RULES AND REGULATIONS

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MEMORIAL HOSPITAL –

UNIVERSITY OF COLORADO HEALTH

MEDICAL, DENTAL AND PODIATRIC STAFF BYLAWS, POLICIES, AND

RULES AND REGULATIONS

RULES AND REGULATIONS

Updated March 23, 2011

This update reflects all revisions to the Rules and Regulations beginning with the initial revision of previously existing Rules and Regulations approved by the Medical Executive Committee on April 16, 2002 and approved by the Board of

Trustees on April 25, 2002, through and including revisions approved by the Medical Executive Committee on March 15, 2011 and approved by

the Board of Trustees on March 23, 2011.

Chair, Board of Trustees Date: March 23, 2011

Chief of Staff

Date: March 15, 2011

Amended MEC 5/2015 Approved Board 6/2015

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RULES AND REGULATIONS OF THE

MEDICAL, DENTAL AND PODIATRIC STAFF OF MEMORIAL HOSPITAL

CONTENTS PAGE

ARTICLE I: DEFINITIONS I-1

ARTICLE II: GENERAL HOSPITAL RULES ll- 1

SECTION 1. Admission and Discharge of Patients II-1

SECTION 2. Medical Records II-3

SECTION 3. Prescription of Treatment II-6

SECTION 4. The Laboratory II-6

SECTION 5. Consultations II-7

SECTION 6. Emergency Department Services II-7

SECTION 7. Supervising Practitioners (Proctors) II-8

SECTION 8. Informed Consent II-9

SECTION 9 Interns and Residents II-9

ARTICLE III: DELINEATION OF PRIVILEGES lll- 1

SECTION 1. Preamble III-1

SECTION 2. Core Privileges and Supplemental Privileges III-1

ARTICLE IV: DEPARTMENT OF HOSPITAL CARE lV-1 AND COMMUNITY CARE RULES

SECTION 1. Surgical Sections IV-1

SECTION 2. Section of Obstetrics and Gynecology IV-2

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RULES AND REGULATIONS OF THE

MEDICAL, DENTAL AND PODIATRIC STAFF OF MEMORIAL HOSPITAL

ARTICLE I: DEFINITIONS

DEFINITIONS: For the purposes of these Rules and Regulations, unless stated otherwise, the following definitions will apply:

1.1 BOARD means the Board of Directors of the Hospital or its designated committee.

1.2 CHIEF EXECUTIVE OFFICER means the individual appointed by the Board to act on its behalf in the overall administrative management of the Hospital, and his designees.

1.3 CHIEF MEDICAL OFFICER means the individual appointed by the Chief Executive Officer, in cooperation with the Board, to act as the chief medical officer of the Hospital, in cooperation with the Chief of Staff.

1.4 CHIEF OF STAFF means the Chief of Staff of the Medical Staff and his designees.

1.5 CLINICAL PRIVILEGES or PRIVILEGES means the authorization granted by the Board to render specific patient care services.

1.6 CREDENTIALS MANUAL means the Hospital's Medical Staff Policy on Appointment, Reappointment, and Clinical Privileges.

1.7 DENTIST means a doctor of dental surgery (D.D.S.) or doctor of dental medicine (D.M.D.).

1.8 EX OFFICIO means service as an appointee of a body by virtue of an office or position held and, unless otherwise expressly provided, means without voting rights.

1.9 HOSPITAL means Memorial Hospital – UCH unless specifically stated otherwise. As used in these Bylaws and related documents, Memorial Hospital-UCH includes Memorial Hospital Central, Memorial Hospital North, and all outpatient clinics, urgent and after hours clinics, and subspecialty clinics.

1.10 JOINT CONFERENCE COMMITTEE includes one or more officers of the MEC and Board and a representative of Hospital Administration.

1.11 MEDICAL EXECUTIVE COMMITTEE (MEC) means the Executive Committee of the Medical Staff.

1.12 MEDICAL STAFF means all physicians, dentists and podiatrists who have been appointed to the Medical Staff by the Board.

1.13 MEDICAL STAFF LEADER means any Medical Staff officer, department chair, and/or committee chair.

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1.14 MEMBER means any physician, dentist, or podiatrist who has been granted Medical Staff appointment and clinical privileges by the Board to practice at the Hospital.

1.15 ORAL SURGEON means a licensed dentist with advanced training qualifying him for board certification by the American Board of Oral and Maxillofacial Surgery. The term

"dentist," as used in these Bylaws and related documents, includes oral surgeons.

1.16 PATIENT CONTACTS means the admission and/or primary responsibility for a patient admitted as an inpatient or outpatient to the Hospital, or the performance of a diagnostic service or clinical procedure on a patient admitted to the Hospital at the request of the practitioner who admitted or has primary responsibility for the patient. Consultation for the purpose of evaluating or providing an opinion on the patient's condition where a patient visit is conducted and/or a report is generated by the consulting practitioner and included in the medical record, shall also constitute a patient contact.

1.17 PHYSICIAN includes both doctors of medicine (M.D.s) and doctors of osteopathy (D.O.s).

1.18 PODIATRIST means a doctor of podiatric medicine (D.P.M.).

1.19 QUALIFIED MEDICAL PROVIDER is defined as a physician, physician assistant, certified nurse midwife, nurse practitioner and forensic nurse examiner (in caring for a patient with interpersonal violence i.e. sexual assault or abuse.

1.20 SPECIAL NOTICE means hand delivery, certified mail (return receipt requested), or overnight delivery service providing receipt.

Words used in these Rules and Regulations shall be read as the masculine or feminine gender, and as the singular or plural, as the content requires. The captions or headings are for

convenience only and are not intended to limit or define the scope or effect of any provision of this document.

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ARTICLE II: GENERAL HOSPITAL RULES

SECTION 1. Admission and Discharge of Patients

A. Patients may be treated at Memorial Hospital only by those licensed independent practitioners who have been granted appropriate clinical privileges to manage and coordinate the patient’s care, treatment and services. A patient’s general medical or psychiatric condition is managed and coordinated by a doctor of medicine or osteopathy.

Medicare patients are under the care of a (1) doctor of medicine or osteopathy, (2) doctor of dental surgery or dental medicine and (3) a doctor of podiatric medicine.

Medicare patients admitted by a Certified Nurse Midwive, who have been granted admitting privileges, must be under the care of a doctor of medicine or osteopathy.

B. No patient shall be admitted to the Hospital until a provisional diagnosis has been stated by the Attending Staff Member.

C. At all times the Attending Staff Member shall be responsible for giving

information in his or her possession necessary to assure the protection of the patient, Hospital personnel, and other patients. If a patient needs

Transmission-Based Precautions, this will be accomplished in accordance with the Hospital's Isolation Policy (CITATION).

D. The Hospital shall admit patients suffering from all types of disease, except when the primary diagnosis is one of mental illness of such a degree that the Hospital is not able to provide adequate protection for the patient and others.

Memorial Hospital does not provide psychiatric or substance abuse services. In the event of a psychiatric emergency, however, the Hospital does provide

contract arrangements for consultative or transfer services to an appropriate psychiatric facility. Should a physician have a patient with a psychiatric emergency or mental health management issue, he or she may contact supervisory staff from the Medical Social Work Department, the Emergency Department, or from any patient care unit for assistance in obtaining a

consultation or transfer. In all cases, medical stabilization will take place prior to any transfer to a psychiatric facility.

E. Any patient requiring more than routine nursing care must provide for special duty nurses, except when the patient is placed in a special care unit.

F. Any person presenting himself for treatment who has no attending physician will be assigned to the Staff Member on the appropriate Emergency Room Call List.

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G. Routine admission x-rays will not be performed unless instructions for same are included in an individual practitioner's standing orders for his/her patients.

H. Patients shall be seen by a physician, nurse practitioner or physician assistant, at least once in every twenty-four (24) hour period. In addition, inpatients must be seen and a note written on the calendar day of discharge by either a physician, nurse practitioner or physician assistant.

I. Patients shall be discharged only upon an order of the Attending Staff Member or the Staff Member on call for the Attending Staff Member. At the time of

discharge the Attending Staff Member or the Staff Member on call for the

Attending Staff Member will enter a final diagnosis on the medical record. When any patient insists upon leaving the Hospital without an order from the Attending Staff Member or the Staff Member on call for the Attending Staff Member, the Hospital shall make a reasonable effort to obtain a signed release from the patient. Should the patient refuse to sign a release, the nurse in charge shall so indicate on the chart.

J. Usual discharge hours are from 8:30 a.m. to 11:30 a.m. Every effort will be made by Attending Staff Members to discharge patients during these hours.

K. When a patient dies in the Hospital, the nurse in charge shall notify the Attending Staff Member, who shall examine the patient and make the appropriate

pronouncement. In the event the Attending Staff Member is not available, assessment of cessation of life and pronouncement of death shall be made in accordance with hospital policy.

L. When a patient dies in the Hospital, it shall be the responsibility of the Attending Staff Member or designee to notify the next of kin.

M. No autopsy shall be performed without written consent of the legally authorized relative or agent, as specified by the Colorado Revised Statutes. All autopsies shall be performed by the Hospital pathologist, or by a practitioner to whom he or she may delegate the duty, and a complete written report of the findings shall be included in the patient's medical record.

N. If for any reason an attending physician or on-call physician is not available, cannot be contacted, or refuses to respond, when a patient may be in need of care, practitioners in the following order of availability shall be contacted: the designated Section representative, chair of the appropriate department, the Chief of Staff, or the Chief of Staff Elect; provided, however, that in the case of a

patient in a Hospital department or unit which has a medical director, the first practitioner to be contacted shall be the medical director or designee. The responsibility of the available representative is to review the case in order to determine what, if any, care is needed. If care is needed, the available

representative is authorized to either arrange for or to provide appropriate care.

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The attending physician or on-call physician may be subject to formal action in accordance with Article 6 of the Credentials Manual for failure to respond without good cause.

O. Discussions with family members regarding organ donation will be conducted in accordance with the Hospital policy.

SECTION 2. Medical Records

A. The Memorial Hospital medical record of each patient is the property of the Hospital. Such medical records shall not be removed from the Hospital's

jurisdiction and safekeeping except in accordance with a court order, subpoena or statute. Patients may request copies of their medical records in accordance with the Patients’ Rights and Responsibilities.

B. In the case of readmission of a patient, previous records shall be available for the use of the Attending Staff Member.

C. The Attending Staff Member shall be held responsible for the preparation of a complete medical record of each patient within ten (10) days of discharge.

D. The Attending Staff Member shall record in the medical record, as soon after admission as possible, the provisional diagnosis and an initial progress note stating the cause of hospitalization and the clinical findings.

E. A medical history and physical examination must be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

The medical history and physical examination must be completed and documented by a physician, oral maxillofacial surgeon, podiatrist, or other qualified licensed individual in accordance with State Law and hospital policy.

An updated examination of the patient, including any changes in the patient’s condition, must be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. The updated examination of the patient,

including any changes in the patient’s condition, must be completed and documented by a physician, an oral maxillofacial surgeon, or other qualified licensed individuals in accordance with State Law and hospital policy.

When Medical Students, Interns and/or Resident physicians and/or other dependent practitioners are involved in patient care, entries made by such individuals in the medical records that are the responsibility of the Attending Medical Staff Member, as described in this Section, shall be countersigned by the Attending Medical Staff Member.

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When a Physician Assistant is providing services to hospitalized patients, the licensed supervising physician shall review the quality of medical services rendered every two working days by reviewing and signing the medical records to assure compliance with the physicians’ directions. Inpatient history and physical exam reports and discharge summaries documented by a Physician Assistant must also be reviewed and co-signed by the attending physician. The Physician Assistant’s performance of a delegated medical function shall comply with the board’s regulations and any restrictions and protocols of the licensed supervising physician and hospitals.

1. Inpatient histories and physicals and discharge summaries performed by a certified advance practice nurse (NP) must be co-signed by an attending physician. For histories and physicals completed by an advanced practice nurse prior to an inpatient admission, the attending physician must complete an interval H&P note at the time of admission.

2. When more than one member of the medical staff is treating the patient, the attending provider is responsible for coordination of care and designation of responsibility.

F. Nurse midwives may: (1) admit patients as provided by state law; (2) perform and record the history and physical examination; and (3) practice normal obstetrics and gynecology in a manner consistent with their delineated hospital privileges in accordance with his/her collaborative practice agreement, and all applicable policies and procedures of the hospital.

G. If the history and physical is performed prior to admission, it must be updated to accurately reflect the presence or absence of any changes in the interval

between the initial document and the time of admission by the operating surgeon.

The H&P may be completed by the patients’ primary licensed independent practitioner or another physician in the operating surgeon’s practice in accordance with state law and hospital policy.

1. A durable, legible copy of the office or clinical prenatal record may be used on obstetrical records for the history and physical in addition to an H&P interval note which must be completed upon admission, and include a Physical Examination/Assessment.

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H. Prior to surgical cases, it shall be the responsibility of the operating surgeon to record evidence of adequate preoperative study, including the admission history and physical examination, or, when he or she is not the Admitting Staff Member, a surgical consultation. He or she shall also record the preoperative and

postoperative diagnosis, orders, and progress notes immediately after surgery.

1. Obstetrical cases: A complete physical examination will be recorded in the medical record prior to any major surgical procedures (e.g., Cesarean sections or postpartum tubal ligations). A history and physical performed within thirty (30) days of the procedure is acceptable only if it is updated on the day of the procedure.

2. Outpatient procedures: Outpatient surgical procedures performed under general anesthesia will have a complete documented history and physical examination on the medical record prior to surgery. A history and physical performed within thirty (30) days of the procedure is acceptable only if it is updated on the day of the procedure. Those performed with conscious sedation and/or local anesthesia require a limited history and physical relevant to the procedure being performed.

I. Except in emergencies, a complete history and physical examination must be written or dictated and on the medical record before surgery. Failure to do this will be cause for postponing surgery, unless the surgeon states in writing that any delay would be detrimental to the patient. The following is an excerpt from the History and Physical policy. A history and physical shall be completed as soon as possible after emergency surgery.

1. At a minimum, the history and physical (H&P) will contain the following ele ments.

A. For minor invasive procedures with local, regional anesthesia or sedation (i.e., local incision, insertion of IV lines, epidurals, cardiology, invasive radiology, endoscopy, and special procedures):

1) History/details of present illness 2) Level of consciousness

3) Cardiac assessment 4) Respiratory assessment 5) Current medications 6) Allergies

B. For invasive outpatient procedures with general, regional, or spina l anesthesia:

1) History/details of present illness 2) Past history: medical and surgical 3) Allergies

4) Current medications

5) Relevant social/family history 6) Physical examination

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7) Conclusions or impressions 8) Treatment plan

C. For non‐invasive outpatient diagnostic studies requiring general a nesthesia, i.e. MRI, CT,

2. Audiology tests and EEGs, a complete pre‐anesthesia evaluation shall serve as the H&P.

3. For inpatients and all other patients not referred to above:

1) Chief complaint/reason for admission 2) History/details of present illness

3) Past history: medical and surgical (except newborn) 4) Relevant social/family history

5) Review of systems 6) Physical examination 7) Current medications 8) Allergies (except newborn) 9) Relevant psychosocial needs 10) Conclusions or impressions 11) Treatment plan

J. All operations performed shall be fully described by the operating surgeon in a brief post-op note, which must be completed immediately upon conclusion of the procedure before responsibility for the patient’s care is transferred to the next provider and level of care. A complete, formal operative record shall be

completed within 24 hours of discharge/visit/procedure. No standard numbered operative reports will be accepted.

K. All post-operative records shall contain a post-anesthesia evaluation. An individual who is qualified to administer anesthesia is permitted to conduct the post-anesthesia evaluation.

L. A podiatrist or an oral surgeon who admits a patient without medical problems may complete an admission history and a physical examination and assess the medical risks of the procedure to the patient if qualified to do so. The privilege of performing an admission history and physical examination by a podiatrist or an oral surgeon will be limited to those podiatrists or oral surgeons whose

qualifications have been reviewed by the Credentials Committee of the Medical Staff, and who have been found to be currently competent to conduct a complete history and physical examination. Performance and dictation of a history and physical exam by a Category ll, AHP must be validated and counter signed by the AHPs collaborative or supervising physician.

M. The use of unapproved symbols and abbreviations in the medical record is not permitted. A list of prohibited symbols and abbreviations can be found on the facility’s intranet.

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N. A Discharge Summary recapitulating the reason for hospitalization, the significant findings, the procedures performed the care treatment and services rendered, the condition of the patient, at discharge, documentation of information provided to patient and family, and provision for follow-up, will be included in the medical record.

1. In the event of death, a Discharge/Death Summary indicating the reason for admission, the findings and course in the hospital, and the events leading to death will be included in the medical record.

2. When a patient is transferred to a different level of care within the hospital and the licensed independent practitioner changes, a transfer summary, (outlining the reason for hospitalization and transfer, the significant findings, procedures performed, the care, treatment, services and condition of the patient at transfer) may be substituted for the discharge summary. If the licensed independent practitioner does not change, a progress note may be used.

SECTION 3. Prescription of Treatment

A. All orders for treatment (including drugs to be self-administered by the patient) shall be signed, dated and timed by the Attending Staff Member and shall specify drug name, dosage, frequency, and route of administration. The following

categories of staff are authorized to take verbal and/or telephone orders:

1. Registered Nurse

2. Licensed Practical Nurse 3. Registered Dietitian 4. Respiratory Therapist

5. Physical Therapist, Occupational Therapist, Speech Therapist 6. Registered Pharmacist

7. Certified Imaging Staff 8. Medical Social Workers

B. Licensed Practical Nurses are permitted to take orders only within their scope of practice. Registered Dietitians, Respiratory Therapists, Physical Therapists, Occupational Therapists, Speech Therapists, Registered Pharmacists and Medical Social Workers are permitted to take orders applicable only to their departments. Certified Imaging Staff will take verbal orders for diagnostic, therapeutic and interventional imaging studies only. Verbal and/or telephone orders shall be signed by the employee to whom dictated, with the name of the prescribing Staff Member, per the employee's name. All verbal and/or telephone orders shall be signed, dated and timed by a physician within forty-eight (48) hours. If a physician authenticates the verbal order of another physician, the authenticating physician assumes responsibility for the order being complete, accurate and final.

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SECTION 4. The Laboratory

A. Patients admitted to the Hospital for surgical procedures shall have certain routine laboratory examinations at the discretion of the admitting physician.

Patients presenting for outpatient surgery shall have laboratory work performed at the discretion of the surgeon or anesthesiologist. Laboratory work at outside CLIA-certified laboratories, within thirty (30) days of scheduled surgery shall be recognized as complying with this regulation with the exception of pregnancy testing for women of child-bearing age, which must be done within two (2) days of surgery.

B. Tissues and foreign substances removed at operation shall be sent to the Hospital Pathology Department for such examinations as may be needed to arrive at a pathological diagnosis. The following shall be exceptions to the requirement for pathology review: metallic orthopedic devices, pacemakers and batteries, toe nails, certain foreign bodies, well-healed scars, plastic ear tubes and similar artificial materials, arthritic bone removed during routine joint

arthroplasty, foreskins below age twelve (12), ribs removed to enhance operative exposure, and other specimens as identified in the Laboratory’s Exemption from Examination policy. A written report of the pathologist's findings shall be included in the patient's medical record.

C. Prenatal screening of obstetrical patients shall conform to current standards recommended by the American College of Obstetricians/ Gynecologists (ACOG).

All women admitted for delivery, abortion (spontaneous or therapeutic), or any obstetrical event that might allow fetal cells to enter a mother’s circulation shall have their ABO/Rh type tested. (Hospital Blood Bank records may be checked to ascertain the woman’s Rh type.) If a woman is Rh negative, the need for Rh immune globulin injection is assessed. Appropriate testing is performed as required by the American Association of Blood Banks (AABB) and College of American Pathologists (CAP), including atypical red cell antibody screen and fetal maternal hemorrhage studies.

D. Genetic screening of all newborn infants shall conform to State Law.

E. Annually, the Hospital Medical Executive Committee reviews and approves laboratory policies addressing the approved reference laboratories used by the Hospital, criteria for autopsy, submission of surgical tissues for pathology review, approved STAT tests, and definitions of critical values used in the Laboratory for calling results.

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SECTION 5. Consultations

A. A satisfactory consultation includes examination of the patient and review of the medical record by a member of the Medical Staff with privileges in the

appropriate department. A written opinion signed by the consultant must be included in the medical record. When operative procedures are involved, the consultation note, except in emergency, shall be recorded prior to operation.

B. Consultation shall be required in all procedures for the sole purpose of

sterilization for medical reasons. If sterilization is elective and requested by the patient, and the practitioner agrees, consultation is not necessary.

C. Consultation shall be required in all cases in which the diagnosis is obscure or where a patient fails to respond to treatment within a reasonable period of time.

D. Judgment as to the serious nature of the illness and the question of doubt as to diagnosis and treatment rests with the Attending Staff Member, who shall be responsible for requesting consultation when indicated.

E. The attending Medical Staff Member is personally responsible for requesting a consultation from another physician. All requests for consultation must be made directly physician-to-physician. Writing an order for a consultation in the medical chart may not be done solely to request a consultation; nurses or the unit

secretary may assist the physician in obtaining the consultation. The medical staff member seeking the consultation will provide the consultant with the following information either verbally or in writing: 1) When or how urgently the patient needs to be seen, 2) What specific problems / questions are to be addressed, 3) How the requesting physician may best be reached if the consultant has additional questions, concerns or comments.

SECTION 6. Emergency Department Services

A. All patients who present to the Emergency Department will be seen as soon as possible by a qualified medical provider for an appropriate medical screening examination to determine if the patient has an emergency medical condition. A qualified medical provider is defined as a physician, physician assistant, certified nurse midwife, nurse practitioner and forensic nurse examiner (in caring for a patient with interpersonal violence i.e. sexual assault or abuse. If the patient is unstable, emergency care will begin immediately.

B. If the patient is stable, the patient (and/or family) will be asked for the name of their private practitioner. This practitioner, or his/her designee, will be notified according to his/her prior requests on file at the Emergency Department. If the private practitioner has requested to be contacted, but cannot be located, after fifteen (15) minutes the emergency physician may initiate treatment as indicated.

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Calls will continue to the private practitioner until he/she is informed of the patient's visit to the Emergency Department.

C. Patients presenting for treatment who do not have a personal practitioner shall be referred to the on-call staff physician.

D. Referral for follow-up, admission, or consultation for unassigned patients will be made to the on-call physician for the appropriate specialty.

E. The on-call physician assumes responsibility for the admission and/or follow-up care for the particular problem for which the patient presents himself at the

Emergency Department. If important diagnostic data becomes available after the patient has left the Hospital, the Emergency Department shall be responsible for calling both the patient and the practitioner in order that proper follow-up can be made and these calls shall be documented on the patient's chart. If the patient does not contact the on-call staff physician within seven (7) days following the referral, the on-call staff physician shall have no further responsibility for the admission and/or follow-up care for the particular problem for which the patient presents himself to the Emergency Department.

F. In the event that a problem cannot be completely managed by the emergency physician, the responsible private practitioner or on-call physician will be notified.

G. The on-call physician is obliged to cover the posted schedule or make

arrangements for another practitioner to cover for him/her. The day will run from 7:00 a.m. to 7:00 a.m. A phone response time of fifteen (15) minutes to calls received from the Emergency Department is expected. The physician, podiatrist, allied health practitioner (Category l (NP, CNM), Category ll (NP, CNM, PA)) should respond within the timeframe discussed with the Emergency Department physician requesting the consultation.

H. The emergency physician will not assume any inpatient responsibilities except in a dire emergency, when requested to do so by the Nursing Unit or the attending physician.

SECTION 7. Supervising Practitioners (Proctors)

Initial clinical privileges, whether granted at the time of initial appointment, reappointment or during the term of an appointment, shall be provisional in

accordance with Section 3.B of the Credentials Manual, and the Executive Committee may determine to appoint a supervising practitioner. If a supervising practitioner has been appointed, it is the responsibility of the practitioner being supervised to notify his/her supervising practitioner of admissions and scheduled surgery in order that the supervising practitioner may observe the practitioner's practice as deemed necessary.

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SECTION 8. Informed Consent

A. Documentation of Informed Consent should be made by the practitioner at the time it is obtained. This may or may not appear in the hospital record; however, a notation shall be included in the medical record that said consent was obtained.

B. It is the responsibility of the attending staff member performing a procedure or treatment to obtain Informed Consent prior to the procedure or treatment. The Informed Consent should include all information that a reasonable person would need to be told, under the circumstances, in order to make a decision.

SECTION 9. Interns and Residents

A. Interns and Residents, as defined in these Bylaws and Manuals are participants registered in a professional graduate education program when the graduate practitioner will be a licensed independent practitioner. All roles and

responsibilities normally assigned to a Graduate Medical Education Committee are assigned to the Medical Staff’s Credentials Committee. Interns and

Residents will be governed in accordance with the following rules:

1. Interns and Residents shall be individually assigned to an appropriate clinical department/service by the Credentials Committee and shall always be under the direct supervision of a member of the Medical Staff, as

assigned by the Credentials Committee, who has been granted clinical privileges at the hospital.

2. Interns and Residents shall make application to the Medical Staff Credentials Committee. The decision of the Credentials Committee to recommend that the application be accepted shall be based on the documented training, experience, and demonstrated current competence of the applicant. When assignment to a medical rotation is made, areas of practice shall be specific and limited to those in which the applicant has training and contingent upon the direct supervision of a member of the Medical Staff as assigned by the Credentials Committee. Approval to complete a rotation at the Hospital shall only be granted to these individuals when the training, experience, and demonstrated current competence of the applicant is sufficient to perform the following:

(a) The exercising of judgment within his/her areas of competence, providing that a physician member of the Medical Staff shall have the ultimate responsibility for patient care;

(b) Participating in the care of patients under the direct supervision of a member of the Medical Staff; and

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(c) Within the limits established by the Medical Staff and consistent with the State Practice Acts, the recording of reports and progress notes in patients' medical records.

3. This Section shall not be construed to require that the Credentials

Committee recommend or the Board of Trustees approve any application that has been made.

4. The rotation granted by the Board of Trustees upon recommendation of the Credentials Committee may be terminated at any time by any one of the following: Chief of Staff, the Chair of a Clinical Department, the Chief Executive Officer and the Executive Committee of either the Medical Staff or the Board of Trustees; and no recourse will be allowed the

Intern/Resident whose rotation has been terminated.

5. Interns and residents shall have their performance continually reviewed by their supervising member of the Medical Staff, and any adverse

experience or incident shall be immediately reported to the Chairman of the Credentials Committee or his designee (ordinarily the Chief of Staff or Chief Medical Officer). Written evaluations from the supervising member of the Medical Staff to the individual internship or residency program should also be sent in copy format to the Medical Staff Services Office.

6. The qualifications of interns and residents shall be consistent with, and conform to, all Federal and State licensing and certification requirements.

Provisions in these Bylaws and Rules and Regulations of the Medical and Dental Staff of Memorial Hospital shall in no way compromise the specific requirements and acts allowed as set forth by the Colorado Board of Medical Examiners. All decisions by the Medical Staff Credentials

Committee to not accept an application shall be final, and no recourse will be allowed the intern or resident whose application is not accepted.

7. All interns and residents seeking a rotation at Memorial Hospital must provide:

(a) Proof of current, valid professional liability insurance coverage in a form and in amounts satisfactory to the Hospital;

(b) Proof of participation in an accredited internship or residency program;

(c) A letter from their training program director indicating the intern or resident to be in good standing and that the director supports the request for a rotation at the Hospital;

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(d) Letters from responsible practitioners with whom the intern or resident will be working during the course of the rotation period verifying the practitioner's willingness to accept responsibility for supervising the intern or resident while on service;

(e) In addition to any other requirements, all Residents seeking a medical rotation at Memorial Hospital must provide proof of current Colorado State license, and Drug Enforcement Agency (DEA) number.

8. Interns and residents will not be members of the Medical Staff. They may attend department meetings, continuing medical education conferences, and Medical Staff meetings, but will not be permitted to hold membership on any Medical Staff committee and shall have no vote.

9. Interns and residents may only engage in clinical duties that are within the scope of practice specifically defined and approved for them by the Board of Trustees upon the recommendations of the Medical Staff Credentials Committee. Such clinical duties as more fully described in the medical staff policy on Scope of Activity for Interns, and Scope of Activity for Residents, may consist of, but are not limited to the following:

(a) The evaluation of patients within their area of expertise and the treatment and rendering of therapy to patients which are confined to the specialty in which the individual has the necessary training, experience, and current competence, all under the direct

supervision of the responsible practitioner;

(b) Interns and residents may write orders and progress notes only if such orders and progress notes are countersigned by the

supervising practitioner within twenty-four (24) hours;

(c) At the discretion of the operating surgeon, interns and residents may assist in surgery or special procedures involving patients they are caring for;

(d) Interns and residents may admit patients under the name of the responsible practitioner.

10. Such clinical duties may be exercised by interns and residents under the direct supervision of an assigned member of the Medical Staff, but shall be limited to those requested in writing by the responsible practitioner who must be a member of the Medical Staff with clinical privileges to practice at the Hospital.

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11. Interns and residents shall be responsible for communicating all pertinent information to the responsible practitioner and other Hospital personnel as appropriate, and for providing the appropriate documentation in the

medical record of the patient for whom service, consultation, and/or therapy has been provided.

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ARTICLE III: DELINEATION OF PRIVILEGES

SECTION 1. Preamble

A. Any Medical Staff member may apply to the appropriate clinical department for advancement or extension of his or her privileges upon documentation of training and/or experience in this other specialty field. These privileges may be granted in accordance with the delineation of privileges of that respective specialty department.

B. Any practitioner who upon completion of further training applies to another clinical specialty department for privileges in that specialty area and to whom such privileges are denied, may then request a review by the specialty

department to which they are assigned and subsequent appeal through the Executive Committee. Further appeal provisions are provided for in ARTICLE 7 of the Credentials Manual.

C. No portion of this Section of these Rules and Regulations shall be construed to permit, solely on the basis of provisions contained therein, reduction of privileges held by any member at the time this Section becomes effective.

SECTION 2. Core Privileges and Supplemental Privileges

Each section of the Medical Staff shall delineate core privileges and supplemental privileges. Such privileges shall be incorporated herein by reference.

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ARTICLE IV: DEPARTMENT OF HOSPITAL CARE AND COMMUNITY CARE RULES

SECTION 1. Surgical Sections (Maxillofacial Surgery, OB/GYN, Ophthalmology, Otolaryngology, Plastic Surgery, Pediatric Surgery, Anesthesiology, Cardiac Surgery, General Surgery, Hand Surgery, Orthopedic Surgery, Podiatric Surgery, Neurosurgery, Trauma, Urology, and Vascular Surgery)

A. Surgeons on staff at Memorial Hospital shall take into consideration the following factors when determining whether or not to request surgical assistance:

1. The degree to which the operation is complex and technically demanding, so that joint efforts of the principal surgeon and one or more assistant physicians contribute meaningfully to the successful treatment of the patient.

2. The expected effect of the use of an assistant on mortality and morbidity, including that related to blood loss and duration of the operation.

3. The situations when neither of the preceding factors applies and when the patient's history indicates that there is a substantial risk of complications arising in the course of the operation that would require the services of an assistant at surgery to avoid increasing the risk of mortality or morbidity.

B. Only Doctors of Medicine, Osteopathy, Dentistry or Podiatry and authorized Hospital personnel will be routinely permitted in the Operating Room during surgery. Other persons may be permitted in the Operating Room during surgery provided permission has been granted by the attending physician, the attending anesthesiologist, Hospital Administration and the patient.

C. The surgeon and anesthesiologist shall be in the Operating Room at the time scheduled. If they have not appeared or notified the Operating Room supervisor within fifteen (15) minutes of the time scheduled, the supervisor will be justified in postponing this case until the end of the day's schedule.

D. The anesthesiologist shall familiarize himself with pertinent aspects of the medical history and the condition of the patient prior to surgery.

E. Elective surgery may be performed on patients who have a written, signed, witnessed consent on the chart if they are of legal age. Elective surgery on a person not of legal age, or who is otherwise legally incompetent, may be performed only on written consent of the legal representative of that person, witnessed by Hospital personnel.

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F. If emergency surgery is necessary on a person not of legal age, or on a person of legal age who is unable to give written consent, and no person is available who legally can give consent for the patient; and if, in the opinion of the Attending Staff Member, delay would increase the hazard to the life of the patient, the Attending Staff Member shall so state in writing on the medical record and proceed with the operation.

G. Infections developing post-operatively shall be reported to the Infection Control Committee.

H. It is strongly recommended that consultation be obtained in all cases in this department in the following situations:

1. Those cases listed as critically ill. Terminal cases are not included in this category.

2. All problems involving poor risk patients, doubt as to diagnosis, or doubt as to the choice or timing of the therapeutic procedures.

3. All instances of major post-operative complications.

4. All patients for whom radiotherapy is proposed.

5. Where the proper treatment is controversial.

I. Photography may be performed by authorized Hospital personnel in the Operating Room at the discretion of the attending physician for medical indications, provided the patient's consent has been obtained.

J. Recognizing that surgery is a dynamic specialty with ever-broadening horizons in the development of newer procedures and modification of current operative procedures, it is understood and expected that surgeons will perform new

procedures within the parameters of their specialty provided they have additional training in the new procedures.

K. With approval of the Chair of the Credentials Committee and notification of the Executive Committee, individual preceptor programs may be established using guidelines set forth by the New Procedure Policy of the Department of Surgery.

This will enable members of the combined Medical Staff to acquire training for specified operative procedures.

SECTION 2. Section of Obstetrics and Gynecology

A. Pregnant patients at twenty (20) weeks gestational age or greater requesting an examination or treatment of a medical condition relating to pregnancy will

undergo an OB medical screening examination in the Birth Center. The medical

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screening examination will be performed by a physician or qualified medical person. A qualified medical person is an obstetrical RN with a minimum of two thousand (2,000) hours intrapartum experience with demonstrated competency in performing an OB medical screening examination.

B. The Section of Obstetrics and Gynecology shall establish such policies as necessary to regulate the use of uterine stimulants. Oxytoxic drugs shall be administered to undelivered patients only upon order of the Attending Staff Member. Oxytoxic drugs may be given in the absence of the Attending Staff Member, but may be regulated or discontinued at the discretion of the Charge Nurse at any time. The Attending Staff Member must be readily available during administration of oxytoxic drugs.

C. Patients admitted for delivery or abortion in this Hospital must have a report of Rh determination, performed by an accredited laboratory, at the time of delivery or blood drawn for Rh determination at time of admission, and an original

serology report on the chart before the third post-partum day.

D. For Cesarean sections, a practitioner qualified in resuscitation of the newborn will be notified, and he/she or his/her qualified designee shall be present. The

pediatrician electing to utilize a designee to attend C-sections does so with the understanding that he/she will retain the responsibility for the infant and that the use of a designee does not transfer liability for the infant to the obstetrician.

E. Only Doctors of Medicine or Osteopathy, certified nurse midwives, authorized Hospital personnel, and the father and/or coach, with the explicit permission of the attending physician, shall be allowed in the delivery room (operating room) at any time. These restrictions do not apply to the birthing room.

F. Except in emergency, general anesthesia may be administered only by an anesthesiologist.

G. Photography may be performed in the delivery room (operating room) or the birthing room at the discretion of the attending physician provided the proper consents have been obtained in accordance with III.RR.A.

Amended MEC 5/2012 Approved Board 5/2012 Amended MEC 11/2013 Approved Board 12/2013 Amended MEC 7/2014 Approved Board 8/2014 Amended MEC 4/2015 Approved Board 4/2015 Amended MEC 5/2015 Approved Board 6/2015

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