Applied Sciences

THE LORETTO HOSPITAL

MEDICAL STAFF RULES AND REGULATIONS

Adopted Medical Staff: 10/02/08

Approved by the Board of Trustees: 12/08/08

Revised and Adopted by the Medical Staff: 01/02/09

Approved by the Board of Trustees: 04/06/09

Revised and Adopted by the Medical Staff: 02/02/10

Approved by the Board of Trustees: 03/15/10

Revised and Adopted by the Medical Staff: 04/25/11

Approved by the Board of Trustees: 06/20/11

Revised and Adopted by the Medical Staff: 08/31/15

Approved by the Board of Trustees: 08/31/15

Revised and Adopted as by the Medical Staff: 01/08/19

Approved by the Board of Trustees: 02/27/19

Revised and Adopted by the Medical Staff: 06/19/19

Adopted by the Board of Trustees: 09/10/19

THE LORETTO HOSPITAL

MEDICAL STAFF RULES AND REGULATIONS

TABLE OF CONTENTS

Article I Admission and Discharge of Patients 3 Section 1.1 Admissions 3

Section 1.2 Discharges 5

Article II General Conduct of Care 8 Section 2.1 Responsibility for Care and Treatment 8

Section 2.2 Consultations 8

Section 2.3 Patient Encounters 10

Section 2.4 Informed Consent 10

Section 2.5 Treatment Orders 11

Section 2.6 Standing Orders 14

Section 2.7 Drugs and Medications 14

Section 2.8 Orders for Outpatient Services 15

Article III Seclusion and Restraints 19 Section 3.1 Definition of Restraint 19

Section 3.2 Definition of Seclusion 19

Section 3.3 Use of Seclusion or Restraint 19

Section 3.4 Orders for Seclusion or Restraint 20

Section 3.5 Monitoring of Patients in Seclusion or Restraint 21

Section 3.6 Documentation of Seclusion and Restraint 21

Article IV Medical Records 22 Section 4.1 Medical Records 22

Section 4.15 Medical History and Physical Examinations 25

Article V Deaths and Autopsy 30 Section 5.1 Deaths 30

Section 5.2 Autopsy 31

Article VI Surgery and Procedural Specialties 32 Section 6.1 Pre-Surgical Documentation 32

Section 6.2 Tissue Disposition 33

Section 6.3 Post-Surgical Documentation 34

Section 6.4 Oral Surgery 35

Section 6.5 Obstetrics 35

Section 6.6 Special Privileges 36

Article VII Moderate (Conscious) Sedation 36 Section 7.1 Moderate (Conscious) Sedation 36

Article VIII Emergency Room Facilities 37 Section 8.1 General Policies 37

Section 8.2 Responsibilities of the On-Call Practitioner 38

Article IX EMTALA Policy 38 Section 9.1 Requirements 38

Section 9.2 Medical Screening Examination (MSE) 38

Section 9.3 Stabilization 39

Section 9.4 Duties of On-Call Physicians 39

Section 9.5 Arrangement for Back-Up Call 40

Section 9.6 Transfers and Discharge 40

Section 9.7 Records 41

Section 9.8 Reporting 41

Article X Patient Rights 41 Section 10.1 Exercise of Rights 41

Section 10.2 Privacy and Safety 42

Section 10.3 Confidentiality of Patient Records 42

Article XI Emergency Operations Plan (EOP) 42

The Medical Staff shall adopt Rules and Regulations as may be necessary to implement the general principles as described in the Medical Staff Bylaws and the policies of the Hospital. Such Rules and Regulations shall be accepted or amended on approval by a majority of votes cast by the Medical Executive Committee of the Medical Staff (MEC). Rules and Regulations discussed herein shall relate to the proper conduct of Medical Staff organizational activities in the care of all patients treated at Loretto Hospital, as well as the quality of practice and the standards of performance that are to be required of each Practitioner. These Rules and Regulations shall constitute a supplement to the Medical Staff Bylaws; and be binding on all members of the Medical Staff.

ARTICLE I – ADMISSION AND DISCHARGE OF PATIENTS

1.1 Admissions

1.1.1 Patients are admitted to the hospital only on the recommendation of a licensed practitioner, Doctor of Medicine or Doctor of Osteopathy, permitted to admit patients to a hospital, who are currently licensed and have been granted admitting privileges by the Board of Trustees in accordance with State of Illinois law and the Medical Staff Bylaws.

1.1.1.1 Every Medicare or Medicaid patient must be under the care of a licensed practitioner who is a Doctor of Medicine or Doctor of Osteopathy; or a Doctor of Dental Surgery or Dental Medicine who is legally authorized to practice dentistry by the State of Illinois and who is acting within the scope of his/her license; or a Doctor of Podiatric Medicine, but only with respect to functions which he or she is legally authorized by the State of Illinois to perform; or a Doctor of Optometry who is legally authorized to practice Optometry by the State of Illinois; or a Chiropractor who is licensed by the State of Illinois or legally authorized to perform the services of a chiropractor, but only with respect to treatment by means of manual manipulation of the spine to correct a subluxation demonstrated by x-ray to exist; or a Clinical Psychologist but only to the extent permitted by State of Illinois law. If a Medicare patient is admitted by a practitioner not specified in this Section 11.1.1, that patient is under the care of a Doctor of Medicine or a Doctor of Osteopathy.

1.1.2 All patients shall be admitted to Loretto Hospital without restriction based upon race, color, creed, sex, religion or ability to pay. All patients will receive the same level of care and treatment. Recording race, color, creed, sex, or religion of the patient, as part of the history and physical, is permissible if it will help facilitate statistical, spiritual or diagnostic purposes.

1.1.3 Except in an emergency, no patient shall be admitted to the Hospital until a provisional diagnosis is made or valid reason for hospitalization has been stated and the provisional diagnosis/reason for hospitalization has been given to the admission officer by the Staff Physician and assurance of bed availability has been secured. In the case of an emergency, a provisional diagnosis shall be recorded in the patient’s chart within the first 24 hours of admission.

1.1.4 The patient shall be assigned to the admitting service of his private practitioner. In the case of a patient requiring admission who has no private practitioner, he or she shall be assigned to the on-call attending for the service by the Attending Physician of the emergency room. If possible, patients who are without a private practitioner shall be given an opportunity to select an appointee of the Medical Staff to be responsible for his care while in the Hospital.

1.1.5 A Physician seeking admission of a patient shall give all such information that may be available to him to assure the protection of the patient from self-harm as well as the protection of other patients and Hospital personnel from any cause whatsoever.

1.1.6 If a patient requires custodial protection (and this includes attempted suicide cases) the Physician shall request consultation of a Staff psychiatrist of his choice upon admission of the patient. The psychiatrist will evaluate the patient within twenty-four hours of admission. Patient will be kept on suicide precautions until evaluated by the psychiatrist.

1.1.7 As much as possible, the Physician must furnish all information concerning cases of infection so proper isolation techniques may be taken. The Hospital will not accept contagious cases prohibited by the rules of the Chicago Department of Health or Department of Public Health, State of Illinois.

1.1.8 It will be the responsibility of the Attending Physician to satisfy all requirements of Medicare and/or Medicaid programs as required by law.

1.1.9 Patients shall be admitted to the Hospital on the basis of the following order of priorities when there is a shortage of available beds: (i) Emergency; (ii) Urgent; and (iii) Elective.

1.1.10 Elective admissions to the Hospital shall occur preferably in the morning.

1.1.11 An admission assessment on each patient admitted to the hospital must be completed and authenticated within 24 hours of admission.

1.1.12 Multidisciplinary Plan of Care

Inpatients will have a plan of care initiated within twenty-four (24) hours of admission. The Plan of Care includes: Provider’s orders; Provider History and Physical Examination; Notes (progress, consult, etc.); Conditional documentation; and other appropriate documents that relate the Plan of Care to the Multidisciplinary Team. All disciplines involved in the care of a patient collaborate to develop the patient’s Plan of Care. Each healthcare team member provides input into the Plan of Care. The patient/family/significant other is included in the development, implementation, maintenance, planning and evaluation of the care provided. Patients receive care and treatment based on an assessment of their needs, the severity of their disease, condition, impairment, or disability. The data obtained from the assessment is used to determine and prioritize the patient’s Plan of Care. The patient’s progress will be evaluated as necessary and the Plan of Care will be revised as indicated.

1.2 Discharges

Discharge Plan:

1.2.1 A discharge plan shall be initiated within 24 hours of the admission. The Hospital must have an effective Discharge Planning process that applies to all patients. The Hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. The Hospital must provide a discharge planning evaluation to the patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning, and to other patients upon the patient’s request, the request of a person acting on the patient’s behalf, or the request of the physician.

1.2.2 The discharge planning evaluation must include the likelihood of a patient needing post-hospital services and the availability of the services. The discharge planning evaluation must include the likelihood of a patient’s capacity for self-care or the possibility of the patient being cared for in the environment from which he or she entered the hospital. The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan.

1.2.3 The Hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.

1.2.4 The Hospital must arrange for the initial implementation of the patient’s discharge plan. The Hospital must reassess its discharge planning process on an on-going basis. The reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs.

1.2.5 Referrals should be made to the Social Services Department indicated.

Discharge Orders and Discharge Summary:

1.2.6 Patients shall be discharged only on written order of the Attending Physician. The Attending Physician shall see that the record is complete, state his final diagnosis and sign the reports.

1.2.7 The Discharge Order shall be completed 24 hours in advance of the intended discharge date and, where indicated, the assigned Social Worker shall be notified whenever necessary.

1.2.8 The Discharge Summary shall be completed within, or prior to seven (7) days of discharge. The medical record must contain a discharge summary with outcome of hospitalization, disposition of case and provisions for follow-up care. The Discharge Summary must include Reason for Hospitalization; Significant Findings; Procedures and Treatment Provided; Patient’s Discharge Condition; Patient and Family Instructions (as appropriate); and the Attending Physician’s Signature and should also include at least the following:

1) Patient Demographics (Patient name; Patient Identifier/Medical Record Number; and Gender);

2) Visit/Encounter (Admission Date; Discharge Date; Discharge Diagnosis; and Discharge Disposition);

3) Diagnosis (Pre-Existing/Developed Conditions Impacting Hospital Stay; Conditions not Impacting LOS);

4) Course While in Hospital (Presenting Complaint(s); Summary Course in Hospital; Investigations – Summary of Examinations and Tests conducted while in Hospital; Interventions (Procedures & Treatments); Documentation of complications, hospital acquired infections, an unfavorable reactions to drugs and anesthesia, and Final Diagnosis;

5) Alert Indicators – Allergies;

6) Discharge Plan – All Medications at Discharge; Follow-Up Instructions for Patient; Follow-Up Plan Recommended for Receiving Provider(s); Referrals (Referrals that have been initiated by the sender); and Copies to be Sent To (Other clinicians who are included in the care of patient).

1.2.9 The MD/DO or other qualified practitioner with admitting privileges approved by the Board of Trustees, in accordance with State of Illinois law and hospital policy, who admitted the patient is responsible for the patient during the patient’s stay in the hospital. This responsibility would include developing and entering the Discharge Summary. Other MD/DOs who work with the patient’s MD/DO and who are covering for the patient’s MD/DO and who are knowledgeable about the patient’s condition, the patient’s care during the hospitalization, and the patient’s discharge plans may write the Discharge Summary at the responsible MD/DO’s request. In accordance with hospital policy, and 42 CFR Part 482.12(c) (1)(i), the MD/DO may delegate writing the Discharge Summary to other qualified health care personnel such as Nurse Practitioners and MD/DO Assistants to the extent recognized under State of Illinois law or a State of Illinois regulatory mechanism.

Whether delegated or non-delegated, it is expected that the person who writes the Discharge Summary to authenticate, date, and time their entry and additionally for delegated discharge summaries, it is required that the MD/DO responsible for the patient during his/her hospital stay to co-authenticate and date the discharge summary to verify its content. The discharge summary requirement would include outpatient records.

Medical Certification of Death:

1.2.10 Medical Certification of Death: The Attending Physician is required to complete the “Cause of Death” and “Physician’s certification” portions of the certificate within twenty-four hours after the death so that the mortician can meet the requirements for filing. The Physician should be given opportunity to arrange for any necessary post-mortem examination of his patient before the body is embalmed. The public interest requires that the cause of every death be determined as fully and accurately as possible. The body must not be removed to a mortuary until the Attending Physician has agreed to its removal from the place of death. To facilitate this, the Physician should, when notified of the death, and if no autopsy has been secured, give the cause of death so that the mortician may call the Department of Health and secure permission for the removal of the body. All deaths shall be reviewed at the next meeting of the respective clinical Department of the Medical Staff.

ARTICLE II – GENERAL CONDUCT OF CARE

2.1 Responsibility for Care and Treatment

2.1.1 A Doctor of Medicine or Doctor of Osteopathy is on duty or on call at all times in the hospital to provide medical care and onsite supervision when necessary. The patient is under the care of a doctor of medicine, a doctor of osteopathy, a doctor of dental surgery, a doctor of podiatric medicine, a doctor of optometry, a chiropractor or a clinical psychologist, each practicing within the extent of state and federal law and as privileged and credentialed under the Medical Staff Bylaws. Further, a doctor of medicine or osteopathy shall be responsible for the care of each patient with respect to any medical or psychiatric condition that is present on admission or develops during hospitalization and is not specifically within the scope of practice of a Doctor of Dental Surgery, Dental Medicine, Podiatric Medicine, or Optometry, a Chiropractor, or Clinical Psychologist, as that scope is: A) Defined by the Medical Staff; B) Permitted by State of Illinois law; and C) Limited under CMS paragraph 482.12 (c )(1)(v) with respect to Chiropractors.

2.1.2 Whenever the responsibilities of the patient’s Attending Physician are permanently transferred to another Medical Staff member qualified to act as the patient’s Attending Physician, the outgoing Attending Physician shall clearly note the transfer of responsibility to the new Attending Physician in the patient’s Medical Record.

2.2 Consultations

2.2.1 The good conduct of medical practice includes the proper and timely use of consultation. Judgment as to the seriousness of the illness and the resolution of any doubt regarding the diagnosis and treatments rests with the Practitioner responsible for the care of the patient. On the other hand, it is the duty of the organized Medical Staff, through the Department Chairmen and the Medical Executive Committee, to see that those Practitioners practicing in the Hospital do not fail to call consultants as needed.

2.2.2 When the clinical presentation of a patient is not within the scope and expertise of the primary Physician, consultation with an appropriate Physician is recommended.

2.2.3 The consultation must be performed by a Physician who is credentialed in the field in which his opinion is sought.

2.2.4 Applicants for active membership must agree to provide care and consultation for any patients admitted to the Hospital or arrange for alternative consultation if the initial consult is refused in accordance with these bylaws and rules and regulations.

2.2.5 Requests for consultation should be made by direct personal communication from the Attending Practitioner to the Consulting Practitioner.

2.2.6 Upon notification, it is expected that consultations will be provided by the end of the following day. Any delay is to be promptly discussed with the Attending Practitioners. When operative procedures are involved, the consultation note, except in an emergency, shall be record prior to operation.

2.2.7 For each patient on whose case a Consultant agrees to consult, the Consultant shall review the patient’s medical record, conduct an appropriate history and physical examination of the patient, and prepare a written or dictated Consultation Report signed by the Consultant that reflects an actual examination of the patient and the patient’s medical record.

2.2.8 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.

2.2.9 Consultation is recommended in major surgical cases in which the patient is not a good risk; in all cases in which the diagnosis is obscure, or when there is doubt as to the best therapeutic measure to be utilized; and in all cases where a patient is suicidal. Judgment as to the serious nature of the illness and the question of doubt as to diagnosis and treatment rests with the Physician responsible for the care of the patient. It is the duty of the Hospital Staff through the clinical Departments and the Medical Executive Committee to see that members of the Staff do not fail in the matter of calling Consultants as needed.

2.2.10 In circumstances of grave urgency, the President & CEO and Medical Staff President or their respective designee, shall at all times have the right to call in a Consultant after conferring with the appropriate departmental chairperson.

2.2.11 If the Attending Physician and consultant disagree, a second Consultant should be called for an opinion.

2.2.12 Children under age twelve (12) who need special treatment procedures and/or adolescents who need psychiatric or substance abuse services are referred to other specialty hospitals.

2.2.13 Joint Admissions: When requested by the attending psychiatrist, a Physician who does not have consultative privileges may follow and treat the patient on the Psychiatry Unit subject to the limits of his privileges and as permitted by the respective Department policies.

2.2.14 The patient or the patient’s surrogate decision-maker must be advised of the requested consultations and the name of the Consultant by the Attending Physician.

2.3 Patient Encounters

2.3.1 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.

2.4 Informed Consent

2.4.1 Written Consent: The treating Physician is responsible for obtaining a valid consent in accordance with Hospital policy before initiating treatment. The medical records shall contain evidence of informed consent for procedures and treatments for which it is required by Hospital policy. Consent forms must be signed by the patient or his authorized designee. The name of the Physician who is to perform the procedure or treatment should be written on the consent form in the space provided for this information. There are to be no additions, modifications or deletions to the Informed Consent once it has been signed by the patient or his legal representative. Written consents obtained more than thirty (30) days prior to the initiation of care or treatment will not be valid. Informed Consent will be written in simple sentences and in the primary language of the patient.

2.4.2 No autopsy shall be performed without a properly completed written Informed Consent by the authorized next of kin or the legal representative.

2.4.3 Except in emergencies, patients are entitled to receive, in terms or language that they can understand as much information about the proposed procedure or treatment as may be needed to make an informed decision.

2.4.4 Telephone ConsentWhen a patient is unable to consent for his treatment and when it is impossible for the individuals listed in the applicable Hospital policy to come to the Hospital to sign for the patient’s treatment, it is permissible to accept consent from these individuals over the telephone. In such cases, two individuals, other than the Physician who is to perform the procedure, must witness the consent over the phone. The chart must indicate that telephone consent was received, the name of the witnesses, time, date, and phone number of the person providing the consent, and relationship to patient.

2.4.5 Emergency Consent: In the case of an emergency, and when no consent is able to be obtained from the patient or next of kin (life-threatening situation when death, loss of limb or function of a major organ would probably ensue if medical intervention is not immediately implemented), administrative review is not required. The Physician documents the emergency in the medial record and proceeds with appropriate treatment.

2.5 Treatment Orders

2.5.1 With the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per Physician-approved Hospital policy after an assessment of contraindications, orders for drugs and biologicals must be documented and signed by a Practitioner who is authorized to write orders by Hospital policy and in accordance with State law, and who is responsible for the care of the patient.

2.5.2 Initiation of Medical Staff approved written protocols and/or standing orders for drugs or biological requires an order from a Practitioner responsible for the patient’s care.

2.5.3 Except as specifically provided herein, all orders for treatment shall be in writing. All orders, including verbal orders, shall be dated and timed, and authenticated promptly within forty-eight (48) hours, by the ordering Practitioner or another Practitioner who is responsible for the care of the patient and authorized to write orders by Hospital policy in accordance with Federal and State Law.

2.5.4 In accordance with standard practice, elements that must be present in orders for all drugs and biologicals to ensure safe preparation and administration include: (i) Name of patient (present on order sheet or prescription); (ii) Age and weight of patient, when applicable; (iii) Date and time of the order; (iv) Drug name; (v) Exact strength or concentration, when applicable; (vi) Dose, frequency, and route; (vii) Quantity and/or duration, when applicable; (viii) Specific instructions for use, when applicable; and (ix) Name of prescriber.

2.5.5 If verbal orders are used, they are to be used infrequently. Verbal and telephone orders should relate only to the immediate needs of the patient. Verbal communication of orders should only be used if the circumstances are such that an immediate order is required and it would be impossible or impractical for the ordering Practitioner to write the order without delaying treatment. Verbal orders are not to be used for the convenience of the Practitioner.

2.5.5.1 A Physician may give verbal or telephone orders which can be accepted only by persons who are authorized to do so by Hospital policy and procedures consistent with Federal and State law, such as a house physician, resident, registered professional nurse, advanced practice nurse, physician assistant, registered dietician, registered pharmacist, registered or certified respiratory therapist, licensed clinical psychologist, registered speech therapist, registered physical therapist or certified social worker. Verbal orders must be authenticated within forty-eight (48) hours by the ordering Practitioner, especially any order for narcotics, intravenous medications, restraints, anticoagulants, suicide precaution, pre-operative and postoperative orders and CCU orders.

2.5.5.2 The content of verbal orders must be clearly communicated. All verbal orders must be immediately documented in the patient’s medical record and signed by the individual receiving the order. Verbal orders should be recorded directly onto an order sheet in the patient’s medical record or entered into the computerized order entry system, if applicable.

2.5.5.3 The transcriber of the verbal or telephone order will read back the order and the ordering Practitioner then will confirm the accuracy of the order to conform to patient safety initiatives. Each verbal order shall be dated and timed and identify the name of the individual who gave it and who received it and the record shall indicate who implemented it. Verbal and telephone orders will be flagged for the Practitioner’s signature by the registered nurse or other authorized person who received it.

2.5.5.4 A qualified non-physician practitioner, such as a physician assistant (PA) or nurse practitioner (NP), who is responsible for the care of the patient may authenticate a physician’s or other qualified non-physician’s order only if the order is within his/her scope of practice. If State law requires that the ordering practitioner authenticate his/her own orders, or his/her own verbal orders, then a practitioner other than the prescribing practitioner would not be permitted to authenticate the verbal order.

2.5.6 The Practitioner’s orders must be written clearly, legibly and completely. Orders which are illegible or improperly written will not be carried out until rewritten or understood by the nurse. The use of “Renew”, “Repeat”, and “Continue Orders” are not acceptable.

2.5.7 Patient orders may be written by a House Staff Physician. House Staff Physician orders do not require countersignature by the Attending Physician. This shall not prohibit the Attending Practitioner from writing orders on those patients. The refusal of a Medical Staff member to allow House Physicians to write orders on his private patients shall not be the basis for any sanction or loss of privileges or prerogative.

2.5.8 All requests for treatment, restraints and/or medications shall be in writing and documented on the Order Sheet and shall be signed, dated and timed by the prescribing Practitioner. Seclusion and Restraint orders must be episode-specific, time-limited with specific starting and end times as outlined in the Hospital Seclusion and Restraint Policy and Procedures and in conformance with Article III of these Rules and Regulations.

2.5.9 Orders for anticoagulants, narcotics, antibiotics, hypnotic, tranquilizers, sedatives and steroids shall be cancelled automatically according to Hospital policy unless specifically ordered by a Physician for a longer definite period. All orders for patients shall be reviewed by the Attending Physician at least every third day. The prescribing Practitioner must be notified within twenty-four (24) hours before an order is automatically stopped. If the order expires during the night, the prescribing Practitioner should be so informed the following morning. In no event shall the drug or treatment indicated be given for the maximum duration indicated if the last effective order specifies a shorter interval.

2.5.10 A surgical operation, except ECT, shall automatically cancel all orders, except DNR Orders, which are rescinded during surgery and reinstated after surgery.

2.5.11 Do Not Resuscitate (“DNR”) Orders

2.5.11.1 It is the responsibility of the Medical Staff member to initiate DNR Orders to comply with the Hospital’s Policy on Advance Directives and Patient Rights.

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

2.6 Standing Orders

2.6.1 Each Department of the Medical Staff will determine which, if any, standing orders or screening of patients will be done on patients admitted to the Hospital. Standing orders may be formulated for each clinical department by that Department. Standing orders are orders for tests and/or procedures which the Department has decided are to be performed in the absence of or without individual orders in specific groups of patients and are directly related to the diagnosis or conditions. Initiation of Medical Staff approved written protocols and/or standing orders for drugs or biologicals require an order from a Practitioner responsible for the patient’s care.

2.6.2 Standing orders shall be followed insofar as proper treatment of the patient will allow. When specific orders are not written by the Practitioner, the standing orders shall constitute the orders for treatment and the Practitioner shall sign such orders at the time of his next visit on the following day.

2.6.3 Standing orders are to be reviewed and approved at least annually by the medical staff and the hospital’s nursing and pharmacy leadership and shall be revised as necessary. The sponsoring practitioner authenticates the “Master Copy” as evidenced by his/her signature to ensure current practice is accurate and maintained.

2.6.4 Standing orders must be dated, timed, and authenticated promptly in the patient’s medical record by the ordering practitioner or another practitioner responsible for the care of the patient only if such practitioner is acting in accordance with State of Illinois law, including scope of practice laws, hospital policies, and Medical Staff Bylaws, Rules and Regulations.

2.7 Drugs and Medications

2.7.1 Except as may otherwise specifically be 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 Loretto Hospital Formulary.

2.7.2 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.

2.7.3 Proprietary remedies whose composition is unknown to the Physicians, to the pharmacist or to the Pharmacy and Therapeutics Committee, shall neither be prescribed nor administered to patients.

2.8 Orders For Outpatient Services

The hospital’s outpatient services must meet the needs of the patients in accordance with acceptable standards of practice. Outpatient services must be appropriately organized and integrated with inpatient services. The hospital must assign one or more individuals to be responsible for outpatient services. The hospital must have appropriate professional and non-professional personnel available at each location where outpatient services are offered, based on the scope and complexity of outpatient services. Orders for outpatient services (as well as patient referrals for hospital outpatient services) must be ordered by a practitioner who meets the following conditions:

● Responsible for the care of the patient;

● Licensed in, or holds a license recognized in the jurisdiction (State of Illinois) where he/she provides care to the patient;

● Is acting within his or her scope of practice under State of Illinois law; and

● Is authorized in accordance with State of Illinois law and policies adopted by the Medical Staff and approved by the Governing Board to order applicable outpatient services. This applies to the following:

(i) All practitioners who are appointed to the hospital’s Medical Staff and who have been granted privileges to order the applicable outpatient services.

(ii) All practitioners not appointed to the Medical Staff, but who satisfy the above criteria for authorization by the Medical Staff and the hospital for ordering the applicable outpatient services for their patients.

2.8.1 Policy

The hospital’s Medical Staff policy for authorizing practitioners to refer patients for outpatient services must address how the hospital verifies that the referring practitioner who is responsible for the patient’s care is appropriately licensed and acting within his/her scope of practice. The policy must also make clear whether the policy applies to all hospital outpatient services, or whether there are specific services for which orders may only be accepted from practitioners with Medical Staff privileges. The hospital‘s policy must make any exceptions to the general authorization for referring practitioners clear.

1. Each department performing Outpatient Services for practitioners not on the Medical Staff shall be responsible for verifying current valid licensure and that the ordering practitioner is free from sanctions or exclusions which are imposed by the OIG.

2. Signed, handwritten or electronic prescriptions or orders on prescription or standardized authorization forms known to the department shall be accepted as verification.

3. Verbal orders shall not be accepted from practitioners without clinical privileges.

2.8.2 Procedure

1. Practitioners, defined as any Physician (Doctor of Medicine or Doctor of Osteopathic Medicine), Doctor of Dental Surgery or Dental Medicine, Doctor of Podiatric Medicine, Doctor of Optometry; or a Chiropractor, or a Non-Physician Practitioner, who provide services within the authorized scope of their practice/license. who has been awarded an appropriate degree from an accredited institution and who holds a valid and unsuspended license, issued by the Illinois Department of Financial Professional Regulation to practice his/her respective profession within the authorized scope of his practice/license issued by the Illinois Department of Financial Professional Regulation, with clinical privileges at the hospital may order hospital outpatient services that are within the scope of their privileges granted by the hospital.

2. Departments may also accept orders from non-privileged practitioners for the following outpatient services:

a. Laboratory (Orders for Blood Transfusions require a recent H & P from the ordering provider);

b. Medical Imaging

c. Nuclear Medicine services must be ordered only by practitioners whose scope of Federal or State licensure and whose defined staff privileges allow such referrals. There must be a Director who is a Doctor of Medicine or Osteopathy qualified in Nuclear Medicine,

d. Nutrition Counseling

e. Rehabilitation (Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Rehabilitation, and Audiology). The Director of Services must have the necessary knowledge, experience, and capabilities to properly supervise and administer the services.

f. Respiratory Care Services. There must be a Director of Respiratory Care Services who is a Doctor of Medicine or Osteopathy with the knowledge, experience, and capabilities to supervise and administer the service properly. The Director may serve on either a full-time or part-time basis.

g. Sleep Studies

h. Infusion Therapy (Note: Infusion Therapy requires a recent H & P from the ordering provider)

i. Blood Transfusions (Note: Blood Transfusions require a recent H & P from the provider).

3. Orders from non-privileged practitioners (Non-Medical Staff or Non-Physician Practitioner Staff members) may be carried out only if:

a. The practitioner ordering the service is responsible for the care of the patient; and

b. The hospital has verified all of the following:

(i) That the practitioner holds a current and valid license as follows:

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