RULES AND REGULATIONS OF THE MEDICAL STAFF OF

Section 1.1 Only those Members authorized in accordance with the Bylaws of the Medical Staff may admit patients to the Hospital.

Section 1.2 Only those Members authorized in accordance with the Bylaws of the Medical Staff or the Hospital’s Policies and Procedures may admit patients to any Special Unit.

Section 1.3 The patient’s Attending Physician shall execute, or cause to be executed, all physician responsibilities as to the admission and discharge of patients as expressed in the Hospital’s Policies and Procedures governing admission and discharge of patients from the Hospital or its Special Units.

Section 1.4 At the time of the patient’s admission to the Hospital or any Special Unit, or as soon as possible thereafter, the patient’s Attending Physician, or a member of the House Staff, under the Attending Physician’s supervision, shall record, either an Admitting Note or a History and Physical Examination in the patient’s Medical Record. If an Admitting Note is recorded, the patient’s Attending Physician, or a member of the House Staff, Advanced Registered Nurse Practitioner* or Physician Assistant, under the Attending Physician’s supervision, shall, within twenty-four hours after the patient’s admission, record an appropriate History and Physician Examination in the patient’s Medical Record. Said History and Physical Examination shall be countersigned by the supervising physician at the time of the next visit or prior to discharge, whichever comes first. *Advanced Registered Nurse Practitioner and Physician Assistant must be approved as Allied Health Staff.

Section 1.5 Oral and maxillofacial surgeons who have successfully completed a postgraduate program in oral and maxillofacial surgery accredited by a nationally recognized accrediting body may perform the medical history and physical examination in order to assess the medical, surgical and anesthetic risks of the proposed operative and other procedure(s). Dentists are responsible for the part of their patients’ history and physical examination that relates to dentistry.

Section 1.6 For all patients who have been hospitalized in the Hospital for a period of more than forty-eight hours, the patient’s Attending Physician or House Staff shall either write or dictate a Discharge Summary within forty-eight hours following the patient’s discharge. The patient’s Attending Physician shall sign or countersign the patient’s Discharge Summary.

Section 2.2 Consultations.

2.2.1 Required Consultations:

The following diagnoses/conditions, if not treated by the appropriate specialist, require a consultation by a physician who is credentialed in that field (“Consultant”):

a) All patients who are suicidal require a psychiatric consultation.

b) All patients evaluated for trauma require a trauma consultation as outlined in the Trauma Protocol.

c) All patients 17 years and younger who are on service other than Pediatrics or Family Medicine are required to have an initial consultation with General Pediatrics, a Pediatric subspecialty service, Psychiatry or Family Medicine and follow-up as needed.

d) All patients 18 years of age or older on the Pediatric Service are required to have an initial consultation with General Medicine, an appropriate subspecialty, Family Medicine or another service with adult privileges pertinent to the patient’s diagnosis and follow-up as needed is required.

2.2.2 Ordering Consultations:

When ordering a consultation, the referring Member:

a) Must designate the consultation as either routine or emergent;

b) If emergent, the referring Member should directly contact the Consultant personally if possible;

c) Must designate the consultation as: (i) opinion only; (ii) opinion with order-writing privileges; or (iii) request for transfer to Consultant;

d) Must request a consultation as soon as indicated during a patient visit, and except in unusual circumstances, at least one day prior to discharge.

2.2.3 When Consulted:

When consulted, the Consultant must:

a) Fulfill the consultation request as soon as possible for emergent consultations;

b) Fulfill the consultation request within 24 hours for routine consultations;

c) Conduct an appropriate history and physical examination;

d) Complete the consultation form; and

e) Communicate at the Medical Staff level with the referring Member.

2.2.4 A Consultant who agrees to assume any portion of a patient’s care or treatment shall be responsible for that portion of the patient’s care or treatment until the Consultant informs the Attending Physician that the Consultant is returning such responsibility to the Attending Physician and records a written notation of such in the patient’s Medical Record.

Section 2.3 Patient Encounters. Each Attending Physician and each Consultant who has assumed any portion of a patient’s care or treatment, or another Member covering for them in their absence, shall personally assess their patients at least once per day while admitted to the Hospital or Special Unit. At the time of each such assessment, or as soon as possible thereafter, the Attending Physician or Consultant shall record a Progress Note in the patient’s Medical Record.

Section 2.4 Informed Consent. No care or treatment shall be rendered to any patient in the Hospital, its Special Units, or its Emergency Department without a written consent signed by the patient. In those situations in which the patient’s life is in jeopardy and suitable signatures cannot be obtained, the Member proposing to render care or treatment to the patient shall follow the Hospital’s Policies and Procedures and the Hospital’s Ethics Handbook in either proceeding with treatment or obtaining consent from the appropriate surrogate decisionmaker or in obtaining administrative consent before proceeding with treatment. Written consents obtained more than thirty (30) days prior to the initiation of care or treatment will not be valid.

Section 2.5 Treatment Orders. Except as otherwise specifically provided herein, including Physician Assistants (PAs), and Advanced Registered Nurse Practitioners (ARNPs) pursuant to medically approved protocol, all orders for treatment shall be in writing, dated and timed, and signed by the issuing practitioner and should include the issuing practitioner’s pager number. Orders written by other than a Member or duly licensed member of the House Staff must be cosigned by supervising Member.

Section 2.6 Verbal Orders.

2.6.1 Verbal and telephone orders may be issued by a Member, duly licensed member of the House Staff, or duly licensed practitioner legally authorized to issue orders.

2.6.2 Verbal and telephone orders shall relate only to the immediate needs of the patient.

2.6.3 Verbal and telephone orders shall be issued only if the circumstances are such that an immediate order is required and it would be impractical for the prescriber issuing the order to do so in writing.

2.6.4 Verbal and telephone orders shall be issued by a Member, duly licensed member of the House Staff, or duly licensed practitioner legally authorized to issue orders on a limited basis to licensed nursing service personnel (RNs and LPNs) and registered pharmacists. Verbal orders for respiratory therapy may be given to Respiratory Therapists.

2.6.5 All verbal or telephone orders will be authenticated, dated and timed by the prescribing physician or covering Member within 72 hours of its issuance.

Section 2.7 Do Not Resuscitate Orders

2.7.1 It is the responsibility of the Member to initiate Do Not Resuscitate Orders to comply with the Hospital’s Policy on Advance Directives and Patient Rights.

2.7.2 If a conflict arises with a DNR order, the issue may be directed to the Hospital Ethics Committee.

Section 2.8 Drugs and Medications.

2.8.1 Except as otherwise specifically provided herein, all drugs and medications administered to patients shall be those listed in the latest edition of United States Pharmacopoeia, National Formulary, American Hospital Formulary Services, A.M.A. Drug Evaluations, or the University of Kansas Hospital Formulary.

2.8.2 An order for medication must comply with the Hospital’s Policies and Procedures which govern the content of, and nomenclature and abbreviations permitted in, medication orders, both generally and for specific types of medications.

2.8.3 Hospital supply shall be used for medications administered to patients. Patients may use their own supply only under the following limited circumstances: (a) the medication is not on the Hospital Formulary and a reasonable therapeutic substitution is not available; (b) the Member, pharmacist and patient determine there is a medically necessary reason for the patient to use a personal supply to meet an individual patient need (and this is documented in the chart); or (c) the medication is an investigational medication provided under protocol as part of the patient’s participation in an investigational study. In all of the foregoing circumstances, the medication must be contained in an original prescription container that allows Hospital staff to verify the content.

2.8.4 If a Member intends that a patient be permitted to use personal medications they bring into the Hospital or Special Unit, that Member shall write a complete order for that specific medication. Such order shall comply with Section 2.5 and contain the statement that the “patient may use their own supply” or another statement substantially similar thereto.

2.8.5 A Member may order an investigational drug only if the Member is listed as a principal investigator or co-investigator on a research study approved by the Human Subjects Committee of the University of Kansas Medical Center and provides evidence of such to the Department of Pharmacy. Members of the Medical Staff who order an investigational drug shall cause the basic pharmacological information about the drug to be provided to members of the nursing staff prior to any such member of the nursing staff’s administration of the drug to the patient.

Section 2.9 Restraints and Seclusion

2.9.1 General Standards for all Restraints and Seclusion

2.9.1.1 A Member, or duly licensed member of the House Staff, may order a physical restraint (or a drug to be used as a restraint) or seclusion for a patient only when appropriate alternatives have failed and the restraint or seclusion is necessary to protect the safety of the patient or others. Any physical restraint (or drug used as a restraint) employed shall be the least restrictive restraint necessary to achieve the desired level of restraint.

2.9.1.2 Chemical restraint is any medication used to restrict the patient’s freedom of movement which is not standard treatment for the patient’s medical or psychiatric condition. The Member, or duly licensed member of the House Staff will order any specific nursing assessments depending on the chosen medication.

2.9.1.3 All physical restraint and seclusion orders shall include the time limit for the restraint and/or seclusion. No PRN orders shall be written.

2.9.1.4 Different standards for restraint and seclusion care exist for Behavioral restraints in Psychiatry; Behavioral restraints in non-psychiatric areas and Medical-Surgical restraints. See the following sections for those specific standards.

2.9.1.5 Seclusion is only used in the psychiatric areas of the Hospital.

2.9.2 Behavioral Restraints in Psychiatry:

2.9.2.1 Any Member or duly licensed member of the House Staff who orders a physical restraint or seclusion for any patient hospitalized on a Psychiatry unit, shall ensure that the patient is examined and evaluated by a Member or a duly licensed member of the House Staff within one hour of the patient’s placement in restraints or seclusion, regardless of the length of time the patient is in restraint or seclusion. If the Member who orders the restraint or seclusion is not the patient’s Attending Physician, the Member shall notify the patient’s Attending Physician of the restraint or seclusion as soon as possible.

2.9.2.2 No Member or duly licensed member of the House Staff shall order a physical restraint or seclusion, for a Psychiatry patient, to exceed 3 hours for adults or 1 hour for children and adolescents under 18 years of age.

2.9.2.3 After expiration of the time limit a new order may be issued only after the Member or duly licensed member of the House Staff reevaluates the patient.

2.9.2.4 Monitoring of the Psychiatry patients, cared for with physical restraint or seclusion, occurs via constant observation of the patient.

2.9.3 Behavioral Restraints in Non-Psychiatric Areas

2.9.3.1 Patients hospitalized on a Medical-Surgical or Rehabilitation unit, who demonstrate aggressive or violent behavior will be examined and evaluated by a Member or a duly licensed member of the House Staff within one hour of the patient’s placement in restraints, regardless of the length of time the patient is in restraint. If the Member who orders the restraint is not the patient’s Attending Physician, the Member shall notify the patient’s Attending Physician of the restraint as soon as possible.

2.9.3.2 No member or duly licensed Member of the House Staff shall order a physical restraint for an aggressive or violent Medical-Surgical or Rehabilitation patient, to exceed 3 hours for adults and 1 hour for children and adolescents under 18 years of age.

2.9.3.3 After expiration of the time limit a new order may be issued through a verbal or written order.

2.9.3.4 Monitoring of the patient shall be ensured and occurs by: observation by a qualified person at least every hour; assessment of the patient at least every two hours for adequacy of restraint, presence of any potential injury, adequacy of circulation, desire to eat, drink, or use the toilet; and release and range of motion at least every four hours.

2.9.4 Medical-Surgical Restraints

2.9.4.1 Patients hospitalized on a Medical-Surgical or Rehabilitation unit, whose behavior (non-violent) creates safety concerns, may require physical restraint.

2.9.4.2 If a restraint is initiated by a registered nurse in an emergency situation, an order must be obtained within 2 hours.

2.9.4.3 Members or duly licensed members of the House Staff may renew orders up to a maximum time limit of 24 hours.

2.9.4.4 Monitoring and care shall be ensured and occurs by: observation by a qualified person at least every hour; assessment of the patient at least every two hours for adequacy of restraint, presence of any potential injury, adequacy of circulation, desire to eat, drink, or use the toilet; and release and range of motion at least every four hours.

Section 2.10 Constant Observation.

2.10.1 A Member, or a duly licensed member of the House Staff, may order constant observation for any patient when the patient is actively suicidal, actively homicidal, or when the patient is psychotic, confused, or cognitively impaired with seriously agitated or combative behavior.

2.10.2 Orders for constant observation shall state the dates and times to initiate and discontinue the constant observation.

2.10.3 Any Member or duly licensed member of the House Staff who orders constant observation for a patient must document the reason for the order in the patient’s medical record and reassess the patient and the need for constant observation at least once every 24 hours.

2.10.4 Any Member of the Medical Staff or duly licensed member of the House Staff who believes that a patient requires constant observation for more than 48 hours shall obtain a consultation from a Member in the Department of Psychiatry.

Section 2.11 Diagnostic Procedures. When ordering diagnostic procedures, including but not limited to radiology, lab/pathology, EKG, GI/Endoscopy, echocardiography, and EEG, Members shall include in the written requisition form the appropriate ICD9 code, other appropriate information about the patient’s diagnosis, or the sign or symptom providing the indication for the diagnostic procedure.

Section 2.12 Quality Improvement. Each Member shall cooperate in the Hospital’s quality improvement activities, including responding to reasonable inquiries by any quality improvement or peer review committee of either the Hospital or the Medical Staff regarding the Member’s care and treatment of any patient.

2.13.1 Each Member who agrees to supervise the care rendered by an Allied Health Professional within the Hospital must oversee and direct the work of the Allied Health Professional, accept responsibility for all patient care services provided by the Allied Health Professional, and possess Clinical Privileges which permit the Member to perform the same patient care services performed by the Allied Health Professional.

2.13.3 No Member shall supervise the care rendered by an Allied Health Professional within the Hospital unless the Allied Health Professional has been and remains duly credentialed and approved by the Hospital to perform the patient care services they seek to perform.

2.14.1 Medical Staff Members assigned to the Active Category are required to attend 50% of the General Medical Staff meetings per year.

Section 3.3 Post-Surgical Documentation.

3.3.1 Any Member who performs surgery or a procedure on any patient shall prepare or dictate an Operative Report or Procedure Note immediately following such surgery or procedure, whether the surgery or procedure was performed on an inpatient or outpatient basis. When the Operative Report or Procedure Note is not placed in the record immediately after the surgery or procedure, the Member who performed the surgery or procedure shall record a Progress Note in the patient’s Medical Record immediately following the surgery or procedure.

3.3.2 The anesthesiologist or qualified anesthetist who managed the patient’s anesthesia during surgery shall record a complete written anesthesia record and a written record of post-anesthesia follow-up in the patient’s Medical Record.

3.3.3. Notwithstanding the requirement of Section 3.3.1, the writing or dictation of Operative Reports, Procedure Notes, Progress Notes, and anesthesia records required by this Section may be delegated to a member of the House Staff only if they were physically present during the surgery or procedure.

EMERGENCY

Section 3.4 Emergency Department Call Eligibility.

3.4.1 Members of the Active and Provisional Staffs shall be required to accept Department call on a rotating basis with other Members of the Active and Provisional Staffs in their Clinical Department on a schedule determined by the applicable Clinical Department Chair in accordance with the Bylaws.

3.4.2 In general, Members of the Courtesy and Volunteer Staffs shall not be required to accept Department call, but may accept such call if requested by the applicable Clinical Department Chair, or the Chief of Staff, or as a substitute for another Member who is unavailable for Emergency Department call as scheduled. Notwithstanding the foregoing, Members of the Courtesy and Volunteer Staffs may be required to perform assigned on-call duties and assignments if deemed necessary by the applicable Clinical Department Chair of the department in which the Courtesy or Volunteer Staff Member is assigned.

Section 3.5 The Emergency Department Physician on duty shall supervise all patient care in the Emergency Department delivered by members of the House Staff not supervised in person by another Member.

Section 3.6 The Emergency Department Physician on duty shall care for all Emergency Department patients. Transfer of care of a patient in the Emergency Department to another Member of the Medical Staff requires a written order and acceptance by that Member. A trauma patient with an Attending-to-Attending Physician handoff does not require a written order and acceptance by the Attending Physician trauma surgeon.

Section 3.7 Members shall comply with the requirements of any plan for the care of mass casualties at the time developed by the Authority in the event of any major disaster. All Members shall participate in rehearsals of any such plan for the care of mass casualties as requested by the Authority.

Section 3.8 Each Member is responsible for ascertaining the dates they are to be available on-call for the Emergency Department pursuant to a call list provided in advance to the Emergency Department by their Clinical Department Chair in accordance with the Bylaws and/or the Hospital’s Policies and Procedures.

Section 3.9 In the event a Member will be unavailable to be on call for the Emergency Department on any date such call duties have been assigned to them, such Member shall arrange for another Member to substitute for them during the period of their unavailability and shall notify the Emergency Department, Page Operator, and On Call House Staff Team, of the change in the assigned schedule.

Section 3.10 Any Member on call for the Emergency Department, or a member of the House Staff under the Member’s direct supervision, shall be present in the Emergency Department within thirty (30) minutes of being summoned by the Emergency Department, or sooner as dictated by the nature of the patient’s emergent medical condition.

Section 3.11 Any Member, or any member of the House Staff under the Member’s direct supervision, responding to a summons by the Emergency Department in accordance with this Section shall examine, treat, and stabilize the patient for whom they have been summoned.

Section 3.12 Any Member who examines and/or treats a patient in the Emergency Department shall record, or cause a member of the House Staff under the Member’s direct supervision to record, a written note in the patient’s Emergency Department chart describing the examination and treatment provided to the patient in the Emergency Department and the results thereof.

3.12.1 If the patient is released from the Emergency Department in stable condition, the note shall specifically so state.

3.12.2 If the patient is admitted from the Emergency Department to the Hospital or any Special Unit, the Admitting Note and History and Physical Examination may be used in lieu of a note in the patient’s Emergency Department chart.

Section 3.13 A Member may transfer an unstabilized patient in the Emergency Department to another facility only if:

3.13.1 The Member determines that, based upon the information available at the time of the proposed transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the individual and, in the case of a laboring patient, to the unborn child, from effecting the transfer; and

3.13.2 The Member, or another qualified person, on the Member’s behalf, informs the patient, or other responsible party, of the Hospital’s obligations and the risks of transfer and the patient requests such a transfer in writing.

Section 3.14 Any Member electing to transfer an unstabilized patient in the Emergency Department to another medical facility shall complete and sign a “transfer statement” in a form approved by the Authority.

Section 3.15 In the event of a disagreement between the Emergency Department Physician and the Member(s) summoned to consult on the patient whether a patient has an emergency medical condition and/or should be admitted to the Hospital or any Special Unit, the Member(s) and the Emergency Department Physician shall attempt to resolve the disagreement among themselves. If the disagreement cannot be resolved, the Member(s) and the Emergency Department Physician shall immediately contact the Chief of the Medical Staff or his designee, who shall resolve the dispute.

Section 4.1 General.

4.1.1 All Medical Records, and any copies or other reproductions thereof (unless provided directly to the patient), are the property of the Hospital and shall not be removed from the Hospital Premises for any reason (including research studies or other academic purposes) except as specifically authorized by an appropriate representative of the Authority.

4.1.2 All Medical Records, the information contained therein, 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 and shall be released only in accordance with the Hospital’s Policies and Procedures governing medical records.

4.1.3 Unless otherwise stated in these Rules and Regulations, the content, form, nomenclature, permitted abbreviations, and timeliness requirements of all portions of and entries in the patient’s Medical Record shall be as stated in the Hospital’s Policies and Procedures governing medical records.

4.1.4 Standardized symbols and abbreviations may be used when they have been through the approval process. Those approved are listed in the Hospital Formulary.

4.1.5 All Members shall record their entries in a patient’s Medical Record legibly.

4.1.6 The patient’s Attending Physician shall be responsible for the timely preparation and completion of the patient’s Medical Record. Following discharge of the patient, the Medical Record will be completed within 30 days.

4.1.7 Any Consultant who is consulted as to any patient shall be responsible for the timely preparation and addition to the patient’s Medical Record of a Consultation Report and any other notes, orders and other written entries describing the Consultant’s examination and impressions of the patient, any diagnosis made by the Consultant, any recommended testing and/or course of treatment for the patient, and any testing and/or treatment of the patient undertaken directly by the Consultant.

4.1.8 When recording a History and Physical Examination, Consultation Report, or Progress Note in a patient’s medical record, a Member may reference elements of properly recorded House Staff or medical student histories and physical examinations only if the Member was present for the portion of the history, physical examination, or other patient encounter the Member proposes to reference or has personally verified the information recorded by the member of the House Staff or medical student.

4.1.9 All clinical entries in the patient’s Medical Record shall be accurately dated and authenticated by the individual making the entry, The use of rubber stamp or electronic signatures is acceptable under the following conditions:

a. The physician whose signature the rubber stamp or electronic signature represents is the only one who has the stamp or electronic signature authorization and is the only one who will use it.

b. The physician has placed in the Medical Record Department of the Hospital a signed statement to the effect that he/she is the only one who has the stamp or electronic signature authorization and is the only one who will use it.

4.1.10 Unless otherwise stated in these Rules and Regulations, all Medical Record entries required of any Member may be written or dictated by a member of the House Staff under the Member’s direct supervision.

Section 4.2 Content of Entries.

4.2.1 Admitting Notes. If utilized, Admitting Notes shall contain, at a minimum, the admitting diagnosis, the reason or reasons for admission to the Hospital or Special Unit, pertinent findings, and the course of treatment contemplated.

4.2.2 History and Physical Examination. A written History and Physical Examination shall contain the patient’s chief complaint, details of the patient’s present illness, review of past medical history, relevant social and family histories, inventory of the patient’s body systems, and a comprehensive current physical examination.

4.2.3 Progress Notes. Progress Notes shall include, at a minimum, a description of the patient’s status, including any changes since the last Progress Note, an assessment of the patient’s disease process or injury and its response to treatment, and any changes in the diagnosis and/or treatment plan.

Section 4.3 Standing Orders.

4.3.1 Any Member may utilize preprinted standing orders provided such standing orders, and any revisions thereto, have been approved in advance by the Medical Records Committee and the Executive Committee of the Medical Staff.

4.3.2 Any Member wishing to utilize preprinted standing orders approved in accordance with this Section must, on a case-by-case basis, specifically order that such standing orders be applied.

Section 4.4 Discharge Summaries. All Discharge Summaries shall identify the patient, and contain sufficient information to support the diagnosis, justify the treatment, document the course and results of the treatment, and permit adequate continuity of care among health care providers. Discharge Summaries shall also contain instructions given to the patient relating to physical activity, medication, diet and follow-up care.

4.5.1 A Member shall be allowed access to a patient’s Medical Record for the purpose of bona fide study and research only if the Member is listed as a principal investigator or co-investigator on a research study approved by the Human Subjects Committee of the University of Kansas Medical Center and provides evidence of such to the Medical Records Department.

4.5.2 Any Medical Record utilized pursuant to this Section shall be checked out from and returned to the Medical Records Department in accordance with the Hospital’s Policies and Procedures governing medical records.