is not specifically in the clinical privileges or scope of practice of a dentist, oral surgeon or podiatrist.
1. Provisional diagnosis required: Members must record a provisional diagnosis for the patient at the time of admission. In an emergency, the Member may admit the patient and record the provisional diagnosis as soon as possible thereafter.
2. Members shall provide relevant and appropriate information to Hospital Staff as may be necessary to enable the Hospital to protect the patient from self-harm and to protect other patients, staff, and visitors from possible sources of danger.
3. Members shall report all cases of reportable diseases in accordance with applicable laws and Hospital policies.
C. Admission of Patients:
1. A patient’ s attending physician shall be responsible for executing all physician responsibilities as to the admission and discharge of patients as expressed in the Hospital’ s Policies and Procedures governing admitting and discharging of patients from the Hospital.
2. The admitting order must specify the appropriate status of the patient( e. g., Inpatient status or observation status).
3. Changes in patient admission type / status after the patient is admitted require a new order. Such changes shall comply with applicable state and federal laws and CMS conditions of participation.
RULE 3-3 A.
B.
Medical Records
Definition. Medical records are the physical property of the Hospital. A medical record consists of medical information in the custody of the Hospital Health Information Management( HIM, or Medical Records) Department that is specific to the patient and pertinent to the patient’ s care and treatment. The information contained in the medical record, and any other patient-specific information, shall be treated in accordance with all applicable legal and ethical rules related to the confidentiality of patient medical information.
Access. Original medical records may only be removed from the Hospital in accordance with federal or state laws, court orders or subpoenas. Medical Staff Members, Hospital staff and others may access patient medical records only if they are involved in the care of the patient, or are engaged in peer review, risk management, Medical Staff credentialing, approved research, educational pursuits,
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