April 2015

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Table of Contents

ADMISSION AND DISCHARGE .............................................................................................................................. 5

1.1 Eligibility Criteria ........................................................................................................................................... 5 1.1.2 Categories and Request for Exceptions for Persons Twenty-One Years of Age and older – See Acceptance of Adult Patients policy.1 .................................................................................................................. 5

1.2 Admission Privileges/Responsibility for Care ................................................................................................. 5 1.2.1 Admission Privileges ............................................................................................................................. 5 1.2.2 Medical Staff Responsibility .................................................................................................................. 5 1.2.3 Dentists and Oral & Maxillofacial Surgeons ......................................................................................... 5 1.2.4 Assignment of Alternate Practitioners ................................................................................................... 6 1.2.5 Emergency Admissions/Patient Assignment .......................................................................................... 6

1.3 Admission Priorities and Assignment of Beds During High Census ............................................................... 7 1.3.1 Emergency Admissions .......................................................................................................................... 7 1.3.2 Urgent Admissions ................................................................................................................................. 7 1.3.3 Prescheduled Admissions ...................................................................................................................... 7 1.3.4 Routine Admissions ............................................................................................................................... 7

1.5 Areas of Restricted Bed Utilization ................................................................................................................. 7

1.6 Transfer Priorities ........................................................................................................................................... 7

1.7 Discharge Responsibilities .............................................................................................................................. 8

2. GENERAL CONDUCT OF CARE .................................................................................................................. 9

2.1 Informed Consent ............................................................................................................................................ 9 2.1.1 Informed Consent ................................................................................................................................... 9 2.1.2 Assent of the Patient .............................................................................................................................. 9 2.1.3 Emergency Consent ............................................................................................................................... 9

2.2 Patient Assessment - Initial and/or Reassessment ........................................................................................... 9 2.2.1 Assessment ............................................................................................................................................. 9 2.2.2 Reassessment ......................................................................................................................................... 9

2.3 The Plan for Care of the Patient ..................................................................................................................... 9

2.4 Protection of Patients and Others ................................................................................................................. 10 2.4.1 Restraints ............................................................................................................................................. 10 2.4.2 Suicide Precautions .............................................................................................................................. 10

2.5 Orders ........................................................................................................................................................... 10 2.5.1 Written or Electronic Orders ................................................................................................................ 10 2.5.2 Telephone/Verbal Orders ..................................................................................................................... 10 2.5.3 Requirements for Reviewing and Rewriting Orders............................................................................. 11 2.5.4 Protocols, Orders, and Pathways .......................................................................................................... 11

2.6 Drugs and Medications ................................................................................................................................. 11 2.6.1 Medication Reconciliation ................................................................................................................... 11 2.6.2 Formulary ............................................................................................................................................. 11 2.6.3 Ordering Medications .......................................................................................................................... 11 2.6.4 Investigational Drugs ........................................................................................................................... 11

2.7 Consultation .................................................................................................................................................. 11 2.7.1 Requesting Consultation ...................................................................................................................... 11 2.7.2 Timely Response .................................................................................................................................. 12 2.7.3 Mandatory Consultation ....................................................................................................................... 12

2.8 Patient and Family Education14 .................................................................................................................... 12

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2.9 Review of Care .............................................................................................................................................. 12

2.10 Receipt of Patients After Major Disaster/Disaster Exercises ................................................................... 12

2.11 Comfort Care ............................................................................................................................................ 13

2.12 Resuscitation Efforts ................................................................................................................................. 13

2.13 Hospital Deaths ........................................................................................................................................ 13 2.13.2 Deaths Reported to the Coroner ...................................................................................................... 13 2.13.3 Reporting to the Federally-Designated Organ Procurement Organization (OPO) .......................... 13 2.13.4 Autopsies ......................................................................................................................................... 13 2.13.5 Performance of Autopsy .................................................................................................................. 13 2.13.6 Autopsy Findings ............................................................................................................................ 14

2.14 Determination of Brain Death .................................................................................................................. 14 2.14.1 Notification of Parent or Guardian .................................................................................................. 14

2.15 Organ Recovery for Donation Program ................................................................................................... 14

3. HEALTH INFORMATION MANAGEMENT ............................................................................................. 16

3.1 Content .......................................................................................................................................................... 16 3.1.1 History and Physical Examination (H&P) ........................................................................................... 16 3.1.2 Progress Notes ..................................................................................................................................... 16 3.1.3 Operative Reports and Procedure Notes .............................................................................................. 16 3.1.4 Consult Notes ....................................................................................................................................... 17 3.1.5 Discharge Documentation .................................................................................................................... 18 3.1.6 Recording Final Diagnosis ................................................................................................................... 18

3.2 Clinical Entries ............................................................................................................................................. 18

3.3 Symbols and Abbreviations1 .......................................................................................................................... 18

3.4 Release of Medical Information .................................................................................................................... 19 3.4.1 Request for Records ............................................................................................................................. 19 3.4.2 Ownership of Information .................................................................................................................... 19 3.4.3 Removal of Records ............................................................................................................................. 19 3.4.4 Access to Records ................................................................................................................................ 19

3.5 Confidentiality of Patient Information Obtained Via the Hospital Information System ............................... 19

3.6 Medical Record Completion .......................................................................................................................... 19

4. ADDITIONAL RULES AND REGULATIONS APPLICABLE TO SPECIFIC SERVICES ................... 21

4.1 Rules Regarding Surgical and Invasive Procedure Care .............................................................................. 21 4.1.1 General Considerations ........................................................................................................................ 21 4.1.2 Scheduling Operations ......................................................................................................................... 21 4.1.3 Requirements Prior to Anesthesia and Operations ............................................................................... 21 4.1.4 Starting Time of Operations ................................................................................................................. 22 4.1.5 Operations - Dental Patients ................................................................................................................ 22 4.1.6 Time Out Immediately Prior to the Start of Procedure ........................................................................ 23 4.1.7 Responsibility for the Patient in PACU and ASC: ............................................................................... 23 4.1.8 Discharge From the PACU .................................................................................................................. 23 4.1.9 Specimens to be Examined by Pathology ............................................................................................ 23

4.2 Rules Regarding Anesthesia Services ............................................................................................................ 23 4.2.1 General Consideration ......................................................................................................................... 23

4.3 Emergency Service ........................................................................................................................................ 24 4.3.1 Physician Coverage of Emergency Room ............................................................................................ 24 4.3.2 Notification of the Patient's Physician ................................................................................................. 24

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4.3.3 Medical Screening Examinations ......................................................................................................... 24 4.3.4 Emergency Log .................................................................................................................................... 24 4.3.5 Emergency Medical Condition ............................................................................................................ 25 4.3.6 Emergency Department Records .......................................................................................................... 25

4.4 Obstetric Care ............................................................................................................................................... 25

4.5 Outpatient Care Services ............................................................................................................................... 25 4.5.1 Standards for Patient Flow and Space Utilization ................................................................................ 26 4.5.3. Clinic Activities/Privileges .................................................................................................................. 26 4.5.4 Scheduling ........................................................................................................................................... 26 4.5.5 Clinic Charting ..................................................................................................................................... 26 4.5.6 Quality Improvement ........................................................................................................................... 26 4.5.7 Non-invasive Procedures Performed on an Outpatient Basis Outside of OR ....................................... 26

4.6 Special Care Units ........................................................................................................................................ 27

4.7 Psychiatric Service ........................................................................................................................................ 27

5. PERFORMANCE IMPROVEMENT ............................................................................................................ 28

5.1 Participation: ................................................................................................................................................ 28

5.2 Evaluation of Care ........................................................................................................................................ 28

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ADMISSION AND DISCHARGE 1.1 Eligibility Criteria 1.1.1 The hospital is a pediatric facility with staff and employees specifically trained to care for the pediatric patient. Therefore, except as noted below, the hospital shall only accept inpatients, outpatients, and emergency patients who are under twenty-one years of age for care and treatment. The hospital shall not, however, regardless of age, accept a patient found to be pregnant. Individuals with a psychiatric illness will be transferred to an appropriate facility or admitted with supervision, at the discretion of the Chief of Psychiatry or his designee, until transfer arrangements can be made. Any exception to the age criteria will be made by the Chief Medical Officer in concert with the clinical attending physician. Categories of exceptions include the following:

1.1.2 Categories and Request for Exceptions for Persons Twenty-One Years of Age and older – See Acceptance of Adult Patients policy.1 1.2 Admission Privileges/Responsibility for Care 1.2.1 Admission Privileges: A patient may be admitted to the hospital only by a member of the Active medical staff. In admitting patients, practitioners will follow the official admitting policies2 of the hospital.

1.2.2 Medical Staff Responsibility: Although certain duties may be delegated to the house staff by the ACH medical staff member, the member of the medical staff is responsible for the medical care and treatment of each patient in the hospital, for the prompt completion and accuracy of the medical record, for necessary special instructions. Whenever these responsibilities are transferred to another clinical service, an order covering the transfer of clinical service must be entered into the medical record. The chief of each service will provide a schedule of clinical attendings and housestaff.

1.2.3 Dentists and Oral & Maxillofacial Surgeons

1.2.3.1 A dentist with clinical privileges in pediatric dentistry or general dentistry with the concurrence of an appropriate physician member of the medical staff may initiate the procedure for admitting a patient. This concurring medical staff member assumes clinical attending responsibility for the overall aspects of the patient's care throughout the hospital stay, including the medical history and physical examination. Patients admitted to the hospital for dental care must be given the same basic medical appraisal as patients admitted for other services.

Dentists, who have appropriate post-graduate training, may be granted privileges to admit and to perform history and physical examinations.

1.2.3.2 An Oral & Maxillofacial Surgeon may admit patients, perform history

and physical examinations, and perform procedures as outlined within his/her clinical privileges.

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1.2.4 Assignment of Alternate Practitioners

1.2.4.1 Each practitioner must assure timely, adequate professional care for

his/her patients in the hospital by being available or having available an eligible alternate practitioner with whom prior arrangements have been made and who has at least equivalent clinical privileges at the hospital.

1.2.4.2 Each member of the staff who does not reside within 50 miles, unless

otherwise designated by the service, will name a member of the medical staff, who is an attending who resides in the area and who may be called to attend his or her patients in an emergency, or until he or she arrives. In case of failure to name such an associate, the Chief of the Service, Chief of Staff, or Chief Medical Officer will have authority to call any member of the active staff in such an event.

1.2.4.3 If care of a patient is to be transferred, it is the responsibility of the

attending physician to directly transfer care and to assure that care is assumed in accordance with hospital policy3.

1.2.4.4 Termination of the physician-patient relationship may need to occur

under unusual circumstances when there are irreconcilable differences. To assure that there is no unilateral severance of the professional relationship between a health care provider and a patient without reasonable notice at a time when there is still a need for continuing health care (abandonment) the physician will refer to and adhere to hospital policy4, Terminating the Physician Patient Relationship.

1.2.4.5 Any problems/issues regarding the assignment of an alternate

practitioner as the clinical attending should be resolved between the attending physicians whenever possible. If necessary, the Chief of Service, the Chief of Staff, or the Chief Medical Officer will assign coverage of the patient.

1.2.5 Emergency Admissions/Patient Assignment

1.2.5.1 A patient admitted on an emergency basis, who does not have an ACH staff member as a primary admitting physician, will be assigned to the attending physician in the applicable service.

1.2.5.2 If there is a disagreement over assignment of service or unit, the clinical

attendings should communicate with each other and make a decision. If it cannot be resolved, the Chiefs of Service, Chief of Staff, or Chief Medical Officer will make the decision.

1.2.5.3 Except in an emergency, no patient will be admitted to the hospital until

a provisional diagnosis or valid reason for admission has been stated. In an emergency, such a statement shall be recorded as soon as possible.

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1.2.5.4 Admission to the hospital requires a validly executed admission order and plan of care provided either by the attending emergency room physician or accepting unit attending physician. 1.3 Admission Priorities and Assignment of Beds During High Census The admission of patients during periods of limited bed space availability shall be in accordance with hospital policy.5 1.3.1 Emergency Admissions: The clinical attending physician must provide sufficient information to justify the patient being admitted on an emergency basis. 1.3.2 Urgent Admissions: This category includes those so designated by the admitting physician. 1.3.3 Prescheduled Admissions: This includes all patients who have been scheduled for admission. 1.3.4 Routine Admissions: This includes elective, unscheduled admissions involving all services. 1.5 Areas of Restricted Bed Utilization: Areas of restricted bed utilization and preferred assignment of patients shall be defined within Administrative and departmental policies6 approved jointly by administration and medical staff. 1.5.1 Patients with infectious diseases will be assigned rooms and isolated according to hospital policy7. 1.6 Transfer Priorities 1.6.1 Priorities for transfer of patients shall be in accordance with hospital policy8 and as follows:

1.6.1.1 Patients from any location to an intensive care bed. 1.6.1.2 Emergency Department patients, outpatients, and ambulatory surgery

patients for emergency or urgent admission to a patient bed. 1.6.1.3 Patients with transfer orders from an intensive care bed to other locations

in order to free an intensive care bed for emergency admissions. 1.6.1.4 Patients from temporary placement in a non-specialty unit to the

appropriate specialty unit for the patient. 1.6.2 No patient will be transferred without such transfer being ordered by the patient's physician.

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1.7 Discharge Responsibilities: Patients will be discharged only on a documented order of the authorized Licensed Independent Practitioner (LIP) along with completion of the discharge documentation. Should a patient leave the hospital against advice of the practitioner or without proper discharge, the hospital policy9 concerning procedures for patients discharged against medical advice will be followed. The LIP will document in the patient's medical record stating that the patient left the hospital against medical advice.

Section 1 Policy References

Paragraph Policy 11.1.2 Acceptance of Adult Patients 21.2.1 Patient Admissions, Transfers, and Discharges 31.2.4.3 Patient Admissions, Transfers, and Discharges 41.2.4.4 Terminating Physician Patient Relationships 51.3 Patient Admissions, Transfers, and Discharges 61.5 Refer to admissions policies for ITU, Burn,

IMU, CVICU, and Social Work 71.5.1 Isolation Precautions 81.6.1 Patient Admissions, Transfers, and Discharges 91.7 Discharge Against Medical Advice

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2. GENERAL CONDUCT OF CARE 2.1 Informed Consent 2.1.1 Informed Consent: It is authorized practitioner’s responsibility, as defined by policy1, to obtain the informed consent. The medical record shall contain evidence of informed consent being obtained or the reason why it is not obtainable. 2.1.2 Assent of the Patient: Medical staff should collaborate with patients and parents in making decisions regarding care. Patients should participate in decision-making commensurate with their development and should assent to care whenever reasonable. (Refer to the American Academy of Pediatrics Bioethics Committee Policy Statement – Informed Consent, Parental Permission, and Assent in Pediatric Practice) 2.1.3 Emergency Consent: If immediate treatment is required for an emergency (to preserve life or limb or prevent serious impairment of health), and it is impossible to obtain informed consent, the physician must declare medical necessity and may proceed with the required procedures. The physician must document appropriately in the medial record as soon as possible. Refer to hospital policy2, Patient Consent to Treatment. It is not considered an emergency if a delay will not materially increase the hazards, even though it may be clear that the medical treatment in question will be needed. 2.2 Patient Assessment - Initial and/or Reassessment 2.2.1 Assessment: At the time of admission of a patient to an inpatient status, or within the course of patient contact in an outpatient setting (outpatient clinic, ambulatory surgery center, emergency department), the physician must document the assessment of the patient's relevant physical, psychological, and social status and needs will be made. For inpatients, the initial assessment and diagnosis shall be documented in the admission history and physical examination. For all outpatients, the assessment shall be recorded in the appropriate clinic or emergency department record. The nature and extent of this evaluation will be dependent upon the indication for the patient's visit with the physician and may vary among different clinical settings. 2.2.2 Reassessment: A reassessment is performed and documented daily or more frequently to show a patient's response to treatment and when there is a significant change in the patient's condition or diagnosis. In the case of inpatients, the reassessment by the patient's physician or his/her designee should be documented in the medical record. Transfer of patient to a different service, post-operative and prior to discharge, requires a reassessment documented in the patient’s medical record. 2.3 The Plan for Care of the Patient 2.3.1 Care, treatment, and rehabilitation are planned to ensure that they are appropriate to the patient’s needs and severity of disease, condition, impairment, or disability.

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2.3.2 Care is planned and provided in an interdisciplinary, collaborative manner according to hospital policy3. Documentation includes progress notes, departmental reports, interdisciplinary conference notes, and other records. 2.3.3 The attending physician and service should be identified in the orders at the time of admission and anytime there is a transfer of care or services. Any questions regarding the appropriate attending or service assignment is expected to be resolved through attending to attending communication. 2.3.4 Discharge planning should be initiated according to hospital policy, Discharge Planning.4 2.3.5 The attending physician is responsible for appropriate communication with the patient and/or family. 2.3.6 The attending physician (or designee) is responsible for assuring that documentation is complete for communication with the primary care or referring physician. 2.4 Protection of Patients and Others: The admitting physician is responsible for providing such information to the care team as may be necessary to assure the protection of the patient from self harm, and to assure the protection of others whenever his or her patients might be a source of danger from any cause whatsoever. 2.4.1 Restraints: When a patient needs protection to avoid injury to self and/or others, restraints may be used to immobilize or restrict activity. The hospital policy5 for restraints shall be followed. 2.4.2 Suicide Precautions: In the event a patient is judged to be a suicide risk, the medical and nursing staff, and hospital administration will take precautions for the protection of the patient according to hospital policy6. 2.5 Orders 2.5.1 Written or Electronic Orders: All orders for treatment must be entered into the Medical Record. The practitioner's orders and signature must be documented, complete, and dated and timed. For written orders, signatures shall be followed by the appropriate designation, i.e. MD, APRN, etc. Orders deemed illegible or improperly written, will not be carried out until rewritten or clarified by the nurse. 2.5.2 Telephone/Verbal Orders: Verbal and telephone orders will be allowed when there is no other reasonable alternative to obtaining an electronic or written order and in accordance with hospital policy7. Definitions:

Verbal Order: Physician is physically present when order is given Telephone Order: Physician is not physically present when the order is given and only available by phone.

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2.5.3 Requirements for Reviewing and Rewriting Orders: Physician's orders are to be reviewed and rewritten in the following instances:

2.5.3.1 On admission to or discharge from an intermediate or critical care unit. 2.5.3.2 After a major surgical procedure performed in the operating room.

Medication reconciliation is required following major surgical procedures performed in the OR. This is documented by ordering the patient's post-operative medications. Following minor surgeries such as line placements, endoscopic exams or procedures performed under moderate sedation, medication reconciliation is not required and medications need not be reordered. (Refer to definitions Paragraph 3.1.3, Operative Reports and Procedure Notes.)

2.5.3.3 When care is transferred to another service.

2.5.4 Protocols, Orders, and Pathways: Individualized patient order sets, protocols, and pathways will be approved in accordance with hospital policy8. 2.6 Drugs and Medications 2.6.1 Medication Reconciliation: Medication reconciliation will occur upon admission, transfer to different level of care, and discharge in the inpatient or outpatient setting according to hospital policy9, Medication Reconciliation. 2.6.2 Formulary: Drugs and medications administered to patients shall be those listed in the hospital's drug formulary, except in rare cases, according to the Pharmacy & Therapeutics Committee policy on formulary10. The Pharmacy and Therapeutics Committee is responsible for developing and revising the formulary. 2.6.3 Ordering Medications: The metric system is required for dosing. Orders may not contain unapproved abbreviations. Medications should be ordered by their non-proprietary of official names, instead of proprietary or trade classification names.11

2.6.4 Investigational Drugs: Investigational drugs may be ordered by exception and must be approved by the appropriate Institutional Review Board and clearly labeled as an investigational drug.12 2.7 Consultation 2.7.1 Requesting Consultation: Any practitioner with active clinical privileges can be requested for consultation within his or her area of expertise. The attending physician (or designee) is responsible for requesting consultation and for notifying the consultant. The request for consultation will be documented in the physician orders, giving the consultant (and designee) the authorization to evaluate the patient. In emergency situations, an order for consultation will be placed once the emergent situation has been addressed. Reference hospital policy, Inpatient Medical Services Consultation.13

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2.7.2 Timely Response

2.7.2.1 Consultants are expected to provide an immediate response to all calls deemed emergent by the requesting attending physician.

2.7.2.2 Non-emergent clinic-based outpatient consultation should be provided in

a timely manner with a goal of time-to-next-appointment of 2 weeks or less. 2.7.3 Mandatory Consultation: Except when prevented by an emergent situation, consultation of the appropriate clinical or specialty service is required in the following situations:

2.7.3.1 When requested by the patient or his or her family. 2.7.3.2 Attempted suicide by a patient (consultation by Child and Adolescent

Psychiatry). 2.7.3.3 Suspicion of child maltreatment or neglect (consultation by the Team For Children at Risk). 2.7.3.4 When admitted to the PICU (consultation by Pediatric Critical Care). 2.7.3.5 `When admitted to CVICU (consultation by Cardiology Critical Care).

2.8 Patient and Family Education14

2.8.1 Patient and family education will be provided as appropriate to care. This process will be collaborative and interdisciplinary. 2.8.2 Medical staff shall participate, as part of the interdisciplinary team, in assessing, and improving the education of patients and families. 2.9 Review of Care 2.9.1 Any health care provider with concerns regarding the care of a patient, or who believes that additional consultation is required, should bring this concern to the attention of his or her immediate supervisor who is responsible for evaluating and reporting. 2.10 Receipt of Patients After Major Disaster/Disaster Exercises 2.10.1 In the event of an external disaster in this geographic area, Arkansas Children's Hospital will likely be a recipient of affected infants, children and burn victims. Patients will be received in accordance with the Emergency Operations Plan15. 2.10.2 The Medical Staff will participate in disaster preparedness exercises. A written report and evaluation of all such exercises shall be made to the Medical Staff Executive Committee.

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2.11 Comfort Care: When standard curative treatments and therapies are determined to be medically futile, the medical team and staff at Arkansas Children’s Hospital will provide compassionate care (Comfort Care) which includes medical, social and psychological support to patients and families through the end-of-life process. 2.12 Resuscitation Efforts: Decisions to forego any or all resuscitation measures must be clearly documented in the patient’s medical record, conform to the Advanced Directive policy16 and applicable orders delineated in the order form. 2.13 Hospital Deaths 2.13.1 In the event of a patient death in the hospital, including DOA, the deceased will be pronounced dead by the clinical attending physician, or his/her designee. The declaration of death will be consistent with A.C.A. § 20-17-101, Determination of Death17. The body will not be released until an entry has been made in the medical record of the deceased by a member of the Medical Staff, or his designee. Policies with respect to release of bodies will conform to local and state law. 2.13.2 Deaths Reported to the Coroner: ACH will comply with Arkansas law regarding reporting of deaths to the Pulaski County Coroner and in accordance with hospital policy18, Plan for Response to a Patient Death. 2.13.3 Reporting to the Federally-Designated Organ Procurement Organization (OPO): Consistent with hospital policy19, all patients regardless of age or cause of death shall be routinely referred to our federally-designated OPO. In all cases, organ or tissue procurement will be discussed. 2.13.4 Autopsies: It is the duty of all practitioners to secure meaningful autopsies whenever possible. In all deaths, the possibility of autopsy should be discussed with the family. An autopsy may be performed only with consent, signed in accordance with state law and hospital policy20. These discussions shall be documented in the medical record.

2.13.5 Performance of Autopsy

2.13.5.1 Deaths in which an autopsy should be requested include: • A death which was unexpected • A death in which the cause of death is unclear. • A death following significant unexpected changes in the patient's hospital

course. • A death of a patient who had been on an investigational protocol. • A death which followed a poor or unanticipated therapeutic response. • Any intraoperative death or death within 24 hours of an anesthetic. • Any death of a patient receiving patient-controlled analgesia (PCA) or a

continuous epidural infusion of local anesthetics/narcotics, unless the patient is on comfort care status.

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• An unexpected death within 30 days after surgery.

2.13.5.2 Autopsies will be performed by pathologists, who are members of the ACH Medical Staff, or by a house officer delegated this responsibility and supervised by the attending Pathologist. Provisional anatomic diagnoses will be recorded in the medical record within two (2) working days, and the complete report should be made a part of the record within sixty (60) working days.

2.13.5.3 Under certain conditions, deceased patients who expire outside of the hospital may be referred to the ACH morgue for autopsy21.

2.13.5.4 The pathologist performing autopsy will report any unusual or

discrepant findings as part of the quality improvement peer review process. This information will be provided for evaluation by the attending physician and included in the QI Mortality Review process. 2.13.6 Autopsy Findings: It is the responsibility of the patient's attending physician to assure that the family is informed of the autopsy findings. 2.14 Determination of Brain Death: Determination and documentation of brain death will be in accordance with hospital policy, Brain Death Determination and Documentation22. 2.14.1 Notification of Parent or Guardian: Prior to discontinuance of artificial support systems, the parent or guardian of the patient will be notified of the determination of brain death and of the specific tests performed in reaching that determination. Life support systems will be discontinued by the responsible physician. 2.15 Organ Recovery for Donation Program 2.15.1 A quarterly report of organ and tissue donation shall be made to the Intensive Care and Patient Care Oversight Committees.

Section 2 Policy References

Paragraph Policy 12.1.1 Patient Consent to Treatment 22.1.3 Patient Consent to Treatment 32.3.2 Interdisciplinary Coordination of Patient

Care, Facilitation of Communication 42.3.4 Discharge Planning 52.4.1 Restraints/Seclusion 62.4.2 • Guidelines for Evaluating Patients with

Identified Emotional, Psychiatric, or Substance Abuse Problems

• Suicide Precautions

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72.5.2 • Verbal and Telephone Orders • Prescription Refills

82.5.4 Orders, Protocols, and Pathways 92.6.1 Medication Reconciliation 102.6.2 Formulary 112.6.3 Generic and Therapeutic Equivalent Substitution 122.6.4 Investigational Drugs, Investigational Studies 132.7.1 Inpatient Medical Services Consultation 142.8 Patient/Caregiver Education 152.10.1 Emergency Operations Plan 162.12 Advance Directive 172.13 http://www.lexisnexis.com/hottopics/arcode/

Enter 20-17-101 182.13.2 Plan for Response to a Patient Death 192.13.3 Routine Referral of Organ and Tissue Donation 202.13.4 Patient Consent to Treatment 212.13.5.3 Plan for Response to a Patient Death 222.14 Brain Death Determination and Documentation

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3. HEALTH INFORMATION MANAGEMENT 3.1 Content: The clinical attending physician is responsible for preparation of a complete and legible medical record for each patient. The contents must be pertinent and current. This record will include identification data; chief complaints; personal history; family history; history of present illness; physical examination; special reports such as consultations, clinical laboratory and radiology services, and others; provisional diagnosis; medical or surgical treatment; operative report; pathological findings; progress notes; evidence of multidisciplinary patient and family education; final diagnosis; condition on discharge; summary or discharge note; and autopsy report, when performed. Medical record documentation should relate to the clinical status of the patient and plan of care. Documentation or commentary that is derogatory or inflammatory should be avoided. 3.1.1 History and Physical Examination (H&P): Pursuant to The Joint Commission requirements, please see Medical Staff Bylaws, Paragraph 4.2.6 for policies and procedures regarding H&P.

3.1.2 Progress Notes

3.1.2.1 Pertinent progress notes will be recorded in a timely fashion, sufficient to permit continuity of care and transfer.

3.1.2.2 Progress notes shall reflect interdisciplinary planning of care.

Observations pertinent to the chronology of the patient's hospital stay may be recorded in the progress notes section of the medical record by any member of the health care team.

3.1.2.3 Wherever possible, each of the patient's clinical problems should be

clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatments.

3.1.2.4 Progress notes should be recorded daily on all patients and when there is

a change in clinical status or plan of care.

3.1.3 Operative Reports and Procedure Notes Definitions: High-risk procedures: A procedure that may or may not be an invasive procedure but places

the patient at considerable physiological risk and has increased potential for adverse outcomes, to include cardiac caths and invasive diagnostic radiology. Occurrences of adverse events or complications would not be considered unusual.

Moderate-risk procedures: A procedure involving puncture or incision of the skin or insertion of an instrument or foreign material into the body that puts the patient at a lower risk of physiological or adverse outcome. Adverse events or complications would be unusual.

Low-risk procedures: Non-invasive or invasive procedure with minimal risk for physiological or adverse outcomes. Adverse events or complications would be rare.

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3.1.3.1 Operative Reports are required for all procedures performed in the Operating Room and for high risk procedures. A written procedure note documenting the surgery must be entered in the medical record immediately following the procedure. This will provide for continuity of care until the dictated operative report has been transcribed. Final operative reports will be promptly completed and e-signed following surgery by the surgeon and made a part of the patient's current medical record. The following items must be included in the final operative report:

• Name and Medical Record Number of the hospital • Date and times of the surgery • Surgeon’s, practitioner’s, and assistant’s names and a description of the specific

significant surgical tasks that were conducted by practitioners other than the primary surgeon (significant surgical procedures include: opening and closing, harvesting grafts, dissecting tissue, removing tissue, implanting a devise and altering tissues).

• Pre-operative and post-operative diagnosis • Name of the specific surgical procedures performed • Anesthesia administered • Complications, if any • Description of techniques, finds and tissues removed or altered • Any estimated blood loss • Prosthetic devices, grafts, tissues, transplants or devise implants

It is the expectation that the practitioner will dictate the final operative report immediately following the procedure. Notification to the practitioner from Health Information Management (HIM) shall be provided by email directly to the practitioner on the first working day following the procedure. On the second postoperative day, the practitioner and his/her Chief of Service is notified. If the operative report remains uncompleted by the third postoperative day, HIM shall notify the practitioner, the Chair of the Perioperative Services Council, Surgical Services Director, and Surgery Scheduling. The practitioner will be required to complete delinquent operative report(s) before being permitted to schedule elective cases. Failure to complete the Operative Report within 10 working days of the procedure will be reported to the Chief of Staff and the Chief Medical Officer for appropriate action.

3.1.3.2 For moderate and low risk procedures, a brief procedure note shall be promptly entered in the progress notes. The procedure note should include the reason for the procedure (if not evident in earlier progress note), the procedure that was done, any specimens that were removed, and pertinent findings at the time of the procedure. 3.1.4 Consult Notes: Consultations will show evidence of a review of the patient's record by the consultant, pertinent findings on examination of the patient, and the consultant's opinion and recommendations. This report will be made a part of the patient's record. When operative procedures are involved, the consultation note must be recorded prior to the operation except in emergencies.

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3.1.5 Discharge Documentation

3.1.5.1 The final progress note shall include an assessment of the patient and his/her condition at time of discharge.

3.1.5.2 A comprehensive discharge summary will be completed for all patients

hospitalized over 48 hours. A final progress note may be substituted for the discharge summary for patients hospitalized for less than 48 hours provided the note contains the outcome of hospitalization, disposition of the case, and provisions for follow-up care.

3.1.5.3 The content of the discharge summary must be sufficient to justify the

diagnosis and warrant the treatment and result. 3.1.5.4 All parents/families will receive a Discharge Instructions Summary. The

Discharge Instructions Summary may be used in place of a dictated discharge summary for patients who were admitted to observation status. Medications, care at home, follow-up appointments and plans shall be documented on the Discharge Instructions Summary.

3.1.5.5 There must be an order to discharge patients. 3.1.5.6 Discharge Summaries must be signed by the attending physician. 3.1.5.7 Outpatient and emergency department records should indicate the timing

and location of follow-up for reassessment.

3.1.6 Recording Final Diagnosis: The final diagnosis(es) and patient’s condition at discharge must be recorded in full without the use of symbols and abbreviations, dated, and signed by the responsible practitioner at the time of discharge of all patients. 3.2 Clinical Entries 3.2.1 All clinical entries in the patient's medical record will be accurately dated, timed, and authorship established by electronic or written legible signature. 3.2.2 Health Care providers’ signatures within the medical record shall be followed by the appropriate designation. 3.3 Symbols and Abbreviations1 3.3.1 Abbreviations are strongly discouraged in the final diagnosis, on consent forms, or in any information given to patients/families, such as the educational materials or the Discharge Instructions Summary. 3.3.2 Abbreviations for medications are discouraged. Abbreviations that make an order unclear will be clarified with the prescriber as part of routine pharmacist order intervention and clarification. Refer to hospital policy2 for a list of unapproved abbreviations.

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3.4 Release of Medical Information3: Hospital policies, Use and Disclosure of Protected Health Information and Medical Record Requests, will be followed. 3.4.1 Request for Records: Physicians may request medical records in accordance with hospital policy4. 3.4.2 Ownership of Information: Records created by ACH are owned by ACH regardless of the form, e.g. paper records, microfilm, information in a computer database, pictures, graphs, photographs, x-rays, EKG tracings and videotapes in accordance with hospital policy.5

3.4.3 Removal of Records: Unauthorized removal of original medical records from the hospital or unauthorized use of PHI is reason for disciplinary action, as outlined in Medical Staff Bylaws.

3.4.4 Access to Records

3.4.4.1 On submission of an Institutional Review Board (IRB) approved research protocol to the Director of Health Information Management Department, access to pertinent medical records of patients may be afforded to the member of the medical staff for research consistent with preserving confidentiality.

3.4.4.2 Subject to the discretion of the Chief Executive Officer or Chief Medical

Officer, former members of the medical staff may be permitted access to information from the medical records of their patients covering periods of time during which they attended such patients in the hospital. 3.5 Confidentiality of Patient Information Obtained Via the Hospital Information System: Patient-identifiable information obtained through the hospital information system is confidential and subject to all rules and regulations pertaining to permanent medical records. Inappropriate use of confidential patient information including unauthorized access to the hospital information system, may be grounds for disciplinary action in accordance with the Medical Staff Bylaws. 3.6 Medical Record Completion 3.6.1 The patient's medical record should be complete at the time of discharge, including history and physical, operative reports, progress notes, final diagnosis, and a dictated or written clinical summary.

3.6.1.1 A medical record will be declared delinquent by the Health Information Management Department if it remains incomplete thirty (30) days after discharge.

3.6.1.2 Physicians shall complete all available incomplete records when

resigning.

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3.6.1.3 Service Chiefs, attending physicians, residents, Advanced Practice Registered Nurses, Physician Assistants, and community practice physicians will be notified according to HIM policy of all incomplete charts. On the last business day of each month, individual departments will be fined according to hospital policy6. 3.6.2 Policies and procedures for notification of practitioners with incomplete and delinquent records and for actions to be taken for practitioners with delinquent records will be approved by the Medical Staff Executive Committee. Consistent failure to complete medical records may result in penalties up to and including suspension until records have been completed. (Also refer to UAMS Policy of the Graduate Medical Education Committee; Section: Resident Support/Conditions for Employment; Subject: Medical Records, for responsibilities of the resident for completion of medical records in the major participating institutions.) 3.6.3 A medical record must be completed by the responsible practitioner. Under certain circumstances, an incomplete record may be administratively closed by the Chief Medical Officer. No medical staff member is permitted to complete a medical record on a patient unfamiliar to him or her in order to retire a record that was the responsibility of another staff member who is deceased or unavailable permanently or protractedly for other reasons. Definitions Incomplete record: Any chart of a discharged patient not adhering to the standards set forth

within the Rules and Regulations Delinquent record: Any incomplete record not completed as above within thirty (30)

days after discharge.

Section 3 Policy References

Paragraph Policy 13.3 Complete Medical Record 23.3.2 Complete Medical Record 33.4 • Use and Disclosure of Protected Health

Information • Complete Medical Record

43.4.1 Complete Medical Record 53.4.2 Use and Disclosure of Protected Health

Information 63.6.1.3 Delinquent Medical Record Penalty

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4. ADDITIONAL RULES AND REGULATIONS APPLICABLE TO SPECIFIC SERVICES

4.1 Rules Regarding Surgical and Invasive Procedure Care 4.1.1 General Considerations: The surgical operating suite is an area of specialized services integrated in the total care of the patient. In order to function efficiently, a rational schedule must be maintained. The operative schedule will not be manipulated solely for the convenience of those wishing to use the facility. 4.1.2 Scheduling Operations: Operations will be scheduled in accordance with Operating Room policies and procedures and as approved by the Perioperative Services Council.

4.1.3 Requirements Prior to Anesthesia and Operations

4.1.3.1 Identification of Patient: Positive identification of a patient must be done consistent with hospital policies, Patient Identification and Verification of Patient, Procedure, and Operative Site – (Time Out)1.

4.1.3.2 Preoperative Assessment and Documentation: Medical record content -

A history and physical (H&P) including diagnosis and perioperative plan, should be in the patient’s medical record prior to surgery. (Refer to Medical Staff Bylaws, Paragraph 4.2.6.) For emergency cases, a concise, informative note with pertinent information as to the patient's age, physical condition, diagnosis, operative procedure contemplated must be documented in the patient’s medical record specifically stating emergency or urgent nature of proposed procedure.

4.1.3.3 Diagnostic Procedures: Preoperative laboratory and X-ray examinations

should be appropriate to the patient's condition, diagnosis and procedure. Medical information must include two (2) identifiers that can be used to verify that the information belongs to the patient presenting for surgical or diagnostic procedure.

4.1.3.4 Informed Consent Forms: Standard informed consent documents for

surgery and anesthesia must be properly completed, dated, and timed by a practitioner authorized to perform the procedure. Properly executed informed consents are valid for up to thirty (30) days prior to the surgical procedure. Hospital or procedural staff will confirm the consents on the day of the procedure and document confirmation in the patient's medical record. Consent by telephone may be obtained by the physician who converses with the parent(s) or guardian(s). Witnesses for completion of the informed consent permit or witnessing of consents by telephone must be in accordance with hospital policy, Consent of Patient2. (See also Paragraph 2.1.3, Emergency Consent)

4.1.3.4.1 Should a second operation be required during the patient's stay

in the hospital, a second consent specifically worded as to that procedure will be obtained. 4.1.3.4.2 If two or more specific procedures are to be carried out under

the same anesthetic and this is known in advance, all procedures must be described and consent

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obtained. Certain recurring procedures may fall under the hospital Durable Consent as outlined in the Patient Consent for Treatment policy3.

4.1.3.5 Incomplete Preoperative Evaluation or Documentation: Except in emergencies, the preoperative diagnosis of the patient and appropriate laboratory tests must be recorded in the patient's medical record prior to beginning any surgical or invasive procedure or the procedure shall be canceled. In an emergency, the practitioner shall make at least a comprehensive note regarding the patient’s clinical status and the nature of the emergency procedure, anesthesia and start of the operation. When the H&P examination is not recorded before an operation or any potentially hazardous diagnostic procedure, the procedure shall be delayed, unless the primary physician states in writing that such delay would be detrimental to the patient. (Refer to Medical Staff Bylaws, Paragraph 4.2.6.)

4.1.4 Starting Time of Operations: Every effort should be made to adhere to the scheduled start time of operations. Flagrant or habitual violation will be reported to the Surgical Services Executive Committee.

4.1.5 Operations - Dental Patients

4.1.5.1 Dental Patients may be scheduled as an inpatient or through Ambulatory Surgery by Dentists and Oral & Maxillofacial Surgeons. The appropriate Primary Care Physician or subspecialist should be notified, if appropriate, by the Dentist or Oral & Maxillofacial Surgeon that the dental surgery is planned and the date/time of the scheduled procedure.

4.1.5.2 Oral & Maxillofacial Surgeons have admitting privileges and do not

require dual responsibility involving a physician member of the medical staff. The Surgeon is responsible for meeting all medical record requirements.

4.1.5.3 A patient scheduled for dental care by dentists with privileges in

pediatric or general dentistry as either an inpatient or through Ambulatory Surgery is a dual responsibility involving the dentist and a physician member of the medical staff. At the time of admission, both the name of the responsible dentist and physician will be in the admission order.

4.1.5.4 Dentists' Responsibilities

4.1.5.4.1 A complete operative record, describing the findings and

procedure is required. In cases of extraction of teeth, the dentist shall clearly state the number of teeth and fragments removed.

4.1.5.4.2 Progress notes as are pertinent to the oral condition.

4.1.5.5 Admitting Physicians' Responsibilities

4.1.5.5.1 Medical history pertinent to the patient's general health.

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4.1.5.5.2 A physical examination to determine the patient's condition prior to anesthesia and operation. In the dental Ambulatory Surgery Center, the anesthesia H&P serves as the patient’s H&P.

4.1.5.5.3 Supervision of the patient's general health status while

hospitalized. 4.1.6 Time Out Immediately Prior to the Start of Procedure: In accordance with hospital policy, a World Health Organization (WHO) checklist will be performed. Immediately prior to the start of a procedure, the procedural team will perform a time out in accordance with hospital policy, Verification of Patient, Procedure, and Operative Site – (Time Out)4. 4.1.7 Responsibility for the Patient in PACU and ASC: The disposition of the patient is the responsibility of the physician or his/her designee in whose name the procedure is scheduled. Care of the patient in the PACU is a dual responsibility of both the anesthesiologist and surgeon as long as the patient is in the PACU. 4.1.8 Discharge From the PACU: Discharge from the post-anesthetic recovery area will be at the discretion of the anesthesia staff overseeing the PACU or designee. At the time of discharge from the PACU, responsibility for patient care reverts to the physician who performed the diagnostic or operative procedure unless the post procedure orders provide for the transfer of care to a different primary service. 4.1.9 Specimens to be Examined by Pathology: All appropriate specimens will be sent to the pathologist for examination. A list of specimens exempted from examination by pathology and specimens exempted from microscopic examination but requiring gross examination by pathology will be recommended by the Perioperative Services Council and Chief of Pathology and approved by the Medical Staff Executive Committee. (Refer to hospital policy, Specimens Exempt from the Requirement of Pathologic Examination5.) 4.2 Rules Regarding Anesthesia Services 4.2.1 General Consideration: The standards for anesthesia care apply when patients in any setting receive, for any purpose, by any route, the following:

• General anesthesia or other major regional anesthesia, such as spinal or epidural anesthesia (Refer to Anesthesia Department Policies).

Or

• Moderate or deep sedation (with or without analgesia) that, in the manner used, may

be reasonably expected to result in the loss of protective reflexes. (Refer to hospital policy: Use of Sedation or Analgesia During Procedures6.)

4.2.2 If a patient is to receive general anesthesia, other major regional anesthesia, or moderate or deep sedation, a practitioner with privileges to administer anesthesia or sedation shall perform a pre-anesthetic/sedation evaluation prior to the diagnostic or therapeutic

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procedure. For all instances of general anesthesia or moderate or deep sedation, the patient must be reassessed immediately prior to the administration of anesthesia or sedation. 4.2.3 Following anesthesia or deep/moderate sedation, a post anesthesia/sedation evaluation must be completed and documented by an individual with privileges to administer anesthesia or sedation. The post anesthesia/sedation evaluation will be done after the patient has recovered from the effect of the sedation or anesthesia to adequately participate in the evaluation (if age appropriate) and within 48 hours following the diagnostic or therapeutic procedure. 4.3 Emergency Service

4.3.1 Physician Coverage of Emergency Room: A Medical Staff physician will be on duty in the Emergency Department 24 hours per day. Specialty consultation shall respond in a timely fashion. Additional medical staff coverage and initial consultation may be by house officers, APNs, or PAs under the supervision of a member of the medical staff.

4.3.2 Notification of the Patient's Physician: Any member of the Active Medical

Staff may provide care in the Emergency Department. When it is identified that the patient's primary care physician is a private practitioner who is a member of the Medical Staff and desires to be contacted, the practitioner should be notified at the earliest appropriate time that his or her patient has presented to the Emergency Department. If the practitioner chooses not to come to treat his or her patient, a report of the Emergency Department visit will be provided to the practitioner.

4.3.3 Medical Screening Examinations: Determination of whether an individual who

comes to the Emergency Department has an emergency medical condition shall be made by a physician. If an emergency medical condition exists, the hospital will provide within the capabilities of the staff and facilities such further medical treatment or examination as is required to treat the patient. If it is not within the capabilities of the hospital staff and facilities to treat the emergency medical condition of the patient, the patient will be transferred to an appropriate facility in compliance with Emergency Medical Treatment and Active Labor Act of COBRA and hospital policy6.

4.3.3.1 The hospital may designate a Registered Nurse an Advanced Practice

Nurse, or a Paramedic as Qualified Medical Personnel in the ED when the Hospital is functioning under surge conditions or major disasters. In such times, the designated staff may perform emergency medical screenings. The results of such assessments must then be reported to a designated physician who will make the determination as to whether the patient has an emergency medical condition. If such condition is found to exist, the Hospital will provide treatment as described in 4.3.3.

4.3.4 Emergency Log: The name of every patient seeking emergency care will be

recorded on the Emergency Log and a disposition indicated. Following a medical screening examination, patients with no emergency medical condition may be sent to a more appropriate area to receive care.

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4.3.5 Emergency Medical Condition: An Emergency Severity Index level of 1, 2, or 3 is considered an emergency medical condition. Levels 4 and 5 are considered non-emergency medical conditions.

4.3.6 Emergency Department Records

4.3.6.1 Contents of Emergency Department Records: Emergency Department records must contain at least the following information:

a. Patient identification. When not obtainable, the reason must be entered and emergency identification procedures implemented;

b. Time and means of arrival

c. Pertinent history of illness or injury and physical

findings, including vital signs

d. Emergency care given the patient prior to arrival

e. Diagnostic and therapeutic orders

f. Clinical observations, including results of

treatments

g. Reports of procedures, tests, and results

h. Diagnostic impression

i. Conclusion at the termination of

evaluation/treatment, including final disposition, the patient's condition on discharge or transfer, and any instructions given to the patient and/or family for follow-up care.

4.4 Obstetric Care: No obstetric care will be provided in this hospital, except in cases of emergency. Obstetric cases presenting with emergency medical conditions will be handled in accordance with applicable state or federal laws relating to transferring such patients. 4.5 Outpatient Care Services

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4.5.1 Standards for Patient Flow and Space Utilization:

4.5.1.1 In coordination with the respective clinic Chief Medical Officer, the Outpatient Chief Medical Officer, in collaboration with the appointed hospital administrator, shall be responsible for development of appropriate guidelines for each clinic in reference to patient flow and space utilization.

4.5.1.2 Clinic space will be provided based upon availability, patient volume,

and utilization of allocated space. Hospital-based physicians will have priority for scheduling and space. Community physicians may participate in ACH sponsored clinics at the discretion of the chief of service as needs dictate. The clinic Medical Director will work closely with the Outpatient Medical Director and the appointed hospital administrator to provide oversight and organize clinic personnel. 4.5.3. Clinic Activities/Privileges: Activities conducted in the clinics must conform to the ACH mission statement. Physicians and affiliated health professionals practicing in ACH clinics shall have appropriate clinical privileges. ACH outpatient clinics are organized according to categories of care and will include, among others, a general pediatric clinic and subspecialty clinics. Each clinic will have a clinic Chief Medical Officer who is either the chief of the appropriate service or who may be appointed by the chief of service. 4.5.4 Scheduling: The process of scheduling patients for a specific clinic is the responsibility of the medical and administrative directors. Patients scheduled per unit of time may vary from clinic to clinic. The number should be sufficient to maximize the available space and allow for patient flow with minimal waiting time. Though the time allotted per clinic visit per patient will vary, the physician responsible for the patient shall make every effort to efficiently utilize the time. 4.5.5 Clinic Charting: All records of patients seen on an outpatient basis shall be incorporated into the patient’s official hospital medical record. The physician shall document the patient’s chief complaint and medical history, the findings of the physical examination, medication list, evidence of previous laboratory evaluations, an assessment of the diagnosis or medical impression, and a plan for the future. This plan should include identifying appropriate tests or laboratory evaluations to be ordered, therapies to be administered and medications to be administered and specific recommendations to the patient and his or her family. The physician's documentation should contain evidence of communication with the referring physician or health care agencies and pertinent patient education and/or discharge instructions. The documents should be appropriately signed. Dictated letters to referring physicians may serve as the official clinic visit documentation so long as all the basic requirements for documentation are met within the letter. The physician is expected to communicate with the primary care and referring physician in a timely manner. 4.5.6 Quality Improvement: Quality improvement activities related to clinics will be addressed by the Outpatient Care and Patient Care Oversight Committees.

4.5.7 Non-invasive Procedures Performed on an Outpatient Basis Outside of OR

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4.5.7.1 Patients referred for non-invasive procedures (e.g. MRI, CT) are not required to have a medical history and physical examination completed at ACH prior to the procedure.

4.5.7.2 Patients who require moderate and deep sedation shall have an

appropriate documented presedation history and physical examination consistent with the hospital policy8 for use of procedural sedation performed by an Active Licensed Independent Practitioner with appropriate privileges.

4.5.7.3 Time Out Immediately Prior to the Start of Procedure: When applicable

and immediately prior to the start of a procedure, the team will perform a time out according to hospital policy9. 4.6 Special Care Units 4.6.1 Special care units, such as the Intensive Care Units, will have policy and procedure manuals. The Chief Medical Officer of each special care unit will be responsible for policies and procedures for review by the Intensive Care Committee and approval of the Medical Staff Executive Committee. 4.7 Psychiatric Service: The Arkansas Children's Hospital Psychiatry Service consists of the following services: 4.7.1 Consultation for inpatients and patients in the emergency department requiring psychiatric evaluation and triage is provided 24 hours per day, seven days per week. Emergency consults are responded to within 30 minutes and routine consults will be seen within 24 hours. 4.7.2 Comprehensive outpatient evaluation and treatment for children between the ages of 2 and14 is available. Outpatient treatment for adolescents over the age of 14 is provided at the Walker Family Clinic in the UAMS Psychiatric Research Institute. Psychiatry staff at ACH will help facilitate evaluation of patients age 14 years and older.

Section 4 Policy References

Paragraph Policy 14.1.3.1 • Patient Identification

• Verification of Patient, Procedure, and Operative Site – (Time Out)

24.1.3.4 Patient Consent to Treatment 34.1.3.4.2 Patient Consent to Treatment

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44.1.6 Verification of Patient, Procedure, and Operative Site – (Time Out)

54.1.9 Specimens Exempt from the Requirement of Pathologic Examination

64.2.1 Moderate/Deep Procedural Sedation 74.3.3 Emergency Medical Condition and Screening

Transfer 84.5.7.2 Moderate/Deep Procedural Sedation 94.5.7.3 Verification of Patient, Procedure, and

Operative Site – (Time Out)

5. PERFORMANCE IMPROVEMENT 5.1 Participation: 5.1.1 Members of the medical staff and affiliated health staff are required to participate in the hospital’s efforts to improve patient outcomes, assure patient safety, and reduce medical errors. 5.2 Evaluation of Care 5.2.1 Medical care provided by members of the medical staff will be evaluated both through care delivered directly by the staff member and care delivered by housestaff assigned to the member of the medical staff for care of the patient. 5.2.2 Consistent with Medical Staff Bylaws and hospital policy/procedure1, the Chief of Service or Section Chief has a duty to perform effective peer review that includes focused professional practice evaluations (FPPE) and ongoing professional practice evaluations (OPPE) monitoring and review of performance by individual practitioners assigned to the service/section. 5.2.3 Policies and procedures for peer review are recommended by the Risk Management/Peer Review Committee and approved by the Medical Staff Executive Committee.

Section 5 Policy References

Paragraph Policy 15.2.2 Medical Staff Peer Review Policy, including

Focused Professional Practice Evaluation (FPPE) Ongoing Professional Practice Evaluation (OPPE)

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ARKANSAS CHILDREN’S HOSPITAL

MEDICAL STAFF RULES AND REGULATIONS

APPROVED: Arkansas Children's Hospital Medical Staff Executive Committee April 21, 2015 __________________________________________ Richard J. Jackson, M.D. Chief of Staff APPROVED: Arkansas Children's Hospital Medical Staff April 23, 2015 __________________________________________ Richard J. Jackson, M.D. Chief of Staff APPROVED: Arkansas Children's Hospital Board of Directors April 29, 2015 ___________________________________________ Tom Baxter, Chairman

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Amendment to Medical Staff Rules & Regulations

Reason for Change: Requiring the use of the hospital-approved electronic system for progress notes instead of progress notes written on paper Revised as Follows:

3.1.2 Progress Notes

3.1.2.1 Using the hospital-approved electronic system, pertinent progress notes will be recorded in a timely fashion, sufficient to permit continuity of care and transfer.

3.1.2.2 Progress notes shall reflect interdisciplinary planning of care.

Observations pertinent to the chronology of the patient's hospital stay may be recorded in the progress notes section of the medical record by any member of the health care team.

3.1.2.3 Wherever possible, each of the patient's clinical problems should be

clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatments.

3.1.2.4 Progress notes should be recorded daily in the hospital-approved

electronic system on all patients and when there is a change in clinical status or plan of care. Approved by Medical Staff Executive: October 20, 2015 Approved by Medical Staff General: November 19, 2015 Approved by the Board: December 2, 2015 Reason for Change: Requires, at a minimum, an assessment and plan in the clinic record within 72 hours and a final report within 14 days. Revised as Follows: 4.5.5 Clinic Charting: All records of patients seen on an outpatient basis shall be incorporated into the patient’s official hospital medical record. A summary assessment and plan must be documented in the Medical Record within 72 hours of patient being seen. The final documentation, which must be completed within 14 days, must include the patient’s chief complaint and medical history, the findings of the physical examination, medication list, evidence of previous laboratory evaluations, an assessment of the diagnosis or medical impression, and a plan for the future. This plan should include identifying appropriate tests or laboratory evaluations to be ordered, therapies to be administered and medications to be administered and specific recommendations to the patient and his or her family. Additionally, the documentation must include pertinent patient education and/or discharge instructions. The documents should be appropriately signed. The physician's documentation should contain evidence of communication with the primary care and referring physician and/or other health care agencies. Dictated letters to referring physicians

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may serve as the official clinic visit documentation so long as all the basic requirements for documentation are met within the letter. Approved by Medical Staff Executive: September 15, 2015 Approved by Medical Staff General: November 19, 2015 Approved by the Board: December 2, 2015