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 ,
4879-7702-4986 , v . 1 5