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 |