft tissue
8. Foreskin (newborns only)
9. Debridement (surgeon should describe source, quantity/dimensions of tissue and general appearance of tissue in operative note)
10. Middle ear ossicles
11. Incidental tissues:
12. Tissues removed only for purpose of gaining surgical access from patients who do not have a malignancy
13. Normal tissues removed during a cosmetic or reconstructive procedure that is not contiguous with a lesion and in a patient who does not have a malignancy.
C. The following items should be forwarded to the Department of Pathology for gross examination. (Microscopic examination of the specimens on this list is performed at the discretion of the pathologist or when requested by the clinician).
1. Nasal cartilages
2. Menisci - cartilages
3. Femoral heads
4. Varicose veins
5. Calculi
6. Routine tonsils and adenoids (15 years or younger)
7. Routine disc material
8. Bunions and hammer toes (hallux valgus)
9. Prosthetic breast implants
10. Implantable devices required for tracking under the Safe Medical Devices Act of 1990
III. Consultation and Transfers
A. General Principles.
1. One physician will be in charge of the care of each patient, and the identity of this physician should be documented in the medical record. This is true even for patients with multiple consultants, such as the cardiac patient with musculoskeletal trauma. Patient care will be better served when one physician has the primary responsibility.
2. A patient will not be admitted to the service of a physician unless that physician or his/her designee has first agreed to accept the patient.
B. Transfer of Service. Transfer of a patient from one physician to another should be mutually agreed upon by both physicians and the patient/responsible party. A physician will be responsible for the care of a patient until he/she writes an order to transfer the patient's care to another physician. The transfer of responsibility will be appropriately documented in the physician's order sheet and/or the medical record.
C. Patient Termination of a Physician's Services.
1. When a patient wishes to change physicians, he/she should first notify the correct physician of his/her desire to terminate the relationship and then initiate contact with another physician.
2. If a patient is unable to express himself/herself, it is the responsibility of the patient's representative to communicate on behalf of the patient.
D. Time Frame for Consultations. Requests for consultations should be honored within 24 hours when feasible.
E. Obtaining a Consultation.
1. Except in an emergency, consultations with another qualified physician are required in cases on all services in which according to the judgment of the physician:
a) the patient is not a good medical or surgical risk
b) the diagnosis is obscure, and
c) there is doubt as to the best therapeutic measures to be utilized.
2. A patient has the right to request a second opinion or consultation about his/her medical care. The choice of a consultant should be mutually agreeable to the attending physician and the patient/responsible party.
3. The request for consultation should be made directly between physicians and documented in the physician's order sheet and/or the medical record. A nurse should not be asked to make the initial contact with the consulting physician(s).
F. On-Call Physician Policy
It is the policy of Central Maine Medical Center to comply with the Emergency Medical Treatment and Labor Act (EMTALA). EMTALA requires that any patient who presents at the hospital must receive an appropriate medical screening examination to determine if that patient has an emergency medical condition. If so, the patient’s condition must be stabilized prior to discharge or transfer. The provisions of EMTALA apply not only to the hospital but also to the physician who provides on-call coverage.
1. Purpose: The purpose of this policy is to ensure compliance with EMTALA by explaining the obligations of on-call physicians under the law and under the regulations of Central Maine Medical Center’s Medical Staff.
2. Definitions:
a) Emergency Medical Condition means: Medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that that the absence of immediate medical attention could reasonably expected to result in:
i) Serious jeopardy to the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child).
ii) Serious impairment to bodily functions; or
iii) Serious dysfunction of any bodily organ or part; or
iv) With respect to a pregnant woman who is having contractions: that there is inadequate time to effect a safe transfer to another hospital before delivery; or the transfer may pose a threat to the health or safety of the woman or the unborn child.
b) Stabilize means, with respect to an Emergency Medical Condition as defined above: to provide such medical treatment of the condition as may be necessary to assure, within reasonable medial probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual form a facility; or, with respect to an Emergency Medical Condition involving a pregnant woman: that the woman has delivered (including the placenta).
3. Obligation to Examine Patient: With respect to a patient covered by EMTALA, the on-call physician must come to the hospital when requested by the consulting physician, or any hospital worker making the request on behalf of a physician or nurse who is not available to call the on-call physician directly. Seeing the patient at the on-call physician’s office or clinic is not an option until the patient is determined to be “stable” or not to have an “emergency medical condition” as those terms are defined in the Definitions section above.
4. Disputes Over Need to Respond: If the on-call physician disagrees about the need to come to the hospital, the on-call physician must come to the hospital and render care irrespective of the disagreement. The on-call physician may address the disagreement with the appropriate individual at the hospital at a later time.
5. Assistance in Screening and/or Stabilization: If requested, the on-call physician shall be physically present in the hospital to assist in providing an appropriate medical screening examination, as well as in the ongoing stabilization and treatment of a patient prior to transfer or treatment. The on-call physician shall remain in the hospital until the Consulting physician no longer requires his/her services.
6. Ability to Pay Not Be Considered: With respect to an emergency medical condition, the on-call physician shall not consider the patient’s financial circumstances or the patient’s insurance or means of payment in the decision to respond to, treat, or transfer the patient.
7. Timely Response:
a) Article III, Section II D) 1b of the Medical Staff Bylaws states that coverage must be provided from within thirty (30) minutes drive time of the hospital.
b) The on-call physician is not required to interrupt critical care – that is, care that requires his/her personal management – that he or she is providing to a specific patient.
c) Immediately after the physician finishes caring for the specific patient, he or she will contact the requesting unit, respond if requested, and give an estimated time of arrival.
d) It is not acceptable for on-call physicians to delay seeing an ED patient until the end of office hours or finishing the daily surgical caseload. Nor is it acceptable to hold the patient in the ED until morning.
8. Follow Up Care: Unless other arrangements are made, with respect to an emergency medical condition, the on-call physician shall provide follow-up patient care throughout the episode of illness. The on-call physician may not condition the first follow-up office visit on advance payment or otherwise consider the patient’s ability to pay.
9. Disciplinary Actions: Any violation of this rule by an on-call physician will be reported to the Director of Medical Affairs, then the Medical Staff Executive Committee, in accordance with the Medical Staff Bylaws.
G. Consultants Recommended by Consultants.
1. A consultant who wishes to call in an additional consultant should first discuss the choice of an additional consultant with the attending physician and patient/responsible party. If all parties are in accord, the consultant or attending physician will indicate the additional consultant contact via the physician's order sheet and/or the medical record.
H. Specifying the Consultant's Role.
1. The attending physician should indicate to the consultant(s)(and shall record this) on the physician's order sheet the nature of what he/she desires from him/her:
a) to render an opinion only,
b) to assume management of a specific medical problem, or,
c) to accept the patient in transfer.
2. Nursing service should continue to refer patient management questions to the attending physician unless that physician has specifically written otherwise in the physician's order sheet.
3. The consultation shall include a review of the medical record and an examination of the patient. The consultant's written opinion shall be dictated (preferably) or recorded legibly in the patient's record within 24 hours of the time the patient is seen by the consultant. Upon completion, the consultant should directly contact the attending physician with verbal recommendations. If this is not possible, he/she should record a brief progress note aside from any dictation. The attending physician will discuss the recommendations with the patient/family.
4. If the consultant assumes the overall care of the patient with the approval of the attending physician and patient/responsible party, the patient's care should be transferred to that consultant's service for the period of time he/she assumes primary responsibility for the patient. The transfer of responsibility will be appropriately documented in the physician's order sheet in the medical record.
I. Notification and Role of Primary Physician when Patient is Admitted by Consultant or Physician Other than the Primary Physician.
1. If a patient is admitted by a consultant or physician other than the primary physician, the primary care physician should be notified by the consultant or other physician. This is not to be equated with a request for consultation. The primary physician would not be involved in the care of the patient unless requested by the admitting physician.
IV. Emergency Department
A. For all patients seen in the Emergency Department, an Emergency Department medical record will be initiated and completed including appropriate signatures by the responsible staff. The medical record will document time, means of arrival, conclusions at termination of treatment, final disposition, condition at discharge and follow-up care instructions. The Emergency Department medical record will document those patients who leave against medical advice.
B. When a patient is seen in the Emergency Department or any Central Maine Healthcare facility and identifies a primary care physician, with patient authorization, that physician should be sent a copy of the face sheet, lab results, x-ray reports, and dictated reports from the record, regardless of the primary care physician's staff status, to ensure appropriate continuity of care and follow-up.
C. When a physician wishes his/her patient to be seen in the Emergency Department by another physician, it shall be the responsibility of the patient's physician to initiate communication with the physician who will be seeing the patient and admitting, if necessary.
D. The Emergency Department physician shall not be responsible for the transfer of patient care from one physician to another: that arrangement shall be made directly between the two physicians.
E. If a physician on call is in surgery or is unable to assume responsibility for an Emergency Department patient, the Emergency Department physician must make disposition for the patient. After assessing the urgency of the patient's condition and expected availability of the physician on call, he/she may decide to: (1) await availability of the physician on call; or (2) contact another physician; or (3) transfer the patient to another institution.
F. It is expected that constructive communication regarding this decision should take place between the Emergency Department physician and the physician on call.
G. Any physician, Physicians Assistant, or Nurse Practitioner appropriately credentialed to provide services in the Emergency Department, or any other appropriately credentialed physician may conduct a medical screening to determine whether or not an emergency medical condition exists.
V. Procedures in Cases of Abortions
A. Abortions may be performed at C.M.M.C. only under the following circumstances:
1. where it is determined that the fetus is not viable; or
2. where it is necessary to preserve the life or health of the mother.
B. Abortions may be performed at C.M.M.C. only by a physician with appropriate privileges. The physician shall be responsible for documenting in the medical record the specific circumstances that demonstrated whether the fetus was not viable or that the procedure was necessary to preserve the life or health of the mother.
C. Prior to any abortion, to ensure the consent for an abortion is truly informed consent, the attending physician shall inform the woman in a manner which , in his/her professional judgment, is not misleading and which will be understood by the patient, of at least the following:
1. according to the physician's best judgment, the patient is pregnant:
2. the number of weeks elapsed from the probable time of the conception:
3. the particular risks associated with the pregnancy and the abortion technique to be performed: and,
4. alternatives to abortion such as childbirth and adoption; information concerning public and private agencies and the services available from each.
D. No physician, nurse or other employee at C.M.M.C. who refuses to perform or assist in the performance of an abortion, will because of that refusal, be dismissed, suspended, demoted or otherwise prejudiced or damaged by C.M.M.C. Nor shall such refusal constitute grounds for loss of any privileges or immunities to which such person(s) would otherwise be entitled nor shall submission to an abortion or the granting of consent; therefore, be a condition precedent to the receipt of any public benefits. C.M.M.C. will not discriminate against any patient, physician, nurse, or other employee by refusing or withholding employment from a denying admittance, when such person refuses to perform, or assist in the performance of an abortion.
VI. Medical Records
A. Purpose and Contents.
1. The medical record shall serve to: document provision or facilitation of patient care and decisions associated with same; document financial/legal documentation; assist in clinical research; and facilitate performance improvement activities.
2. The medical record will contain information to document: patient identification; the diagnosis; treatments; the course of hospitalization and results; continuity of care; and provision of adequate follow-up instruction to the patient/family/other responsible party.
3. The Medical Staff has approved the most current Stedman's Abbreviations, Acronyms & Symbols reference manual as the list of medical abbreviations which may be used in the medical record. Abbreviations are not to be used in Discharge Summaries.
4. All medical records will contain common elements (please refer to appendix A: Contents of Records). The medical records will be kept in such a way as to be available and usable by the physicians and hospital staff involved in the care of the patient or assigned peer review/performance improvement activities.
5. After the third (3rd) visit, ambulatory care records shall contain current summary lists of known significant diagnoses, conditions, procedures, drug allergies or adverse reactions and medications used/prescribed for the patient.
B. Ownership and Availability of Records.
1. All medical records are the property of the Medical Center and information from them shall not be released without written permission from patient/legal representative and/or appropriate hospital administration consistent with Maine State and Federal laws or as required by State or Federal law.
2. The original record shall not be removed from the Medical Center premises except by the legally recognized custodian of records (Manager of Medical Information Services or designee) in compliance with a court order, subpoena duces tecum or statute.
3. In case of readmission of the patient, all previous records shall be available for use of the attending physician. Incomplete records will be returned to Medical Information Services - Medical Record Section on the third day following readmission for completion.
C. Physician Responsibilities.
1. The attending physician shall be responsible for preparation of a timely, legible and complete and accurate medical record for each patient treated or assessed at the Medical Center. The parts of the medical record that are the responsibility of the physician must be signed by this individual (e.g. history & physicals, consults, operative and procedure notes orders, progress notes, discharge, or transfer summaries, etc)
2. The attending physician shall be responsible for signing the Attestation and/or Review Abstract form (contained in each inpatient record) after reviewing it for accuracy.
3. Patients will be discharged only on the order of the physician or physician extenders. All discharged medical records will be sent to Medical Information Services - Medical Record Section no later than 9:30 a.m. the day after discharge.
4. A physician may satisfy the requirement of a signature by either a physical signature or by use of an electronic signature prepared in accordance with Medical Staff policies.
D. Medical Record Entries and Access to Medical Records.
1. Hospital clinical and ancillary staff shall be authorized to document in medical records of those patients they are treating, following, or have cared for. Other hospital staff shall have access to medical records per Standing Orders entitled "Confidentiality of Patient Information" and "Release of Information."
2. All medical record entries will be dated and signed denoting the professional discipline of the responsible author. It is recommended that all entries include time.
E. Progress Note. Legible progress notes are required on every acute patient as the course of his/her illness dictates. Progress Notes document appropriate clinical data pertaining to the patient's illness, testing, treatment and response. In no instance will more than two days elapse without writing a Progress Note for any acute patient. Progress Notes for patients who have been classified as non-acute will be updated at least every seven days. The responsible physician must document review of resident's or dependent practitioner's progress note entries.
F. Documentation of Comprehensive History and Physical
1. The content of a comprehensive History and Physical will be provided in an electronic format. Any necessary and pertinent information needed for immediate patient care may be provided at the time of care in any format so long as the information is legible and followed up with a dictated or typed report containing all required elements.
2. The content of the History and Physical will be as follows. An asterisk (*) indicates a minimum requirement:
a) Chief complaint*
b) History of present illness*
i) Labs
ii) Medications*
iii) Indications for surgery (as applicable)
c) Past medical history*
d) Allergies*
e) Family History
f) Social History
g) Review of Systems
h) Physical Examination*
i) Impression (Reason for Admission)*
j) Plan
Content is ultimately dictated by the clinical circumstances.
3. Before surgery, the History & Physical, pertinent diagnostic tests and preoperative diagnosis will be completed and documented in the record.
4. Dependent practitioners with privileges to perform inpatient histories & physicals may do so with the attending physician confirming the findings, conclusions, and assessment of risks by countersignature.
5. When the History and Physical Examination is not recorded/available before the time stated for operation, the operation shall be canceled or delayed until such time as the information is available. An exception may be allowed where any delay in the surgery would pose a critical or life-threatening condition for the patient and the nature of the critical or life-threatening condition is documented.
6. If a History and Physical was done within 30 days before admission, a durable, legible copy of the History and Physical may be used in the record, provided changes that might have occurred are documented in the report at admission.
a) In the case of a surgical patient, if the surgery is scheduled more than seven (7) days after completion of the History and Physical, the surgeon shall discuss with the patient and document prior to surgery any subsequent changes that may have occurred during the interval.
b) If the patient is readmitted to the hospital for the same or similar problem within seven (7) days after discharge, an interval History and Physical is acceptable, provided documentation reflects any subsequent changes that may have occurred during the intervening period. A copy of the previous History and Physical will be included in the current record. The physician may document relevant subsequent changes on this copy or dictate or write the interval History and Physical.
c) Notwithstanding the above, all patients shall receive an updated assessment within 24 hours after admission but prior to any surgery or procedure.
7. For ambulatory surgical patients receiving conscious sedation for procedures, an abbreviated History and Physical may be completed.
a) At a minimum, the Physical will document examination of the heart, lungs, mental status and organ system appropriate to procedure.
b) The History should address present illness, reasons for procedure, significant past history; medications and allergies.
c) For ambulatory patients without sedation, the history needs to address chief complaint, past medical history, medications, allergies, mental status exam and direct examination of the organ system involved.
8. Dentists are responsible for that part of the patient’s history and physical which related to dentistry. Dentists may admit patients to the hospital in collaboration with a member of the Active or Courtesy staff who shall be responsible for the medical aspects of the patient’s care throughout the hospital stay.
9. Podiatrists are responsible for that part of the patient’s history and physical which related to podiatry. Podiatrists may admit patients to the hospital in collaboration with a member of the Active or Courtesy staff who shall be responsible for the medical aspects of the patient’s care throughout the hospital stay.
G. Consent.
1. Proper consents shall be obtained and documented prior to all operative procedures (See CMMC Standing Order 1:4.2). In the absence of such a consent, the operation shall be canceled unless the attending physician documents in the patient’s record the reason for not obtaining consent and that delay of the surgery would be detrimental to the patient. Any procedure that requires a specific consent form requires a written or dictated note in the chart.
H. Orders.
1. All orders for treatment shall be in writing and signed by the responsible physician.
a) An order shall be considered to be in writing if dictated (verbal orders) to a registered nurse and signed by the physician who gave the order.
b) Orders dictated over the telephone (telephone orders) shall be signed by the registered nurse taking the order with the name of the physician or his/her designee who dictated same. The physician who gave the order, shall sign such orders within 72 hours.
c) Orders for patients transferred from ICU/CCU shall be completely rewritten for patients staying in ICU/CCU more than three (s) days.
d) Orders for patients transferred from O.R. shall be completely rewritten with the exception of unusual circumstances.
e) Standing orders for protocol-driven disease management or preventive treatment, as approved by the Executive Committee, shall be exempt from the provisions of this subsection (shall not require a physician order).
2. Attending physicians must countersign inpatient orders of dependent practitioners.
3. The physician, or if he/she is unavailable, the covering physician, shall sign such orders within 72 hours. When the covering physician signs for the verbal order, he/she assumes responsibility for the order being complete, accurate and final.
4. Pharmacists, Physical/Occupational/Respiratory Therapists, Speech Therapists, and Dieticians may also take verbal or telephone orders relating to their discipline specific therapies. These orders must be countersigned by the physician responsible for giving same, or the covering physician as specified above.
5. X-rays. Order for X-rays should include the clinical history and reason for X-ray. Additionally, orders for tests which require clinical interpretation should include relevant written clinical information (history and reason for) to facilitate performance of and appropriate interpretation of the test. This would apply to requests for x-rays, EKGs, EEGs, CAT scan, etc.
6. Food or nutrients. All patients shall receive a prescription or an order for food or other nutrients. Food or other nutrients ordered can range from n.p.o. to regular diets, to parenteral or enteral tube nutrition.
7. Restraints. Restraint orders must be written by a licensed independent practitioner, shall be time-limited, and shall specify whether behavioral or non-behavioral restraints are indicated. PRN orders are not permissible.
I. Operative Reports.
1. All operations performed shall be fully described by the attending surgeon. The Operative Report will contain:
a) name of principal surgeon and assistant(s) if any;
b) preop and postop diagnoses;
c) findings;
d) complications;
e) procedures performed and description of each procedure
f) specimens removed and disposition of each specimen
g) estimated blood loss
h) cultures taken.
i) This will be signed and dated by the principal surgeon.
2. Operative reports shall be dictated immediately. In addition, a legibly handwritten Progress Note naming the procedure, any assistant(s) and any complication(s) is required. Operative reports are required on any procedure that requires a specific consent from the patient.
3. Post Anesthesia Care Unit (PACU) documentation includes: vital signs; level of consciousness; medications and fluids (P.O. & IV); use of blood and its components; unusual events or postoperative complications and management of same.
4. Discharge from the PACU is accomplished by order of a physician or documentation of compliance with discharge criteria as approved by the Medical Staff.
J. Completion of Records.
1. All medical records shall be completed within 15 days after the date of discharge of the patient. Completed means:
a) all signatures have been obtained;
b) all dictations are completed;
c) diagnostic and procedural coding has been accomplished (using the most current and appropriate ICD-9CM and/or CPT references);
d) contents of record document condition on arrival; diagnosis(es); test results; therapy; condition and progress during hospitalization; condition at discharge; discharge summary (or final progress notes, if applicable).
2. Physicians shall when possible, notify Medical Records of anticipated vacations/absences and will make reasonable efforts to complete available medical records prior to such departures. Upon return from vacations/absences, physicians shall make a reasonable effort to complete outstanding records within 48 hours.
K. Discharge Summary.
1. A concise Discharge Summary for all inpatients shall be dictated within five (5) days from the date of discharge and shall contain:
a) reason for hospitalization;
b) all final diagnoses without use of abbreviations or symbols;
c) significant findings;
d) procedures performed and treatment rendered;
e) condition at discharge and
f) instructions to patient and family, if any.
2. Please refer to Appendix B - Guidelines for Discharge Summaries from Medical Records Committee.
3. For normal newborns with uncomplicated deliveries or for patients with a length of stay less than 48 hours with only minor problems, a final progress note containing condition at discharge, discharge instructions and follow-up required may be substituted for a discharge summary.
4. For acute patients subsequently transferred to the Acute exempt Rehab Unit, a complete Discharge Summary will be done. This is a requirement to maintain exempt status as defined per Health Care Finance Commission (HCFA).
L. Suspension Imposition.
1. When rules regarding history and physicals, operative reports, and completion of medical records (VI. F, I and J) are not complied with, the admitting and surgical privileges of the physician will be suspended as prescribed in procedures recommended by the Medical Records Committee and approved by the Medical Staff. These procedures will be uniformly and fairly applied to all members.
a) The Manager of Medical Information Services or designee will report on all matters relating to incomplete records and enforcement of these rules to the Executive Vice President of the Medical Center, the President of the Medical Staff, Medical Executive Committee and Medical Records Committee.
b) The Medical Records Committee shall submit recommendations regarding those matters to the Medical Executive committee as necessary.
c) The Medical Executive Committee shall then recommend to the Board any denials or suspensions of staff privileges or other such disciplinary actions as may be necessary.
2. For the purposes of this section an Administrative Suspension shall be defined as a suspension of admitting privileges, (with exception of service call), and elective operative procedures.
M. AMA Discharges. For patients leaving against medical advice (AMA), the record shall contain a physician order reflecting that the patient left AMA as well as a completed AMA form.
N. Where Rules and Regulations are Silent. In any case where these rules and regulations are silent regarding maintaining medical records, the most recently published standards, interpretations and regulations of the Joint Commission on Accreditation of Healthcare Organization (J.C.A.H.O.) and the Maine State Licensing Regulations shall govern. Copies of these references shall be maintained and available for reference in Medical Information Services.
VII. CMMC Hospital Autopsy Procedure
A. For cases in which autopsies are performed, the provisional anatomic diagnoses are recorded in the record within three days; the completed final autopsy report shall be in the record in 60 days.
B. The following guidelines are submitted for consideration when contemplating a request for an autopsy;
1. Death within 24 hours of admission.
2. Death during a surgical procedure.
3. Unexpected death during diagnostic or therapeutic procedure.
4. Sudden or unexpected death in a stable, uncomplicated patient.
5. Sudden or unexpected death in an uncomplicated patient who was stable at admission and declined unexpectedly during hospitalization.
6. Death in a complicated patient where autopsy would provide useful information concerning procedures, treatment and/or cause of death.
7. Death reviewed by Medical Examiner and autopsy declined where, in the opinion of the attending physician, an autopsy would provide important information concerning procedures, treatment and/or cause of death.
C. Physicians are encouraged to submit other cases which, in their determination may provide important information concerning the decedent's illness, family medical history or other information beneficial to the hospital's performance improvement program.
D. Introduction
1. The autopsy examination is a professional consultation provided by a pathologist on behalf of a requesting physician. In the general practice of medicine, it is important to remember that the pathologist does not directly participate in the care of the decedent. As a result, the pathologist has no knowledge of the patient's clinical course leading up to the patient's death. Therefore, it is imperative that there be direct communication between the physician and pathologist so that the pathologist may fully understand the clinical history of the patient as well as the information the clinician hopes to derive from the autopsy study. A second critical component of this information flow is the availability of the patient chart for the pathologist to review. Too often the autopsy is treated like a laboratory test where an order is simply written with the expectation that the test (autopsy) will be immediately performed. The autopsy examination is a very complex process and requires a greater degree of attention than a routine laboratory test.
2. With these issues in mind, the following protocol has been developed to ensure that requests for autopsies result in the expeditious performance of the examination in all cases. The process requires the close communication of the attending physician and pathologist. No autopsy will be performed unless the entire procedure outlined below is followed.
E. Procedure
1. At the time of patient death, the attending physician or his or her designee should review the hospital indications for autopsy and determine whether an autopsy is warranted. Appropriate communication should take place with other physicians involved with the care of the patient.
2. Obtaining legal consent is the responsibility of the requesting physician and the autopsy consent form should be executed by the physician in the presence of the legally authorized next of kin of the decedent. Autopsy consent may also be obtained via telephone, however the consent must be witnessed.
3. The requesting physician MUST directly contact the pathologist who will be performing the autopsy to discuss the issues of the case. If the death occurs off hours, the physician should contact the pathologist on call, whatever the time of day.
4. The patient chart MUST stay with the patient if there is going to be an autopsy. If for some reason the chart must be located elsewhere, the whereabouts of the chart must be made available to the Pathology Department.
5. Upon receipt of the patient body, completed autopsy consent, telephone conversation with the attending physician and patient chart, an autopsy will immediately commence during regular business hours. Since no support staff is available for autopsy examination after hours or on weekends, autopsy cases received after hours will be performed the morning of the next business day.
6. Following completion of the post mortem examination, the pathologist will issue a Provisional Anatomic Diagnosis within 24 hours. For simple cases, a final autopsy report will be issued within 4 weeks. Complex cases may take up to 3 months to complete.
7. In order to accommodate any special requests, the attending physician should discuss such circumstances with the pathologist.
F. References
1. For reference purposes see Standing Order 2:5,8(R) Medical Examiner Cases.
2. Ordering autopsy - See Standing Order 2:5,1(R3) - Notification to Attending
3. Consent for autopsy - See Standing Order 2:5,2(R3)
VIII. Drug Orders
A. All drug orders shall be clearly defined as to the duration or the number of doses. All medication orders for selected classes of drugs shall be for defined parameters and only discontinued with the consent of the physician unless:
1. The order indicates an exact number of doses to be administered,
2. The exact period of time for the medication is specified, or
3. The attending physician reorders the medication.
B. Drug classes:
1. Narcotics, sedatives and hypnotics - 96 hours;
2. Anticoagulants - 24 hours; antibiotics:
3. Prophylaxis - 24 hours,
4. Empiric Use - 72 hours,
5. Therapeutic - 10 days,
6. Vancomycin - 72 hours; and,
7. Chemotherapy treatment - duration or number of doses must be specified.
C. All drugs with the exception of the above shall have a 30 day stop date.
IX. Major Surgery
A. The attending surgeon has ultimate responsibility for his/her patient. This includes establishing the need for a surgical procedure, the procedure to be utilized, the timing of the procedure, and the need for a practitioner to function as an assistant. In considering the need for an assistant, the physician will consider, among other factors, the nature and difficulty of the procedure, the condition of the patient, the length of time required to complete the surgery, whether or not the surgery presents a distinct hazard to life, and the timely availability of a qualified practitioner.
X. Expedited Review Process
A. Rationale
1. An expedited review process shall allow timely review of medical care rendered by staff members which raise issues of patient safety but do not constitute a sentinel event.
2. This process will be part of the peer review process and therefore will be confidential and protected under state law.
B. Definitions
1. Sentinel event: An unexpected occurrence involving death or serious physical or psychological injury or the risk thereof.
2. Expedited review event: Any care provided by a staff member which may:
a) not meet the applicable standard of care and
b) have adversely affected the outcome of the case, and
c) for which prompt education would improve quality of care.
3. Core physician reviewers: Physicians on the medical staff who agree to be available to review cases subject to the expedited review process. These physicians will represent all medical departments and will be trained in all aspects of the review process.
C. Procedure
1. Event reporting. Any staff member or employee involved with the care of patients can refer an event for possible review. Physicians should report to their department/section chief or directly to the President of the Medical Staff. Events noted by other personnel should be reported through the office of the Vice President of Patient Care Services to the President of the Medical Staff.
2. President review. The Medical Staff President or his or her designee shall review the case within 2 days and determine which of the following categories the case falls into.
a) Sentinel event
b) Expedited review event
c) Routine peer review process
d) No review necessary from Medical Staff perspective
3. If there is a conflict of interest for the Medical Staff President, the Vice President of the Medical Staff will carry out the duties of the President. If the Vice President also has a conflict of interest, the department chair will then be appointed to review the case.
D. Action to be taken. After the initial review one of the following actions will then occur.
1. Sentinel Event: Cases meeting the definition of a sentinel event shall be referred to the Manager of Medical Information Services for root cause analysis. Staff members involved will be notified that this process has been started.
2. Expedited Review. Follow procedure detailed below. Staff members involved will be notified that review is in progress.
3. Regular Peer Review: Follow usual procedures.
E. Expedited Review. The President of the Medical Staff shall within two days appoint a panel of three core physician reviewers and advisors from other department/services as appropriate. The President shall name one of the three reviewers as chair. This panel will focus on obtaining the factual data of the event. It is recommended that the panel include discussion of the case with the attending and other staff. The panel's review will be completed within 7 days. Outside reviewers will be appointed in cases where necessary expertise is not available from the current Medical Staff or where a conflict of interest exists. The Vice President of Medical Affairs will be notified on a timely basis that a review is in progress.
F. Reports. The physician panel shall meet to summarize its findings and evaluate the collected data. The panel will prepare two reports.
1. The first report will be detailed and will be discussed with the physician(s) or other staff member(s) involved. This discussion can be one-on-one or with the entire panel, depending on the preference of the physician(s) involved and is intended to be an educational experience and structured to be collegial and cooperative. The meeting shall be held within two weeks of the event. This report shall be forwarded to the Vice President of Medical Affairs and placed in the 2 year file. No permanent record will be placed in any physician record.
2. A second report, generic in nature and containing no identification of patients or staff, will also be prepared, summarizing the events, delineating the process changes that were suggested and the educational points. This report will be sent to appropriate department chairs, the Clinical Practice Committee and the Executive Committee of the Medical Staff for presentation at their next meeting.
G. While intended to be an educational process, nothing in this policy shall be construed as limiting the ability of any of the individuals or committees listed in Section 1.a. of Article VII of the Bylaws from initiating corrective action based upon the same events which are the subject of the expedited review.
H. Refusal to Cooperate. If staff members involved with the case refuse(s) to meet with the panel, a certified letter will be sent indicating that failure to participate will be referred to the Medical Staff Executive Committee for corrective action.
I. Option. Any physician who is the subject of an expedited review may, at his or her option, chose to move the expedited review to corrective action pursuant to ARTICLE VII of the Bylaws.
J. Professional Competence Committee. The panel of reviewers shall be considered a professional competence committee under the provisions of State law and shall be construed as assisting the Executive Committee with its duties under the Bylaws.
K. Annual Review: This policy and its implementation shall be reviewed annually to assess its effectiveness. This review would include but not be limited to:
1. The total number of reported events.
2. The total number of events acted upon as Expedited Reviews.
3. A general description of the findings of the Expedited Reviews.
XI. Code of Conduct
A. Policy: Central Maine Medical Center shall, at all times, provide an environment where interpersonal conduct recognizes the importance of respectful, honorable, dignified interaction between and among medical staff members and others in the hospital. While there should always be an opportunity for criticism and free speech, such actions should be constructive and take place through appropriate channels. Appropriate channels include one on one conversation and providing input through committees, Chiefs of Departments or Services, Medical Staff Officers, Managers of Nursing or other departments, or the Director of Medical Affairs.
B. Definitions: Behavior may be considered disruptive when it potentially adversely affects patient care or the legitimate operations of the medical center. Behavior may be unusual, unorthodox or different without being disruptive. Expressing criticism of colleagues or the medical center is not sufficient grounds to label behavior disruptive.
C. Unacceptable disruptive conduct may include, but is not limited to, the following:
1. Attacks leveled at other medical staff members or hospital staff, which are personal, irrelevant, or go beyond the bounds of fair professional comment, or similar attacks leveled at patients, family members or visitors.
2. Impertinent or inappropriate comments written in patient medical records, impugning the quality of care in the hospital, or attacking particular physicians, nurses or hospital policy, beyond that which is necessary to document the process of care.
3. Non‑constructive criticism, addressed to its recipient in such a way as to intimidate, undermine confidence, belittle, or to impute stupidity or incompetence.
D. Procedure:
1. Report process: Any member of the Medical Staff who observes what they deem to be disruptive conduct should report it. Any hospital employee who observes disruptive conduct may report it. While anonymous reports are discouraged, every effort will be made to protect the identity of a reporter in circumstances where retaliatory conduct is considered a legitimate possibility. The report shall be submitted to the Director of Medical Affairs, who shall notify the Medical Staff President or his/her designee. Copies may be sent to other medical staff officers or hospital officers at the discretion of the President of the Medical Staff.
2. Determination process: If, in the opinion of the Vice President of Medical Affairs, an incident warrants that action be taken, the Vice President of Medical Affairs shall confer with the President of the Medical Staff or his/her designee and the Chief of the appropriate department or his/her designee, who shall, after appropriate verification of the nature and particulars of the incident, make a determination as to whether action will be taken. If no action is to be taken, no record of the incident will be placed in the member's credentials file.
3. Action: If action is to be taken, a meeting will be held of the President of the Medical Staff or his/her designee and/or the Chief of the appropriate department or his/her designee with the staff member. Refusal of the staff member to meet will be cause for initiation of corrective action.
a) The initial approach should be collegial and designed to be educational and helpful to the staff member, while making clear how and why the behavior was inappropriate and emphasizing that if the behavior continues, more action will be taken to stop it.
b) This meeting shall be documented in the member's credentials file. The member shall have the opportunity to read this documentation and to attach a response. Said documentation shall be considered credentialing materials protected as confidential.
4. The Medical Staff President or designee, at his/her discretion, will communicate to the person reporting the behavior that the issue has been addressed with the member.
E. Documentation: Adequate documentation of disruptive conduct is critical, since it is ordinarily not an individual incident that justifies disciplinary action, but rather a pattern of conduct. Documentation of a specific incident should thus not be expected to bring about definitive action unless that incident is of such severity that definitive action is deemed warranted.
1. Documentation of episodes of disruptive behavior significant enough to trigger the collegial process described in Section D.3a above, but insufficient to warrant disciplinary action, shall be kept in the credentials files for five years and will be considered in the re-credentialing process. The staff member shall be notified of any report or complaint received by the medical staff which the office of medical affairs considers serious enough to warrant action under this policy.
2. If a determination has been made pursuant to Section F that action will be taken, the member will receive a copy of any report or complaint made (either a photocopy of the original or a reproduction which protects confidentiality of the complainant when retaliatory conduct is considered a legitimate possibility).
3. Documentation of incidents serious enough to trigger the collegial process in Section D.3a above shall, when practicable, include:
a) The date, time and location of the incident;
b) If the behavior affected or involved a patient in any way, the name of the patient (and the medical record number if possible);
c) The circumstances, which precipitated or surrounded the incident;
d) An objective description of the behavior in question, limited to factual material and objective language as much as possible;
e) The consequence(s), if any, of the behavior as it related to patient care or hospital operations;
f) A record of any action(s) taken to remedy the situation, including the date, time, place, action, or names(s) of those intervening and the nature of the intervention(s);
g) Documentation of the medical staff member's response to the complaint and the intervention process.
4. A follow-up letter to the medical staff member shall state the problem and the expectation that the member is required to behave professionally and cooperatively. This letter shall also be placed in the member's credentials file.
F. Recurrent episodes of disruptive behavior: If a staff member has been notified of a problem and the disruptive behavior continues or recurs, the Medical Staff President and the Chief of the appropriate department or his/her designee and the Director of Medical Affairs shall confer and the Medical Staff President or his/her designee and the Chief of the appropriate department or his/her designee shall make a recommendation to the Medical Executive Committee regarding what action is appropriate, including but not limited to referral to a behavioral consultant or a recommendation to institute the corrective action process as described in the Medical Staff bylaws. If referral to a behavioral consultant is made, it may include the requirement that an evaluation be shared with the Medical Staff President and Office of Medical Affairs. Whatever action is taken, it shall be documented and placed in the member's credentials file. Continuing membership on the Medical Staff shall be contingent upon the member's appropriate response to the Medical Executive Committee's request.
G. Corrective action: Further incidents shall result in initiation of corrective action pursuant to the Medical Staff bylaws.
H. Rights of the Staff Member: A staff member who is the subject of this policy shall have the right to review and respond to all documentation placed in the credentials file, and to request that corrective action be initiated pursuant to Article VII of the Medical Staff bylaws so that the staff member may avail himself/herself of the procedural rights accorded by said Article.
I. Conflict with Medical Staff Bylaws: This policy is not intended to be the exclusive procedure to deal with inappropriate conduct by staff members and may not be interpreted to suspend or replace any provision of the Medical Staff bylaws.
J. Annual Review: This policy and its implementation shall be reviewed annually to assess its effectiveness. This review would include but not be limited to:
1. The total number of reported complaints
2. The total number of complaints acted upon
3. General description of the types of behaviors reported.
XII. Supervision of Residents in the Inpatient Setting
A. The Residents of the Family Practice Residency Program are supervised by an appointed Attending Physician or faculty member while performing services at Central Maine Medical Center. The Attending Physician or covering Physician shall be an appropriately privileged Medical Staff member. The Attending shall be available at all times, on-site, or via phone/beeper system, while a Resident provides services in the hospital setting.
APPENDIX A.
