HP-00130.pdf

Sample Policies

and Procedures

PAGE 1

C ONFIDENTIALITY OF

ATIENT INFORMATION POLICY

Policy

_______________________ Clinic respects and will protect every patient’s right to have all information

shared with health care professionals to be kept confidential.

Purpose

Patient information, regardless of its medium (written, verbal, or stored in paper, photograph, video,

or electronic format), may be used for a variety of legitimate purposes, for example, patient

care, quality review, education, research, public health, legal and reimbursement. Regardless

of its use, patients must be assured the information they share with health care professionals

will remain confidential. Without such assurance, patients may withhold critical information

that could affect the quality and outcome of care, as well as the reliability of the information.

Scope

This policy applies to all _______________________ Clinic employees and its students. It presents

guidelines that can be used to determine what information is confidential, what constitutes a

breach of confidentiality and the disciplinary process for employees who breach confidentiality.

Definitions

s Confidential information is information derived from a relationship between patients and

health care professionals. Confidential information includes, but is not limited to:

– health/clinical information – diagnosis, treatments, test results, etc.

– demographic information – name, age, address, phone number, etc.

– appointment information – date, time, reason for appointment, provider, etc.

– insurance/financial information – source of payment, account balance, account for billing, etc.

s Employees with access to patient information will only gain access to the information

on a “need to know “ basis-only when it is necessary to perform and complete their

job responsibilities.

Based on Marshfield Clinic policy – rights may be reserved.

ENTER FACILITY NAME

SAMPLE POLICY

s Property: Health records, regardless of the media in which they are maintained, paper or

electronic, are the property of the health care provider. But health information contained in

the records belongs to the patient. Patients are entitled to copies of or to view their records

upon request. Disclosure of health information must be done in accordance with the

Release of Medical Information Policy.

Conduct

s Employees observing other employees violating patient confidentiality inside or outside the

clinic should report the incident to their managers.

s All alleged violations of the Confidentiality Policy will be investigated by managers and/or

appropriate personnel.

s Employees found in violation of this policy are subject to disciplinary action, up to and

including, immediate termination.

Procedure

s Employees may access patient information only when it is necessary to perform their jobs.

s Gossip, careless remarks and idle chatter may be a violation of trust and the patient’s right

to confidentiality.

s Employees are not authorized to access medical records and/or the Marshfield Ambulatory

Record System (MARS), and Combined Medical Record (CMR) to obtain information on

themselves, their spouse or their dependents. While this information is about you and your

family, and you may have a right to know, information must be obtained through proper

channels. Proper channels include calling the attending physician, health care provider

or the Medical Record Department. The Release of Medical Information Policy outlines

the steps required to retrieve information on yourself or your dependents. Employees are

expected to follow the same procedure as nonemployees.

s Patient information must be disclosed only upon written authorization by the patient or

his/her legal representative or where such disclosure is authorized by federal or state law,

subpoena or court order, and in accordance with the Release of Medical Information Policy.

s Managers shall inform and educate employees about the Confidentiality Policy.

s An employee who needs clarification of the Confidentiality Policy should speak with his/

her manager.

s Security: Each employee has a password that enables him/her to access the computer

system. This password is not to be shared with anyone. Each time an electronic record

is retrieved, a tracking system identifies and records the time, date, locations and name

associated with the computer terminal used. This tracking system is capable of identifying

potential abuse. Employees are responsible for all inquires made using their password.

PAGE 2

SAMPLE POLICY

PAGE 3

C ONTROLLED DRUG PROCEDURE

Any Clinic department may make a request of Clinic Pharmacy to stock controlled drugs in

a patient care area. The request shall be made and signed by the department chair or acting

department chair and shall include the date of request, drug name, strength, unit of use

and number of units to be kept in stock. The following guidelines apply to the storage and

distribution of controlled drugs at the

_______________________ Clinic.

Schedule II drugs

An initial prescription stating “department stock” with a doctor’s signature is used to request

department stock (Note: some regional centers will require the use of a DEA 222 form). Clinic

Pharmacy keeps a log of Schedule II drugs dispensed to a patient care area. As a product is

used, the department generates a prescription with the patient’s name, address, drug given,

amount administered, route of administration and doctor’s signature. This prescription is

taken to Clinic Pharmacy for replacement of department stock.

s The controlled drug area must be locked at all times

s Only authorized personnel may have access to the locked area

s The department must keep a controlled drug inventory record of patients who have

received a controlled drug (sample in Section VII - page 4)

s The inventory record must be reconciled on a daily basis

s It is the responsibility of the doctor to write a prescription for the Schedule II item dispensed

Schedule III through V drugs and exempt narcotics

s Drug storage area must be locked at all times

s Access to drugs granted to authorized personnel only

s A controlled drug inventory record must be maintained and reconciled daily

s A prescription is not needed to request these items from the pharmacy

s The department manager or designee will review the controlled inventory records monthly

and will sign the inventory record to indicate that it has been reviewed and that there are

no discrepancies

Controlled drug inventory record discrepancies

s Any discrepancy between the inventory record and amount of drug in stock must be

reported in writing immediately to: department manager, pharmacy manager, physician/

surgeon department chair and administration

s Discrepancies will be documented on an incident report and forwarded to legal services staff.

Based on Marshfield Clinic policy. Rights may be reserved.

ENTER FACILITY NAME

SAMPLE POLICY

PAGE 4

Date Department

C ONTROLLED DRUG RECORD

Comments M.D. Signature

Starting inventory

(units of use)

Name, strength and

unit of use

Checked by

Patient Name Time Dose Dose Dose Dose DoseBal Bal Bal Bal Bal

ENTER FACILITY NAME

Based on Marshfield Clinic policy. Rights may be reserved.

PAGE 5

C ONTROLLED DRUG RECORD INSTRUCTIONS

s This form will be used by all departments and regional centers for all doses of controlled

drugs kept in stock.

s A new form will be used each day and the day’s date will be recorded at the top of the form.

s The name of the department or regional center will be indicated at the top of the form.

s The name, strength and unit of use (ie, vial, syringe, ampule, tubex, and tablet) of each

controlled drug kept in stock will be recorded in the vertical columns at the top of the form.

s The starting inventory of each drug in units (ie, vial, syringe, ampule, tablet) will be

recorded in the appropriate space under the name of the drug. This will be the same as

the ending balance from the previous day. This will be verified by comparing the actual

physical inventory with the recorded inventory and will be initialed in the space provided.

s When a dose(s) of drug is taken for a patient, the patient’s name, time of day, dose(s) taken,

remaining balance, physician’s name and signature of the person taking the drug will be

recorded on the same line in the appropriate box. The new balance will be the result of

subtracting the dose(s) taken from the prior balance.

s If a dose(s) of drug is taken for a patient but not used, a separate line entry will be made

indicating “returned from

_____________” along with the time, dose(s) returned, new balance

and signature of the person returning the drug. The new balance will be the result of

adding the amount returned to the previous balance.

s If a dose(s) of drug is taken for a patient but only a portion of the dose(s) is used, the

remaining amount of drug returned will be indicated in the comment section of the row in

which the amount of the drug taken initially was recorded. At the close of the day, all of

these partial doses will be destroyed. The destruction will be witnessed by two people who

will place their initials next to the amount of drug destroyed.

s When a new supply of drug(s) is received, an entry will be made, “received from

____________,”

time received, number of doses received, resulting balance, and the signature of the person

receiving the drug(s). The new balance will be the result of adding the number of doses

received to the previous balance.

s At the close of each day, the ending balance will be compared to the actual number of

doses in the inventory to make sure the two match. If they do not, steps should be made

to reconcile the difference. If it cannot be reconciled, the discrepancy should be reported

immediately to the department manager or acting manager.

s The balance indicated at the end of the day should be the same as the starting inventory

for the next day.

s These records will be kept for five years.

s During nonoperating hours, the controlled drug records will be kept in a separate location

from the controlled drugs.

Based on Marshfield Clinic policy. Rights may be reserved.

PAGE 6

E MERGENCY PROCEDURES (LARGE CLINIC)

Bomb Threat – Condition Yellow

Condition Yellow is the code used to notify departments and employees that a bomb threat

has been received. Instructions will be given if areas are to be evacuated.

If you receive a bomb threat:

s Stay calm.

s Question caller and document as much information as possible. (Where is the bomb?

When is it set to go off? Why did they place the bomb here?)

s Immediately dial 6 and report the threat to telecommunications.

s Notify manager of the call.

Telecommunications and administration actions

s Telecommunications will notify Clinic Administration.

s Clinic Administration will then evaluate the bomb threat and will call local emergency

services to notify them of the bomb threat.

s Upon direction from Clinic Administration, telecommunications will make the following

announcement over the public address system:

“ATTENTION PLEASE – CONDITION YELLOW”

(Instructions will follow this announcement if areas are to be evacuated.)

Department actions

s Upon notifications of Condition Yellow, departments will do an immediate search of the

department and all patient areas. The searchers should look for any objects not usual to

the area or any type of package, box, bag, etc., left unattended.

s If a suspicious object is found, do not touch or move it. Report the object to

telecommunications by dialing 6. Prepare to evacuate the area per the Evacuation Procedure.

Evacuation Procedure

Notification

Notice to evacuate an area, department, floor, building or entire facility will be announced

over the public address system. The announcement will include:

s areas to evacuate

s place to evacuate to

s elevators that may be used for nonambulatory patient evacuation

s if employees are released to go home

Based on Marshfield Clinic policy. Rights may be reserved.

ENTER FACILITY NAME

SAMPLE POLICY

Procedures

Upon notification to evacuate:

s Stay calm

s Ensure all personnel are notified of evacuation notice

s Log off computers

s Collect personal belongings such as coats, keys and purses

s Escort all patients out of department, close main department doors and escort patients out

of building

s Transport patients needing recovery or medical care to hospital

s Evacuate to designated area per public address announcement

s Do not stay near buildings

Postevacuation

Following evacuation of the Clinic:

s Do not re-enter the building until the all-clear announcement is made.

s Stay in designated evacuation area unless released home by official administration notice.

Fire – Operation Red

R.A.C.E. (follow these steps in the event of a fire)

Rescue and/or remove all people from immediate danger of smoke.

Alarm – Dial 6 and specify building, department and location of fire or smoke or pull a fire

alarm box. Announcements of a fire or evacuation will be made over the public address

system using the code, “OPERATION RED – (building, department and location)”

The fire department will be notified.

Confine fire and smoke by:

– closing doors

– shutting off fans, gas, oxygen and electrical equipment in immediate area

Extinguish fire by:

– using portable extinguisher if safe to do so

– smothering with blanket, if available

PAGE 7

Evacuation

s Move patients away (horizontally) from fire and smoke.

s Have one or more employees stay with patient group.

s Evacuate down stairwells only when told to do so or if situation requires evacuation of

the floor.

Tornado – Condition Black

Tornado WATCH: indicates weather conditions are such that a tornado could occur.

When a tornado watch is issued by county emergency government, telecommunications

will make the following announcement:

“A TORNADO WATCH HAS BEEN ISSUED FOR

________ COUNTY. THIS WATCH WILL

BE IN EFFECT UNTIL ________ O’CLOCK.”

Tornado WARNING: indicates a tornado has been sighted or has been detected by

local radar.

When the county emergency government alerts telecommunications of a tornado warning,

telecommunications will make the following announcement:

“ATTENTION ALL PERSONNEL – CONDITION BLACK. PLEASE MOVE TO A SAFE

AREA.” (This announcement will be repeated.)

s Move all patients/people away from exterior windows or glass areas to interior hallways.

s Close all doors to outer exam rooms and offices.

s When danger has passed, telecommunications will announce:

“CONDITION BLACK – ALL CLEAR” (This announcement will be repeated)

PAGE 8

E MERGENCY PROCEDURES (SMALL CLINIC)

Employees must be familiar with office-specific fire and tornado plans.

Tornado

If a tornado watch is issued, receptionist informs all patients and staff. Receptionist

continues to monitor weather status.

If a tornado warning is issued, receptionist:

– informs all patients and staff that a tornado warning has been issued

– assists in moving all patients away from exterior windows to interior hallways or to the

basement of the building

– moves all patients back to office, when danger has passed

Fire

s Rescue and remove all persons from immediate danger of smoke/fire.

s If fire alarm has not gone off, call 911 stating, “We have a fire at (address)

______________________.”

s Confine fire and smoke by closing doors and/or turning off any equipment.

s No person will take time to gather any personal items.

s Extinguish fire by using fire extinguisher or smothering with blanket, if available.

s No one may return to the office until authorized by fire department official.

PAGE 9

G ENERAL EQUIPMENT AND

PPLIANCE MAINTENANCE

_________________ Clinic’s guidelines to electrical safety.

Handle equipment with care.

s All electrical equipment should have a three-prong plug for proper grounding.

s Disconnect plug from outlet by grasping the plug, not the cord.

s Pull plug directly out of outlet. Do not rock back and forth.

s Do not allow power cords to come in contact with plumbing fixtures, water pipes, radiators

or other equipment in contact with ground.

s Do not allow power cords to kink, twist or come in contact with wet surfaces.

s Do not step on plugs or line cords, as this can break wires within.

Be alert to signs of trouble.

s Report any mild shock immediately and discontinue using the device. Place “DO NOT

START” sign on the equipment, stating the problem.

s Report any mechanical problem.

s Report frayed wires, plugs loose in outlets, loose switches, anything suspicious (broken or

bent). Inspect before using.

s Report all suspicious odors associated with the use of electrical equipment.

s Do not place liquids on top of electrical equipment.

s If a power cord or plug is warm to the touch, remove the equipment from service and send

it for repair.

Follow electrical safety.

s Do not use “cheater” adapters.

s If an extension cord is necessary, use only a three-wire grounding cord. Cords longer than

10 feet are potentially hazardous.

s Do not operate electrical equipment before reading manufacturer’s instructions and

reviewing precautions.

s To keep static electricity at a minimum, always touch cart before touching the patient.

s Do not touch the patient and the equipment at the same time. Train yourself to touch only

the patient or the equipment.

s Do not touch two electrical devices at the same time (one might not be grounded or might

have a greater leakage than the other).

s Do not attempt to make electrical repairs of any kind yourself.

s Unplug all electrical equipment that is not in use.

s Keep line cords out of traffic paths.

s If a patient is connected to any electrical device, do not use ungrounded equipment.

s Do not use multiple outlet adapters.

AGE 10

Based on Marshfield Clinic policy. Rights may be reserved.

AGE 11

I NFECTION CONTROL PLAN

Standard Precautions

At _______________________ Clinic universal/standard precautions have been observed since

1988. Under standard precautions, all blood/body fluids of all patients must be considered

potentially infectious. Preventing exposure to blood/body fluids is dependent on the

caregiver’s interaction with the patient rather than on the patient’s diagnosis.

Engineering Controls

A primary means to eliminate or minimize exposure to blood/body fluids includes the use

of engineering controls whenever possible. These controls are preferred, as safety is not

behavior dependent but is an integral part of that device/equipment.

The following are examples of engineering controls used at _______________________ Clinic:

s Handwashing facilities (or antiseptic hand rinses) that are readily accessible to all

employees who have the potential for exposure

s Needle containers that are closable, puncture-resistant, leak-proof on the sides and bottom,

color-coded or labeled with a biohazard sign are located where needles are used or can be

found. All sharps containers are to be sealed and disposed of either before or at the time

the container reaches the “full” line.

s Specimen containers that are leak-proof, color-coded or labeled with a biohazard sign if

not easily recognized as a specimen and puncture-resistant, if necessary.

s Laminar airflow hoods and biological safety cabinets

s Protective needles and needle blocks

s Hemostats or forceps

Engineering controls must be periodically evaluated to determine where controls can be

updated, and where engineering controls can be instituted. In addition, engineering controls

must be regularly examined and maintained or replaced to ensure their effectiveness. This

evaluation and examination process will be done in the following ways:

s Annual review of the Infection Control Plan

s Department-specific universal precautions review

s Regularly scheduled preventive maintenance checks

s Biannual department safety assessments

s Quarterly exposure data reporting to Safety Committee

s Ongoing product evaluation by individual departments and purchasing department

s Representation of Infectious Disease Department on various Clinic-wide committees

s Employee health nurse and Infectious Disease Department consultation by employees

and managers

Based on Marshfield Clinic policy. Rights may be reserved.

ENTER FACILITY NAME

SAMPLE POLICY

Work Practice Controls

Performing a task in a manner that will reduce the likelihood of blood/body fluid exposure

is called a work practice control. Many work practice controls have been in place at

_______________________ Clinic for some time.

The following work practice controls have been incorporated into the Infection Control Plan:

s Employees must wash their hands immediately or as soon as possible after removal of

gloves or other personal protective equipment.

s When handwashing sinks are not readily accessible, an antiseptic hand rinse must be

readily accessible. When antiseptic hand rinses are used, hands must be washed with soap

and water as soon as possible.

s Hands and other body surfaces must be washed with soap and water immediately when

contaminated with blood/body fluids. Mucous membranes must be flushed with water

immediately after exposure to blood/body fluids.

s Contaminated needles or sharps must not be bent or broken, but placed uncapped into

puncture-resistant needle containers located where needles are used or expected to be

found. When needle containers are not readily accessible in area of use, a portable needle

container must be used.

s Contaminated needles or sharps will not be recapped or removed unless no alternative is

feasible or such actions are required by a specific medical procedure. When recapping or

needle removal is required, a mechanical device (hemostat or needle block) or one-handed

recap technique must be used. Two-handed recapping must never be done.

s Contaminated reusable sharps will be placed in the appropriate container immediately or

as soon as possible after use. Employees cannot retrieve contaminated reusable sharps

from these containers with their hands, but must use a mechanical device.

s Eating, drinking, applying cosmetics or lip balm and handling contact lenses is prohibited

in work areas where blood/body fluid exposure may occur.

s Food and drink is not kept in refrigerators, freezers, on countertops or other storage areas

where blood/body fluids are present.

s All procedures involving blood/body fluids will be performed in such a manner as to

minimize spraying, splattering, splashing or generation of droplets of these fluids.

s Mouth pipetting or suctions of blood/body fluids is prohibited.

s Specimens of blood or body fluids are placed in designated leak proof containers which

are appropriately labeled. Secondary containers are used if the specimen can puncture

the primary container or if outside contamination of the primary container occurred.

s Equipment which becomes contaminated with blood/body fluids is examined and

decontaminated prior to servicing or shipping. If decontamination is not feasible, a

biohazards label identifying the contaminated portions is attached to the equipment.

This information must be conveyed to all employees and individuals having contact

with the contaminated equipment prior to handling, servicing or shipping.

All department managers and housekeeping senior employees are responsible for ensuring

implementation and compliance with pertinent work practice controls in their area.

AGE 12

AGE 13

I NFECTION CONTROL TRAINING

Educating employees is extremely important when attempting to eliminate or minimize

employee exposure to bloodborne pathogens. Therefore, all new employees are required to

participate in a training program on bloodborne pathogens. In addition, all employees will

participate in yearly training sessions on bloodborne pathogens.

All new employees, as well as employees changing jobs or job functions, will be given any

additional training their new position requires at the time of their new job assignment.

Human Resources Development is responsible for developing the training program and

facilitating the provision of the training. Department managers and supervisors are responsible

for seeing that all employees who have potential exposure to blood/body fluids receive this

training. Managers and supervisors are also responsible for informing the Human Resources

Development Department of employment changes that would necessitate the provision of

additional training.

Training Topics

The topics covered in the training program include, but are not limited to:

s The bloodborne pathogens standard

s The epidemiology and symptoms of bloodborne disease

s The mode of transmission of bloodborne pathogens

s The Infection Control Plan and where to obtain a copy

s Appropriate methods for recognizing tasks and other activities that may involve exposure

to blood/body fluids

s A review of the use and limitations of methods that will prevent or reduce exposure such

as engineering controls, work practice controls and personal protective equipment

s Selection and use of personal protective equipment including types available, proper use,

locations, removal, handling, decontamination and disposal

s The labeling and signage system

s Information on the Hepatitis B vaccine including its efficacy, safety, method of

administration, benefits and “no charge” availability

s Actions to take and people to contact when an exposure occurs

s The procedures to follow if an exposure occurs including the method of reporting and

medical evaluation

s Information on the postexposure evaluation and follow-up provided

Training Methods

The training program will be accomplished through several teaching methods depending on

the trainee’s education level and department/unit. All training sessions will include both time

for interaction and the trainer’s name and telephone extension for questions.

Based on Marshfield Clinic policy. Rights may be reserved.

ENTER FACILITY NAME

AGE 14

M EDICATION DISTRIBUTION

AND STORAGE PROCEDURES

s Any drug product distributed as a sample to a patient shall be documented in the patient’s

medical record. This documentation shall include: drug name, drug strength, quantity,

frequency of dose, duration of use and documentation of instruction to patient.

s The sample to be distributed must be ordered and physically verified by the provider before

being given to the patient.

s Patients receiving samples shall be given written instructions which include the items listed

above and other pertinent drug information.

s When appropriate, the patient shall be given a written prescription or the prescription may

be called to a pharmacy.

s Any documentation in the patient’s chart must be counter-signed by a provider.

s If the patient’s chart is unavailable, a form may be filled out according to the above

procedures and affixed to the patient’s progress notes when chart is available.

s No department shall keep in stock any samples of controlled substance nor exempt

narcotics (e.g. codeine-containing cough syrups).

s Each department shall designate a minimal number of employees to manage the samples.

Their duties include:

– monthly checking for outdated drugs

– placing of samples delivered by sales representatives or common carrier into the cabinets

– assurance of proper storage conditions

s Outdated samples shall be delivered to pharmacy of

_____________.

s Pharmaceutical manufacturer vendors must conform to a vendor-visitor policy.

Based on Marshfield Clinic policy. Rights may be reserved.

ENTER FACILITY NAME

AGE 15

M EDICAL RECORD DOCUMENTATION POLICY

LECTRONIC)

Medical and psychiatric records are maintained in a uniform and consistent manner.

Electronic Transcription System

Document creation

s Only hospital, clinic or clinic regional center personnel who have access to the Electronic

Transcription System may upload a transcribed document to the electronic record.

(e.g. Transcribing, Pathology, Radiology, Psychiatry, etc.)

Document editing

s Only hospital, clinic or clinic regional center personnel who have access to the Electronic

Transcription System may correct a document that has been uploaded.

Corrections/addendums

s Definitions

– Corrections: A revision in the body of the original document.

– Addendum: Follow-up dictation to be appended to the original document, labeled as an

addendum and placed at the end of the document.

– Clinic notes: The provider may specify whether a piece of information should be an

addendum, correction or a separate document.

Hospital reports

s Determination as to whether the dictation is a correction or addendum is made by the

transcriber, based on hospital medical record and transcribing department guidelines.

Medical Center Documents

Document creation

s Create Short Documents (CSD) allows individual users with appropriate access to type their

own notes into the electronic record. The document is approved and signed upon uploading.

Document editing

s Must be done through the transcription system.

Based on Marshfield Clinic policy. Rights may be reserved.

ENTER FACILITY NAME

SAMPLE POLICY

Suppressed Documents (previous versions)

s When a signed document is revised in any way, the previous document is not deleted but

is suppressed and available for review when necessary. A message appears on the current

version indicating that a previous document exists. A message also appears on the previous

document indicating the dates it was available as a current version. When a signed document

needs to be removed from the patient’s record, the notation “Document uploaded in error”

appears in place of the text. As with other suppressed documents, the previous version is

available for review when necessary and the same messages appear on each version.

Deleting Uploaded Documents

s An unsigned document can be deleted in its entirety by transcription management

and designees.

s Documents not approved to be a permanent part of the medical record.

– It is possible that information not approved to be a permanent part of a patient’s medical

record could be uploaded. This type of information should not be on the electronic

medical record system and should be purged. No message will appear indicating that

the document has been purged. Further steps will be taken if the information needs to

be retained in another format.The system allows it to be removed from the file with

a specific authorization from either a chairperson of the Medical Record Committee,

medical director and/or assistant to the medical director.

s The documentation must be investigated by appropriate personnel (e.g. hospital or clinic

medical record manager, Legal Services Department or Risk Management).

Electronic Signature

s Documents that are transcribed and uploaded to the mainframe must be signed

electronically. With the exception of pathology reports, unsigned documents are available

for viewing on the electronic record with a specific level of access.

s Unsigned documents are flagged with one of the following messages:

– reviewed

– pending review by the author

– unverified

– in process of revision

s Cosigning provider may elect to require the author to “approve” the document prior to the

document appearing on screen for signature. In these cases, the cosigning provider can

review and sign unapproved documents by using the ALL option.

s Providers may elect to have their medical assistants flag a document as “Reviewed” before

it can be batch signed.

s Batch signing – Each document must be reviewed by the physician or author and flagged

as “reviewed” before it can be batch signed

s If corrections or addenda are made to a signed document, the revised document must be

electronically signed again.

AGE 16

s Though the body of the document may display the names of several people responsible for

dictation and review of the document, only the cosigning provider may electronically sign

the document. The author’s review does not appear as a signature.

s The access code grants access to sign electronic documents. The provider number makes

available the list of documents needing signature. The system allows only authors/

supervisors within the same author group (department) to sign each other’s documents.

Cosignature Requirement

s Certain categories of authors are required to have the signature of a cosignature provider

on their document. If desired, documents may be signed by the supervisor without approval

by the author.

Acknowledging a Document in the Absence of the Author

s In the event that a physician or other clinician terminates employment, for any reason,

the department chairman or department supervisor shall electronically sign the document

that will be recognized as an acknowledgment of the document in the absence of the

author. This signature does not act as an authentication or validation of the accuracy or

the validity of the document. This acknowledgment signature will initiate printing into the

Transcription Cumulative Report.

Printing of Electronic Documents

s When an electronic document is electronically signed it will print a paper record that is

available for filing into the combined paper record. Documents print in exact chronological

order according to the service date. Some documents print in cumulative reports and some

documents print on separate pages.

s During a hospitalization, any document transcribed and uploaded via the Electronic

Transcription System will print on the unit as a temporary copy. The document does not

have to be signed in order to print.

s Any electronic document signed during the hospitalization will print a paper record the

evening of discharge for filing in the combined paper record.

s Printing Clinic Alcohol and Drug Treatment Program and Psychiatry documents:

– Psychiatric and Alcohol and Drug Treatment Program documents identified as “restricted”

print only on the Psychiatric Transcription Cumulative Report (TCR) that is filed in the

Clinic Psychiatry Department. The TCR filed in the combined record contains a summary

of the Psychiatric Discharge Summary and some psychiatric clinic notes, which include

diagnosis, medications and follow-up plans.

– See “Documents With Restricted Access” for a break-down of these documents. Hospital

psychiatric consults: Upon upload from the transcription system to the MARS system, these

documents will print on the printer closest to the patient’s bed location. After signature,

these documents will print on white paper separate from the TCR. These white pages will

be placed in front of the buff TCR. These documents will not print in the Psychiatric TCR.

AGE 17

s Printing of Laboratory Cumulative Reports (LCR)

– Once the lab result is determined, it is sent through the interface to the mainframe

into the lab result file. The record is written, which triggers the LCR to be created. That

evening, the LCR is printed and is available to be interfiled in the patient record.

– The LCR includes results of lab tests ordered by providers for hospital, clinic and outreach

patients. Lab results for regional center patients print at the site of the visit.

– Laboratory results for hospital inpatients automatically print on the unit as a temporary copy

as soon as the result is available. Temporary copies are replaced with original LCRs daily.

s Printing of Radiology Cumulative Reports (RCR)

– Once the radiology interpretation is dictated and transcribed, it is uploaded on the

radiology system.

– The temporary, unverified report is printed at the nursing station and on the unit (if the

patient is admitted) upon uploading.

– The RCR is done as an addendum at the end of the report.

– The RCR may contain both verified and unverified reports.

s Printing of documents from PHAMIS

– Prior to discharge Active Care Plans and Active Medication Profiles are printed and

available on the hospital unit. After discharge, the Care Plan History and Discharge

Medication Administration Profile are printed and become a permanent part of the

patient record.

Access Code

s The access code grants access to sign electronic documents. The provider number provides

the list of documents needing signature. The system allows only authors and supervisors

within the same author group to sign each other’s documents.

s Dictate and listen access to hospital dictation system: A unique number is assigned to each

user and monitored by hospital transcribing. This number establishes access to dictate

reports and/or listen to dictated reports. An audit trail is available.

There Are Five Levels of Access to MARS Screen 293 – Display Document

Level 1 – allows review of general medical information

Level 2 – allows review of restricted access documents when “RA” is typed in request field

Level 3 – allows review of restricted access documents without using any special commands

Level 8 – allows review of unsigned pathology documents and review of restricted access

documents by using “RA”

Level 9 – reserved for use by Information Systems staff only

s Level of access is specific to each employee and is determined by access needed to perform

current job duties.

s The level of access is assigned by Information Systems upon request and approval by the

employee’s supervisor/manager.

AGE 18

Documents With Restricted Access

Documents identified by Psychiatry and Alcohol and Drug Treatment Program as requiring

restricted access are:

Hospital

s Psychiatry

– psychiatric history and physical

– psychiatric discharge summary

– psychosocial history and assessment

– psychosocial database notes

– psychosocial evaluation

– psychological testing

– psychological evaluation

– psychological database

– AODA evaluation

Clinic

s Psychiatry and AODA

– psychiatric note

– psychiatric telephone note

– psychiatric testing

– psychiatric correspondence

Only users with the appropriate level of access may view these documents on screen 293 –

Display Document.

Audit Trail

s Access to confidential electronic information produces an audit trail that may be requested

for review.

Confidentiality

s The medical record, including the electronic record, is confidential and intended only for

lawful use by the patient’s physician and others with a legitimate, authorized need to know.

It is the solemn ethical and legal responsibility to keep patient information confidential and

to use only within the scope of our work responsibilities.

AGE 19

Retention

s Medical records are preserved either in paper, electronic, optical or microfilm format.

Pathology

s In general, pathology reports are only available for review on MARS screen 293 after

the Pathologist has electronically signed them. The index directs the viewer to contact

Pathology prior to signature. Access Level 8 permits review and printing of these

documents prior to signature. If a provider requests a printed copy from Medical Records

because of an emergency, an effort would be made to telephone the author for permission

to print the document. If the author cannot be reached, the provider on call from that

department would be telephoned. If not reachable, the document would be printed and the

medical director would be notified that this action had taken place.

Outreach

s Includes cases where providers see patients at a location other than a provider’s primary

site. In these cases, an uploaded document prints in the TCR at the provider’s primary site.

The facility at which the patient was seen also receives a copy of the document.

AGE 20

M EDICAL RECORDS DOCUMENTATION POLICY

AMPLE 1)

All providers must sign their dictation.

Providers must verify that there is an entry for every date of service.

The following providers do not dictate (they write all notes)

Chart Division

Inside Front Cover: Problem list

Allergy injection schedule

Preliminary/interim culture results

Clinic copy of reference lab test requisition

Current prenatal record

Progress Notes: Progress notes (in reverse date order)

History and physical forms

Verify that provider notes are signed

Laboratory: Lab results

Outpatient pathology results

Pap results

Colposcopy pathology

(Paps and pathology are entered behind lab sheets)

Verify that all results are initialed

X-ray: Outpatient X-ray reports

IVP results

Mammograms

Doppler studies

Verify that all results are initialed

Special Tests: EKGs

HIV results/consents

Echocardiogram results

Holter monitor results

Stress EKG

EMG/nerve conduction studies

Androscopy/colposcopy forms/consents

Pulmonary function reports

Mini-mental results

Blood pressure scans

Verify that all results are initialed

AGE 21

Based on Doctors’ Clinic, Wisconsin Rapids, policy. Rights may be reserved.

Hospital: Hospital records

ER reports

Delivered/itemized OB sheets

Colonoscopy reports

Endoscopy reports

Special Exams: Physical forms–copies only (includes life, school/kdg, day care,

employment, DOT, all drug screen paperwork, children’s routine

exam checklists) Travel immunization paperwork/consents

Correspondence: Letters/records from other physicians

Copies of Aeromed, home health, nursing home papers

Release of information from clinics or insurance companies

Copies of vouchers

Blood pressure papers

Vaccination/immunization consents

Cardiac rehab reports

Disability/time loss forms

Release to work

Insurance referrals

s Each page in the record must contain the patient’s name.

s Personal biographical data must be verified at each visit including the name, address,

phone number, insurance and employer.

s All entries in the medical record must contain author identification.

s All entries in the medical record must be dated.

s All entries in the medical record must be legible.

s Medication allergies and adverse reactions must be prominently noted in the record.

If the patient has no known allergies or history of adverse reactions, this must also be

prominently noted in the record.

s All provider notes; laboratory, X-ray and special test results; and correspondence must be

signed by the provider before being entered into the chart.

s All errors in the medical record must be corrected by drawing a single line through

the error and indicating the correction. All corrections must be initialed. Under no

circumstances may data be erased or covered with correction fluid.

AGE 22

M EDICAL RECORDS DOCUMENTATION POLICY

AMPLE 2)

Policy

The Clinic shall maintain a medical records system from which chart information can be

collected, processed, maintained, stored, retrieved and distributed promptly.

Procedure

s Clinical information relevant to a client is to be available to authorized personnel only

during the hours the center is open to patients. Access to records for emergency purposes

by authorized personnel is through the nursing supervisor in respective institutions.

s A system of identification and filing shall be employed which insures the prompt location of

patient records.

s An individual medical record is to be established for every client receiving care. The record

is maintained in the Clinic location, identified by the client as their primary site for care.

s Medical records shall not be removed from the Clinic location of primary care. Copies may

be provided.

s Except when required by law, any record that contains clinical, social, financial or other

data on a patient is to be treated as strictly confidential and protected from loss, tampering,

alterations, destruction and unauthorized or inadvertent disclosures.

s Medical records are to be preserved record retention guidelines. All active records are to

be kept in the designated medical records file. Inactive records shall be kept secured in a

locked storage area and available only to authorized personnel.

s When appropriate, a signed and witnessed informed consent form is to be obtained and

included in the medical records.

s The content and format of medical records, including the sequence of information, shall

be uniform.

s Written consent shall be obtained from the patient before medical information can be

released. Copies of medical records may be given directly to a requesting client. Contents

of all information to be released shall be reviewed by qualified health care professionals.

s Patient record entries shall be completed and authenticated by the signature of all health

care providers.

s All record entries shall be legible and comprehensible to all clinical personnel. Allergies

shall be noted in red on the face sheet.

s All records shall contain a diagnostic and problem list and allergy survey, to provide an

easily visible summary of ongoing care.

s Significant health care advice given to a client by telephone shall be entered in the patient’s

record and appropriately signed.

AGE 23

Based on Eagle River Clinic policy. Rights may be reserved.

s When necessary, to assure continuity of care, records of a patient who was treated

elsewhere (e.g., by another physician, hospital, ambulatory surgical service, nursing home

or consultants) shall be obtained.

s All medical records shall be kept secure in a locked file and away from possible damage

(fire-prone areas, water damage) when the Clinic is closed. Files shall be available to

authorized personnel during hours of operation. Authorized personnel shall include nurse

practitioners, occupational health specialists, registered nurses, physicians, receptionist

and secretarial staff who have direct responsibility for the charts, consulting physicians

and medical advisor. Medical records may be reviewed by individual patients or agents

who present a patient’s written and signed authorization. This review shall take place only

under the direct supervision of authorized Clinic personnel.

s Recording on a client’s chart:

– clinical notes in connection with patient visits are to be written at the time of each visit.

– patient’s name is to be written on each sheet in the medical record.

– entries in patient’s record for each visit must include, but are not limited to the following:

- date, chief complaint or purpose of visit and history of present illness;

- physical findings;

- diagnosis or clinical impression;

- therapies and education;

- disposition, recommendations and instructions

- signature of provider

– blood pressure checks, lab tests or brief follow-ups may include pertinent information only.

AGE 24

AGE 25

M EDICATION DISTRIBUTION

AND STORAGE STANDARDS

Policy

This policy provides standards for medication management at _________________ Clinic and includes

procedures for ordering, handling, storage and administration of medications (including samples).

Objectives

s Drug samples obtained from pharmaceutical representatives will be stored and managed

in accordance with Drug Sample Distribution and Storage Procedures.

s Controlled substances will be obtained, stored and dispensed in accordance with

Controlled Drug Procedure.

s Administration of medication will be performed only by personnel with adequate

educational preparation and technical skills.

s Licensed RN and LPN scope of practice is defined in Chapter 441, Wisconsin Statutes, and

Chapter N, Wisconsin Administrative Code. Physician assistant scope of practice is defined

in Chapter Med 8, Wisconsin Statutes.

s Physicians and surgeons assume medical liability for tasks delegated to medical personnel.

s Clinic departments will address medication management standards at the department level

and file a plan which addresses specific department needs.

Standards

s No medication will be administered without a physician’s/surgeon’s order. Medications may be

given from standing orders approved by a section or department. Drugs given in an emergency

situation must have an order written on the chart within 24 hours of the drug administration.

Nurse practioners, certified registered nurses, anesthetists and physician assistants with

medication prescribing authority are restricted to practice as determined by licensure.

s All medications administered to patients will be documented on the medical record.

s Employees responsible for administering medication must have adequate knowledge of

the action of the medication and potential side effects for the patient.

Based on Marshfield Clinic policy. Rights may be reserved.

ENTER FACILITY NAME

SAMPLE POLICY

s Drugs and the route of administration will be classified according to the degree of expertise

required for safe administration and will be assigned to one of the following categories.

Minimum education and training requirements are listed:

Category I

– medical assistant diploma or equivalent

– completion of approved medication administration course

– knowledge of emergency procedures

Category II

– current licensure as an LPN, or certification/registration as a technician

– knowledge of emergency procedures

Category III

– current licensure or certification as an RN, CRNA, PA

– specialized training in the area of expertise

– knowledge of emergency procedures

Category IV

– current licensure as an MD, DO, or DDS (oral surgeon)

– knowledge of emergency procedures

s A Medication Management Standards Committee will be appointed by the medical director.

The mission of this committee will be to make recommendations for the ordering, storage

and dispensing of medications (including samples) at

_______________________ Clinic and to

review medications for classification by route of administration. The committee will report

to the Professional Practice Committee and Medical Director and have representatives from

physicians/surgeons, Pharmacy, Quality Improvement, Nursing, and technical areas, and

member representatives from the Safety Committee and Human Resources Development.

Classification of medications will be made with the following considerations:

s Route of administration

s Side effects and toxicity to the patient

s Therapeutic index

s Risk of anaphylaxis

s Exposure hazards for the handler

s Complexity of preparation

AGE 26

s Each department manager will file a plan with the chairperson of the Medication

Management Standards Committee addressing medication procedures and identifying

personnel trained to provide services. The plan must also address patient care issues such

as recovery of sedated patients and plans for emergency resuscitation in the event of

anaphylactic reactions.

The department will be updated annually or as changes occur within the department.

A signed medical liability waiver by the supervising physician/surgeon must be on file for

each nonlicensed employee.

s A department may ask to have new drugs classified for administration in a patient care

area by submitting the drug under consideration to the Medication Management Standards

Committee. The new drug proposal should include information regarding the route of

administration, side effects, toxicity to the patient, therapeutic index risk for anaphylaxis,

exposure hazards for the handler, complexity of preparation and technical difficulty of the

administration procedure.

s Staff members found to be in noncompliance with this policy are subject to disciplinary

action consistent with clinic policy.

AGE 27

M ISSED PATIENT APPOINTMENTS

In the event that a scheduled appointment is missed, a note is made on the provider’s

appointment schedule so he or she is aware of the patient’s missed appointment. The

provider then determines if the patient needs to have the appointment rescheduled. If it is

determined that the patient needs the appointment rescheduled, the appointment coordinator

communicates with the patient via telephone. If the patient is unreachable by telephone, a

letter is sent to the patient signed by the provider. Three attempts will be made to reschedule

the patient’s appointment.

If the provider determines a follow-up appointment does not need to be scheduled, a letter is

sent to the patient to alert them of the missed appointment.

AGE 28

AGE 29

O N - SITE MEDICAL EMERGENCIES

(SAMPLE 1 SMALL CLINIC)

Recognition

Definition: A CODE BLUE occurs when someone requires basic or advanced life support –

when a patient stops breathing and/or no pulse is detected or it is apparent that a patient

may soon require life support.

Action

s The person recognizing the situation shall call out “Code Blue at (location),” visibly see

someone acknowledge hearing it, and establish CPR. If need to do overhead page, “press

Feature button and 61 0,” then call for a code, “Code Blue at (location).”

When a code is called, staff should proceed to their assigned station and ensure that all

other staff members are aware of the code.

s If the patient is not a Code Blue but appears to need care emergently, immediately inform

the registered nurse or provider. Overhead page, “press Feature button and 61 0,” then call

for “medical providers please report to (location).”

Receptionist Role

1. When directed, call 911 for ambulance stating, “We have a medical emergency at ____________

Clinic, located at (address)

____________________________________.”

2. Clear patients or family from the immediate area and close other exam room doors.

3. Pull health record (if not already pulled) and give to medical assistant or provider.

4. Maintain control of waiting room.

5. Inform other patients regarding delay/cancellation/change of appointments.

6. Assist family members in contacting next of kin, obtaining necessary transportation and

general comfort.

7. Be available to assist with phone calling or documentation of events if needed.

8. Copy patient registration form, family history form, progress notes and flow sheet of code

events to send with ambulance crew.

Office Manager

s Assist receptionist as needed.

Medical Assistant’s Role

1. Bring emergency equipment to the site of the patient – code cart, oxygen tank, IV pole.

2. Provide CPR if needed until relieved by another staff member trained in CPR.

3. Remove patients jacket and clothes as appropriate, cover with gown or sheet.

ENTER FACILITY NAME

Based on Bridge Community Health Clinic policy. Rights may be reserved.

SAMPLE POLICY

O N - SITE MEDICAL EMERGENCIES

(SAMPLE 2 SMALL CLINIC)

A medical emergency (Code Blue) occurs when someone requires basic or advanced life

support, e.g. when a patient stops breathing and/or no pulse is detected or it is apparent that

a patient may soon require life support

Procedure

The person recognizing the situation shall call out “Code Blue” to make other staff members

aware of the situation and to begin CPR (if needed). If the patient is not unresponsive but

appears to need care emergently, the person immediately informs the receptionist. If the

person finding the patient is not the provider, the person immediately notifies the provider

and then the receptionist. The provider assesses the patient and instructs the receptionist.

The receptionist does the following:

s Calls 911 for an ambulance, stating “We have a medical emergency at (address)

_______________”

(if the provider instructs him or her to do so)

s Removes other patients and/or family from the immediate area

s Pulls the patient’s file for provider review

s Maintains control of the waiting room

s Directs the ambulance staff to the patient when they arrive

s Informs other patients regarding delay, cancellation or change of appointments

s Remains available to assist with telephone calling or documentation of events if needed

s Copies any forms needed to send with ambulance

AGE 30

AGE 31

O N - SITE MEDICAL EMERGENCIES

(SAMPLE POLICY LARGE CLINIC)

Policy

When the switchboard calls a Dr. 6 on the overhead paging system, it indicates that a

medical emergency is taking place. This policy, which applies to departments that have Dr. 6

equipment, outlines how those departments should respond when a Dr. 6 is announced.

Procedure

1. Phone Dr. 6 to switchboard. Identify Clinic Dr. 6 location (building, department and floor). If

victim is age 12 or under, indicate Pediatric Dr. 6. Switchboard pages Dr. 6 team on special

beeper system.

s ECG response

– ECG (Clinic) is on Dr. 6 beeper. Go to cart elevator and take control with key. If Dr. 6 is

on the lower level, go to elevator bank B or C and proceed to lower level. If Dr. 6 is on

ground, first, third or fourth floors, use key to proceed to that floor

s Crash cart from floor of Dr. 6 responds to the emergency.

– lower level – Cardiac Rehab Cart

– ground floor (including Lawton Center) – Urgent Care Cart

– first floor (Pediatrics, OB/GYN, Family Practice) – Pediatrics Cart

s A registered nurse from the Chemotherapy Clinic will respond to all Clinic Dr. 6s.

s Any available registered nurse on the same floor as the Dr. 6 should respond to

the emergency.

s Escorts wait four minutes after overhead page, then take transport cart to the scene.

2. Dr. 6 team members arrive, identify themselves, and take charge of resuscitative efforts.

3. After a Dr. 6

s If your cart responds to a Dr. 6 call, contact the nearest department that has a cart and

request temporary coverage until your cart has been returned/replaced.

s Call the department at the hospital who is responsible for stocking Dr. 6 cart and request

to exchange a Dr. 6 cart. A Dr. 6 cart will be brought to your department.

s Remember to transfer the suction unit, blood pressure cuff, stethoscope, and defibrillator

to the new cart. Replace the suction canister if it was used during the emergency.

s Check the defibrillator unit for adequate supplies.

Based on Marshfield Clinic policy. Rights may be reserved.

ENTER FACILITY NAME

SAMPLE POLICY

4. After-hours emergencies

s Personnel working evening, night, weekend or holiday hours should know the location

of the nearest Dr. 6 cart.

s Departments involved in patient-seeing activities should have a Dr. 6 cart readily available.

This could mean borrowing and returning a cart until such activity has been completed.

AGE 32

AGE 33

O N - SITE MEDICAL EMERGENCY

E QUIPMENT MAINTENANCE

Policy

Defibrillators, crash carts and portable suction machines serve as the standard equipment for

emergencies in the medical complex. This equipment needs to be routinely maintained and

checked to ensure proper functioning.

This policy applies to the departments that house the equipment. The manager and two other

staff in such departments will be selected to perform maintenance checks, monitor equipment

inventories and act as liaisons to Biomedical Electronics.

Procedure

1. Defibrillator maintenance

Weekly check by department personnel

s Visual inspection

– verify unit is plugged in

– verify green battery charge light is lit

– verify adequate strip paper is in place for recorder

– verify ECG lead patches and defibrillator paddle gel pads are present and have not

reached their expiration dates

– check paddle cable and ECG trunk cable and lead set for wear and tear

s Operational check

– unplug unit from wall

– turn power switch on

– verify adult paddles are installed

– set energy select control to 100 joules position

– switch the placement of paddles and place apex paddle in the left holder and the

sternum paddles in the right holder

– press either charge button

– wait for “charge done” tone and lamp to light

– verify that delivered energy displayed on monitor is at 100 joules

– WARNING: Keep hands clear of the paddle electrode edges

– grasp handles and depress both discharge buttons simultaneously. Recorder will run

and record results

– return paddles to their original positions

Based on Marshfield Clinic policy. Rights may be reserved.

ENTER FACILITY NAME

SAMPLE POLICY

Verification of test results

s Check that recorder runs. Time, date and energy delivered should be legibly printed on

top of strip paper.

s Check recorder strip for delivered energy

s Verify that the battery charge light is not flashing. Flashing light indicates possible battery

failure.

End of test

s Turn unit off and verify that paddles are returned to original position.

s Plug AC cord back into wall.

s Verify that battery charge light is lit.

s Initial the weekly check sheet.

s Notify the Biomedical Electronics Department of any defibrillator function problems.

2. Blood pressure cuff and stethoscope

s Check for the presence of a blood pressure cuff and stethoscope as part of the weekly

inspection. Confirm that gauge is set at 0.

3. Portable suction machine

s Check for the presence of appropriate canister and tubing as part of weekly inspection.

The Biomedical Electronics Department will make a quarterly check on machine function

and oil level.

4. Oxygen tank

s Check volume of oxygen in the tank as part of the weekly inspection.

– close regulator valve (turn towards “off”)

– open tank shut-off valve (counter-clockwise) with attached wrench

– check gauge for volume of tank. If there is less than 1500 PSI of oxygen, call

respiratory therapy for a replacement

– close tank shut-off valve. Open regulator valve. Gauge will then return

to “empty”

5. Dr. 6 cart stocking/maintenance

s The Dr. 6 carts are routinely stocked by the Supply, Process and Distribution Department

in the hospital and the hospital pharmacy.

AGE 34

O N - SITE MEDICAL EMERGENCIES

E QUIPMENT CHECKLIST

AGE 35

Visual Check of Defibrillator

Weekly Check

Casing intact

No objects on top

Operating instruction labels are present

Unit plugged into live outlet

Battery charging indicator light on

10 ECG monitoring electrode (check expiration date)

Adult and pediatric paddles (&/or adapters)

Gels or other conductive media

ECG recording paper (1 roll loaded and 1 spare roll.

End of roll marker not displayed on loaded roll)

*2 packs defibrillator electrodes (check expiration date)

*2 packs pacing electrodes (check expiration date)

*Internal defibrillator paddles (check sterilization

expiration date)

Paddle cables not damaged

Paddle cable/connectors securely engaged

Disconnect from power outlet

Turn unit on and verify monitor display is functional

Verify paddles release from housing easily

Verify paddle conductive surface free of “pitting” and clean

Charge defibrillator to 100J and verify charging time is

< 10 seconds

Discharge defibrillator into build-in test load; verify

adequate output energy

Verify recorder prints with correct time/date

Plug unit into power outlet and verify battery

charging indicator is on

*Using pacemaker test load, verify pacemaker operation

Suction tubing and canister present and in good condition

Condition of oxygen tank

Volume of oxygen in tank (if < 1500 PSI, replace)

Blood pressure cuff and stethoscope present and in good condition

Functional Check of Defibrillator

Check of Other Equipment

Defibrillator Housing

Power Supply

Supplies

Paddles

Date

Initials

AGE 36

P ATIENTS’ BILL OF RIGHTS SAMPLE 1

The following list of patient rights is not intended to be all inclusive. Every patient has the

right to:

– be treated with dignity and respect.

– privacy and confidentiality concerning their medical care.

– have their questions, concerns or complaints addressed in good faith.

– be provided with current, complete information about his or her diagnosis, indications for

tests and procedures, treatment and alternatives and prognosis.

– make choices and decisions regarding their medical care.

– be provided with information necessary to give informed consent prior to any procedure

or treatment.

– change physicians if other qualified physicians are available.

– receive, on request, information about fees and charges, and receive an explanation of

his or her bill, regardless of source of payment.

– receive, on request, a copy of his or her medical record.

– have an advance directive concerning treatment or designation of a surrogate

decision maker.

Based on Marshfield Clinic policy. Rights may be reserved.

ENTER FACILITY NAME

AGE 37

Based on Saint Joseph’s Hospital of Marshfield policy. Rights may be reserved.

P ATIENTS’ BILL OF RIGHTS SAMPLE 2

s Patients have the right to considerate and respectful care.

s Patients have the right to obtain from their providers, complete current information

concerning their diagnosis, treatment and prognosis.

s Patients have the right to receive from their providers, necessary information to give

informed consent prior to the start of any procedure and/or treatment.

s Patients have the right to refuse treatment to the extent permitted by law, and to be

informed of the medical consequences of this action.

s Patients have the right to every consideration of privacy concerning their own medical

care program.

s Patients have the right to expect that all communication and records pertaining to their

care should be treated as confidential.

s Patients have the right to expect that the facility (clinic/hospital), within its capacity, makes

a reasonable response to the request of patients for services.

s Patients have the right to obtain information about any relationship the facility has with

other health care and education institutions as their personal care is concerned.

s Patients have the right to be advised if the facility proposes to engage in research affecting

their care or treatment. Patients have the right to refuse to participate in such projects.

s Patients have the right to expect reasonable continuity of care and the right to know, in

advance, what appointment times and providers are available and where.

s Patients have the right to examine and receive an explanation of their bills regardless of

source of payment.

s Patients have the right to know what facility rules and regulations apply to their conduct

as patients.

ENTER FACILITY NAME

P ATIENTS’ RESPONSIBILITIES TO FACILITY

(Clinic/Hospital)

s Patients, to the best of their ability, have the responsibility to bring with them information

about past illnesses, hospitalizations, medications and other matters relating to their health.

s Patients have the responsibility to cooperate with all facility personnel caring for them, and

to ask questions if they do not understand any directions given to them.

s Patients have the responsibility to be considerate of other patients, and to see that their

visitors are considerate as well.

s Patients have the responsibility to keep appointments or to telephone the facility when

they cannot keep a scheduled appointment.

s Patients have the responsibility to be prompt in their payment of facility bills, and to

provide the information necessary for insurance processing.

s Patients have the responsibility to respect others, the property of other persons, and the

property of the facility.

s Patients and their families/visitors have the responsibility to abide by facility rules

and regulations.

s Patients have the responsibility to follow the instructions and medical orders given to them

by their medical providers.

s Patients have the responsibility to inform facility administration, as soon as possible, if

they believe that any of these responsibilities have not been or may not be fulfilled. Upon

discharge from the facility, patients have the responsibility to maintain the treatment

recommended by their provider and to notify the provider of any changes.

AGE 38

ENTER FACILITY NAME

Based on Saint Joseph’s Hospital of Marshfield policy. Rights may be reserved.

P ROCESS FOR HANDLING COMPLAINTS

AND QUALITY ASSURANCE ISSUES

Patients who feel their rights have been violated may file a grievance. The patient will not be

threatened or penalized in any way for presenting concerns either informally or formally by

filing a grievance. Steps for handling complaints and quality assurance issues

are as follows:

s The patient is encouraged to first talk with their provider about any concerns he or she may

have.

s If the patient is not comfortable talking with the provider, he or she may speak with the

office manager.

s If the issue is not resolved to the patient’s satisfaction, the patient has the option to file

a formal grievance with his or her insurance company.

s If the issue is still not resolved to the patient’s satisfaction, the patient has the option to

file a formal grievance with the State of Wisconsin.

AGE 39

Based on Marshfield Clinic policy. Rights may be reserved.

ENTER FACILITY NAME

S MOKE-FREE ENVIRONMENT

Policy

_______________________ Clinic believes a “smoke-free” environment is essential to the health and

welfare of its patients and staff. As such, smoking is banned within its facilities and adjacent

premises including all entrances and parking areas.

Procedure

It is each person’s responsibility to help carry out the spirit of the policy in a way that fosters

good patient and employee relations.

Employees are encouraged to contact the Human Resources Department if they have any

questions regarding this policy. Complaints regarding violations of this policy may be filed

under an employee grievance. The filing of complaints using the grievance procedure will

enable the clinic to take appropriate measures to alleviate conflict (i.e. between smokers and

nonsmokers) before a serious employee relations or legal concern develops.

Employees who find it difficult to comply with this policy are encouraged to take advantage

of the cessation programs available in patient education and the clinic’s Employee Assistance

Program. Staff members found to be in noncompliance with the policy are subject to

disciplinary action similarly to noncompliance with any clinic policy.

AGE 40

Based on Marshfield Clinic policy. Rights may be reserved.

ENTER FACILITY NAME

S TANDARD/BODY ISOLATION PRECAUTIONS

IN THE CLINIC SETTING

All human blood and body fluids will be treated as if potentially infectious.

Barrier precautions will be routinely used by all personnel for their own protection.

s Gloves must be worn whenever the possibility of touching blood and body fluids exists,

mucous membranes, nonintact skin, or for handling items or surfaces soiled with blood

and body fluids.

– gloves should be changed after contact with each patient

– if a glove is torn or a needle stick occurs, the glove should be removed and a new glove

used as promptly as safety permits

s Masks and protective eye wear (goggles, glasses, face shields) must be worn whenever a

chance of droplet spray of blood or other body fluid exists.

– masks are required to be worn in combination with eye protection devices such as

goggles or glasses with solid side shields or chin-length face shields

s Impervious gowns or aprons and shoe coverings must also be worn when any blood or

body fluid splash is anticipated.

s All barriers must be removed and discarded or cleaned thoroughly when contaminated,

between patients and before leaving the work area.

s Hands and other skin surfaces must be washed immediately and thoroughly if

contaminated or whenever gloves are changed.

s All personnel will prevent injuries caused by sharps.

s Do not recap, break or cut contaminated needles.

– dispose of immediately in impervious needle containers. If recapping is necessary, a

recapping device such as forceps or needle block should be used. A one-handed scoop

method may be used if necessary

s Broken glass and used scalpel blades must also be disposed of in needle containers.

– always use forceps or other mechanical device to place or remove scalpel blade on handle

– sharps should be removed from any instruments before being sent to Control Sterilization

– needles and other sharps should not be sent to the lab unless the lab has been contacted

beforehand and notified that they are being sent

AGE 41

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Gloves must be worn and all effort must be made to use mechanical emergency respiratory

devices and pocket masks during a Dr. 6 emergency resuscitative effort.

Spills of blood or body fluids will be cleaned up as soon as possible with a solution of

SuperGuard disinfectant, 1 part household bleach to 10 parts water, or another chemical

germicide that is approved for use as a disinfectant that is tubercolocidal.

s Gloves must be worn to clean up spills.

s Visible material should first be removed and then the area should be disinfected.

All reusable instruments that come in contact with blood, body fluids and mucous

membranes must be sterilized or a high-level disinfectant used on them before they can be

used on another patient.

Any employee who has open, weeping lesions on his/her hands must refrain from direct

hands-on patient care and from handling patient care equipment and/or wastes until the

condition resolves.

Housekeeping personnel will wear gloves when collecting and transporting trash. Trash must

be carried away from the body to prevent contamination.

Heavily soiled linen or trash that is known to be infectious will continue to be red-bagged.

Lab specimens will be transported inside a secondary container that will have a biohazard

sticker applied.

Failure to comply with these guidelines will result in disciplinary action.

AGE 42

U NIVERSAL STANDARD PRECAUTIONS

Policy

Universal precautions are to be used for all patients.

Procedure

Personnel

s Needle shall not be bent, broken or resheathed, but shall be promptly placed into approved

disposal systems.

s Gloves are to be used for all patients when contact with mucous membranes, nonintact

skin or a body substance is anticipated.

s Gowns shall be worn when clothing may be soiled with body fluids, blood secretions

or excretions.

s Hand washing remains the best protection against spreading infection or

becoming infected. Hands should be washed after removing gloves and before leaving

the room. Hands shall be washed thoroughly and immediately if they become contaminated

with blood.

s Goggles are to be worn if there is a potential for splatter.

Environment

s Laboratory specimens shall be placed in an impervious bag for transport to the lab.

Contamination and disinfection: Contaminated reusable items are sent to Central Sterilizing

for resterilization.

s Resuscitation: Pocket ventilation masks will be available for use immediately accessible

in the clinic area.

s Blood or other potentially infectious spills shall be cleaned up promptly with a 1:10 dilution

of bleach or disinfectant.

s Sharps disposal units: full needle containers must be closed and placed in the designated

area to be transported by housekeeping personnel for disposal.

AGE 43

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U NIVERSAL STANDARD PRECAUTIONS

(AIDS/H

EPATITIS B)

Objective

Protection of staff from HTLV III virus (suspected cause of AIDS) and Hepatitis B virus.

Guidelines

s Hand washing remains the best way to stop the spread of ALL communicable disease.

s Patients who have been diagnosed or are suspected of having AIDS or Hepatitis B should

have a red sticker on their chart jacket stating “Body Fluid Precautions.”

– all test requests for these patients should be marked in red pen or pencil at the top of the

form “Body Fluid Precautions”

– personnel handling any body fluids from these patients, especially blood, should wear

gloves while obtaining or handling these specimens

– linen contaminated with body fluids should be double bagged in red bags and marked

“Body Fluid Precautions” so that the laundry staff can handle them in a way that protects

them also

– dressings and other disposable items should be double red bagged and incinerated

immediately

– needles, IV tubing and scalpel blades should be placed in red plastic sharps containers,

sealed, and incinerated immediately. Scalpel handles and other instruments should be

cleaned and autoclaved

s All horizontal surfaces in the exam room in which the patient was seen should be wiped

down using the standard disinfectant in the proper solution. Follow label instructions. If

any body fluid is spilled on the floor, the spill should be wiped up immediately with the

standard disinfectant. Person wiping up spill should wear gloves. Gloves and rags used

should be double red bagged and incinerated. If it is possible, don’t use the room for

the rest of the day if there was a major spill. Mark the room door with a piece of paper,

“Contaminated – Body Fluid Precautions.” This will alert Housekeeping to the need for

special care in cleaning.

s When finished with patient care – WASH YOUR HANDS!!

Addendum

Some of these precautions are probably excessive; however, care must be taken to protect

the care givers.

These patients are like all others in that they are frightened and anxious. They need us – we

can’t ignore them.

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