II. |
Exception to General Rule....................................... 8 |
III. |
Repeated Use of Prohibited Abbreviations.............. 8 |
RULE 3-4 |
CONTENT OF THE HISTORY AND PHYSICAL EXAMINATION............ 8 |
|
A. |
FOCUSED HISTORY AND PHYSICAL EXAMINATION..................... 8 |
|
B. |
HISTORY AND PHYSICAL EXAMINATION......................................... 9 |
|
RULE 3-5 |
PHYSICIAN ORDERS....................................................................................... 13 |
||
A. |
ORDERS.................................................................................................... 13 |
||
1. |
General Rule.................................................................................. 13 |
||
2. |
Illegible Orders.............................................................................. 13 |
||
B. |
VERBAL / TELEPHONE ORDERS.......................................................... 13 |
||
1. |
Authentication Required................................................................ 13 |
||
2. |
When Appropriate.......................................................................... 13 |
||
3. |
Acceptance..................................................................................... 13 |
||
4. |
Protocol.......................................................................................... 13 |
||
5. |
Signing of Order............................................................................ 14 |
||
RULE 3-6 |
CONSENT AND DISCLOSURE........................................................................ 14 |
|
A. |
INFORMED CONSENT REQUIRED...................................................... 14 |
|
B. |
DISCLOSURE OF UNANTICIPATED OUTCOMES |
|
AND MEDICAL ERRORS....................................................................... 14 | ||
RULE 3-7 |
MEDICATIONS.................................................................................................. 14 |
|
A. |
COMPLIANCE WITH CLINICAL AND HOSPITAL POLICIES.......... 14 |
|
B. |
MEDICATIONS OF PATIENTS TRANSFERRED |
|
WHEN THERE IS A CHANGE IN STATUS.......................................... 14 | ||
C. |
BLANKET ORDERS................................................................................ 15 |
|
RULE 3-8 |
PROVIDING CARE, TREATMENT AND SERVICES................................. 15 |
|
A. |
DAILY CARE OF PATIENTS................................................................. 15 |
|
B. |
CONSULTATIONS.................................................................................. 15 |
|
D. |
SEDATION / ANESTHESIA ASSESSMENTS......................................... 17 |
|
1. |
Pre-Anesthesia Assessment........................................................... 17 |
|
2. |
Post-Anesthesia Assessment.......................................................... 18 |
|
3. |
Pre-Sedation Assessment............................................................... 18 |
|
E. |
OPERATIVE CARE OF PATIENTS........................................................ 18 |
|
1. |
Immediate Progress Note after Surgery......................................... 18 |
|
2. |
Post-Operative Report.................................................................... 19 |
|
F. |
TRANSFER OF CARE............................................................................. 19 |
|
G. |
TERMINATION OF PHYSICIAN-PATIENT RELATIONSHIP............ 19 |
|