RULES
& REGULATIONS OF THE MEDICAL STAFF OF SJMC
The Rules and Regulations of the Medical
Staff of Subang Jaya Medical Centre have been formulated by the Hospital based
on deliberations with and in conjunction with the Medical Advisory Board.
These Rules and Regulations may be amended
periodically to reflect the Medical Advisory Board's deliberations and
discussions with the Hospital Administration. Amendments to the By Laws, Rules
and Regulations will be distributed by circular memorandum to the Medical Staff
as well as reviewed at Quarterly Medical Staff meetings. A current copy of the
Rules and Regulations will be maintained at all times in the office of the
Director of the Hospital as well as the Medical Staffs secretary's office.
QUALITY
ASSURANCE
All Consultant Medical Staff shall
participate in such Quality Assurance activities as may from time to time be
organized by SJMC including without limitation
1.
Evaluating practitioner and institutional performance
through valid and reliable measurement systems based at least in part on
objective, clinically valid criteria.
2.
Engaging in the ongoing monitoring of critical aspects of
care and enforcement of medical and hospital policies.
3.
Evaluating practitioner credentials for initial and
continued affiliation with SJMC and for the delineation of clinical privileges
for each individual practitioner to insure the delivery of the highest quality
of care.
4.
Arranging for practitioner participation in programs
designed to meet the educational needs of its members.
5.
Assuring that medical and health care services at SJMC are
appropriately employed for meeting patients' medical, social and emotional
needs, consistent with quality health care resource utilization practices.
ADMISSION
OF PATIENTS
All Consultant Medical Staff shall
1.
Not admit any patient whose primary diagnosis is of a
psychiatric nature, including violent or custodial psychiatric disorders,
chronic drug addiction, chronic alcoholism.
Further for any patient who develops or exhibits
psychiatric problems while in the Hospital and should these-problems represent
a safety hazard to the patients, employees or medical staff members, Consultant
will agree to transfer the patient within twenty four (24) hours to the
appropriate psychiatric facility.
2.
Ensure that a general consent form approved by SJMC, signed
by or on behalf of every patient admitted to the hospital, is obtained at the
time of admission.
3.
Ensure that except in an emergency, no patient shall be
admitted to the hospital until a provisional diagnosis or valid reason for
admission has been stated.
4.
Ensure that in the case of an emergency admission, the
patient shall be seen, the provisional diagnosis and the admission note shall
be hand written by the admitting practitioner, and placed in the chart within
no more than six (6) hours of admission. An emergency is defined as a condition
in which the life of the patient is in immediate danger, and in which any delay
of administering treatment would increase that danger.
5.
Ensure that in the case of an admission through the
Emergency Room and not defined as an emergency, the patient shall be seen by
the admitting practitioner, the provisional diagnosis and admission note shall
be hand written by the admitting practitioner, and placed in the chart within
twelve (12) hours of admission. Specific times may be defined by each division
but shall not exceed the twelve (12) hour limitation.
6.
For routine admissions (other than same day surgeries)
ensure that patients arrive at the Hospital between the hours of 1:00 PM and 6:00
PM. Patients scheduled for morning surgeries must be admitted prior to 6:00 PM
the evening before. Patients scheduled for afternoon surgeries must be admitted
no later than 9:00 AM that morning but may be admitted the day before.
7.
In the event of admission of an emergency case be prepared
to justify to the Chairman of the Medical Advisory Committee and such
committee(s) as SJMC shall designate that said emergency admission was a bona
fide emergency. The history and physical examination must clearly justify the
patient being admitted on an emergency basis and these findings must be
recorded on the patient's chart.
8.
Be responsible for the medical care and treatment of each of
his or her patients in the hospital, for the prompt completeness and accuracy
of the
medical record, for necessary special instructions and, if applicable, for
transmitting reports of the condition of the patient to the referring
practitioner and family. Whenever these responsibilities are transferred to
another SJMC medical practitioner, a note covering the transfer of
responsibility shall be entered on the doctor's order sheet of the medical
record and in the progress notes.
9.
Be responsible in all of his admissions for giving such
information that may be necessary to assure the protection of other patients
from those who are a source of danger from any cause whatsoever. Any patient
who, on admission or after admission, is discovered or suspected of having a
contagious disease must be placed in isolation in accordance with the hospital's
isolation policies and procedures. For routine admissions (other than same day
surgeries) ensure that patients arrive at the Hospital between the hours of
1:00 PM and 6:00 PM. Patients scheduled for morning surgeries must be admitted
prior to 6:00 PM the evening before. Patients scheduled for afternoon surgeries
must be admitted no later than 08:30 AM - 09:00 AM that morning.
10.
Accept unassigned patients admitted through the Emergency
Room on a rotation basis as defined by SJMC.
11.
Ensure that each patient admitted to the hospital for
surgery and/or invasive procedures shall have the following routine diagnostic
studies
(a)
Hb, TWC, Urinalysis.
(b)
These procedures need not be done on any patient who is
readmitted within thirty (30) days of their previous discharge from SJMC.
(c)
Any laboratory procedure completed in the attending
practitioner's office or an approved laboratory within the preceding seven (7)
days of admission is acceptable provided a report is submitted to the Hospital
prior to or upon admission of the patient.
12.
In the case of an attending surgeon, ensure that all major
surgical patients, forty years of age or older, who will undergo major regional
or general anaesthesia have a chest x-ray and ECG on the medical record prior
to surgery.
13.
Ensure that any verbal orders given to an SJMC registered
nurse shall be signed within twenty four (24) hours by the attending
practitioner.
14.
The Consultant being a Dentist ensure that any patient
admitted for dental care by a dentist shall have a medical history and
examination performed by a medical practitioner within twenty-four (24) hours
of admission, in addition to the dental history and dental examination.
The care of the dental patient is the dual
responsibility of the SJMC dental Consultant and an SJMC medical practitioner,
each limited to his respective field. The discharge of the patient shall be on
written order of the dentist.
15.
Ensure that if any question as to the validity of admission
to or discharge from the Intensive Care Unit or the Coronary Care Unit should
arise, that decision is to be made through consultation with the attending
practitioner and the Chairman of the Medical Advisory Committee or his
designee.
DISCHARGE OF PATIENTS
All Consultant
Medical Staff shall
1.
Ensure that patients shall be discharged only upon a written
order of the attending practitioner. Any patient leaving the hospital without
the consent of the attending practitioner shall be required to sign a statement
that he/she is voluntarily leaving the hospital "against the advice"
of the practitioner and that in so doing absolves the practitioner and the
Hospital from any and all responsibilities presently or subsequently resulting
therefrom.
2.
Ensure that as attending practitioner his patients are
discharged by 11:00 on the day of discharge.
3.
Ensure that at the time of discharge, the patient's medical
record is satisfactorily completed; with record of the final diagnosis, the
prognosis, the local and general conditions of the patient, the advised
subsequent care and the name of the practitioner to whom the patient is
directed to report for any further medical attention.
MEDICAL RECORDS
All Consultant
Medical Staff shall
1.
Ensure that he prepares a complete and legible medical
record for each patient. This record shall be current and include identification;
date; complaint; personal history; family history; history of present illness;
physical examination; special reports such as consultations, clinical
laboratory and radiology services, and other diagnostic and/or therapeutic
studies; provisional diagnosis; final diagnosis; condition on discharge;
summary or discharge note; clinical resume; and autopsy report when performed.
2.
Ensure that a complete admission history and physical
examination is written or dictated within twenty-four (24) hours after admission
of a patient and is always in the medical record prior to any clinical or
surgical procedure to be performed which requires patient's written consent. When such
history and physical are not written before the time of the operation, the
operation shall be cancelled, unless the attending surgeon states in writing
that such delay constitutes a hazard to the patient's health and welfare.
3.
Write or dictate an admitting note briefly summarizing the
patient's condition on admission, the reason for hospitalization, and the
treatment proposed. If a patient is readmitted within thirty (30) days with the
same condition, the previous history and physical examination, supplemented
with an interval note will suffice.
4.
Record pertinent progress notes at the time of observation
sufficient to permit continuity of care. The patient's clinical problems shall
be clearly identified in such notes and correlated with specific orders as well
as treatment. The attending practitioner shall write progress notes at least
daily or at intervals appropriate to the case so as to reflect accurately the
patient's course in the Hospital. Progress notes shall be written at least
daily on critically ill patients and on those where there is difficulty in
diagnosis or management of a clinical problem.
5.
As attending surgeon, fully and carefully describe all
operations performed within twenty four (24) hours following surgery for
outpatients as well as inpatients. This report shall be promptly signed and
made a part of the patient's medical record.
6.
Accurately date and authenticate all clinical entries in the
patient's medical record. Authentication means written signature or
identifiable initials. Symbols and abbreviations may be used on the medical
record only when they have been approved by SJMC. An official record of
abbreviations shall be kept on file in the Medical Records Department.
7.
Record in full the final diagnosis without the use of
symbols or abbreviations and date and sign at the time of discharge for all his
patients except when a pathologic tissue report is not available.
8.
Write or dictate a discharge clinical summary on all medical
records for his patients hospitalized over forty eight (48) hours, except for
certain selected patients with minor problems as identified and approved by
SJMC. In these instances, a short form medical record with a final summation
progress note is acceptable. Short forms may be appropriate for such conditions
as tonsillectomies, cystoscopies, lacerations, plaster casts, removal of
superficial growths and minor outpatient surgical procedures. This form should
at least contain a brief resume of the patient's condition, pertinent physical
finds, treatment given and other data to justify the diagnosis and treatment.
The record should be signed by the attending practitioner. All medical records
are the property of SJMC and shall not be removed from the hospital premises
except upon court order.
9.
Ensure that all medical records are completed within fifteen
(15) calendar days after a record is placed into the Consultant's incomplete
chart file. An additional period of seven (7) calendar days may be granted, at the end of
which the practitioner's admitting and surgical privileges shall be
automatically suspended until such time as the delinquent records are completed
to the satisfaction of SJMC. Exceptions to this regulation may be made in the
event the Chairman of the Medical Advisory Committee is informed in writing of
a practitioner's illness or absence from the city. Any practitioner suspended
three (3) times within any twelve (12) month period for delinquent records
shall be subject to disciplinary action.
ORDERS FOR TREATMENT OF DRUGS
All Consultant
medical Staff shall
1.
Ensure that all orders for treatment are in writing. Only
practitioners may dictate telephone orders. Such orders shall be signed by the
registered nurse to whom dictated, with the name of practitioner "per
(his/her name)". The practitioner will authenticate such orders by
signature at the next visit to the Hospital, but not later than twenty four
(24) hours, and failure to do so shall be brought to the attention of the Chief
of Division for appropriate action.
2.
Ensure that orders are written clearly, legibly, and
completely. Orders which are illegible or improperly written shall not be
carried out until rewritten or understood by the nurse. The use of
"Renew", "Repeat", "Continue Orders" is not
acceptable.
CONSULTATIONS FROM OTHER CONSULTANTS
All Consultant
Medical Staff shall
1.
Ensure that another Consultant must be well qualified to
give an opinion in the field in which his opinion is sought. The status of a
Consultant is determined by the Hospital on the basis of training, experience,
competence, and current capability.
2.
Ensure that any consultation from another Consultant is
ordered in writing. Consulting practitioners may not write orders unless
authorized in writing by the attending practitioner.
3.
Ensure that a written opinion signed by the other Consultant
must be included in the patient's medical record. When operative procedures are
involved, the consultation note shall be recorded prior to the operation. A
satisfactory consultation includes examination of the patient and the record.
HOSPITAL DEATHS
All Consultant
Medical Staff shall
Ensure that in the
event of a hospital death, the deceased is pronounced dead by the attending
practitioner or any SJMC medical practitioner within a reasonable time. The
body shall not be released until this notation is made in the patient's medical
record.
EMERGENCY SERVICES
All Consultant
Medical Staff shall
1.
Ensure that an appropriate medical record is maintained for
every patient receiving
emergency service and incorporated in the patient's medical record, if such
exists.
2.
Comply with SJMC's policy regarding emergency care. All
emergency department patients who have no source of payment and cannot be
transferred to a Government supported hospital shall be attended by SJMC
medical practitioners and shall be assigned to the service concerned in the
treatment of the disease which necessitated admission. No practitioner shall receive
any compensation from the Hospital for attendance on the case of such patient
who is admitted by the Hospital. Patients who have the ability to pay will be
attended by their own SJMC-affiliated practitioner. If the patient does not
have an SJMC-affiliated practitioner he shall be assigned to the practitioner
on call in the service to which the illness or condition of the patient
indicates treatment.
3.
Participate in SJMC's fire and disaster drills. SJMC
Disaster Plan will be rehearsed at least twice a year and it is the
responsibility of the Consultant to participate in and report to his assigned
stations.
PROFESSIONAL CHARGES
All Consultant
Medical Staff shall
1.
Be responsible for documenting the professional charge for a
service rendered on the forms and according to the procedure specified by SJMC.
2.
Notify SJMC in the event that Consultant decides to modify
or write off his professional charge for a service for which SJMC has already
billed the patient.
3.
Cooperate with and assist the hospital in making arrangements with a
patient for collection of an outstanding debt.
4.
Agree not to require any patient to pay separately to the
Consultant any professional charge for services rendered at SJMC.
5.
Agree to care for employees of SJMC and their immediate
families at the charge code of D for visits and E for procedures, and not to
charge for more than one (1) minor visit per day.
6.
Agree to participate in the Corporate Programs offered by
SJMC at the appropriate charge codes for various corporate programs and for
patients under these programs to charge for no more than:
(a)
Two minor visits per day, and
(b)
One major visit per admission
except for emergency visits to the patients.
a:Rules.new/14/8/95
Received 14 Sept 1995
https://drsjmc.tripod.com/index.htm
Created:- 22 Feb 2003
Last Updated:- 22 Feb 2003