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1). If the patient was seen in Illinois, verify that the practitioner holds a current and valid license (and/or certification, as appropriate) to practice his or her profession. Such verification shall be made through the Illinois Department of Financial and Professional Regulation (IDFPR) License Lookup OR

2. If the patient was seen outside of the State of Illinois, verify that the practitioner holds a valid license (and/or certification, as appropriate) in the state or jurisdiction where he or she saw the patient. Such verification shall be made in accordance with that state or jurisdiction’s process for verifying practitioner licensure or certification. Licensure in other states are verified by the respective State Medical or other professional Board.

(ii) That the practitioner is acting within the scope of his or her practice in ordering the hospital outpatient services. In some cases, the practitioner’s license or certification may be sufficient evidence of an order being within his or her scope of practice (e.g., a physician referring a patient for a basic blood test). In cases where additional information may be required regarding the practitioner’s scope of practice, the hospital shall confirm with a hospital or other health care facility at which the practitioner practices that the order is within the scope of the practitioner’s privileges or other authority to provide care at such health care facility.

iii) That the practitioner has not been excluded from federally funded health care programs by the Office of Inspector General of the U.S. Department of Health and Human Services. Such verifications shall be made through the OIG’s List of Excluded Individuals/Entities (http://oig,hhs.gov/exclusions/).

iv) That the practitioner has not been excluded by the U.S. General Services Administration from receiving federal contracts, certain subcontracts, and certain financial and non-financial assistance and benefits. Such verification shall be made through the GSA’s Excluded Parties List System (http://www.sam.gov/portal/SAM/).

4. Practitioners included in the EMR dictionary have had verifications completed.

5. Practitioners not included in the EMR dictionary will need verifications completed.

ARTICLE III – SECLUSION AND RESTRAINTS

Seclusion or Restraint may only be imposed to insure the immediate physical safety of the patient, a Staff member, or others and must be discontinued at the earliest possible time.

3.1 Definition of Restraint

A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmet, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort). A physical escort would include a “light” grasp to escort the patient to a desired location. If the patient can easily remove or escape the grasp, this would not be considered physical restraint. However, if the patient cannot easily remove or escape the grasp, this would be considered physical restraint and all the requirements would apply.

3.1.1 Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or

3.1.2 A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.

3.2 Definition of Seclusion: Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.

3.3 Use of Seclusion or Restraint

3.3.1 Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a Staff member, or others from harm.

3.3.2 The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a Staff member, or others from harm.

3.3.3 Seclusion may only be used for the management of violent or self-destructive behavior.

3.3.4 The use of seclusion or restraint must be in accordance with a written modification to the patient’s plan of care.

3.3.5 All use of seclusion or restraint must be implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by Hospital policy in accordance with the law of the State of Illinois.

3.4 Orders for Seclusion or Restraint

3.4.1 The use of seclusion or restraint must be in accordance with the order of a Physician or other licensed independent Practitioner, who is responsible for the care of the patient and who is authorized to order seclusion or restraints by Hospital policy in accordance with the law of the State of Illinois.

3.4.2 Orders for the use of seclusion or restraint must never be written as a standing order or on an as needed basis (PRN).

3.4.3 The Attending Physician must be consulted as soon as possible if the Attending Physician did not order the seclusion or restraint.

3.4.4 Unless superseded by the law of the State of Illinois, if more restrictive:

3.4.4.1 Each order for seclusion or restraint used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a Staff member, or others may only be renewed in accordance with the following limits for a total of 24 hours:

3.4.4.1.1 Four (4) hours for adults 18 years of age or older;

3.4.4.1.2 Two (2) hours for children and adolescents 9 to 17 years of age; or

3.4.4.1.3 One (1) hour for children under 9 years of age.

3.4.5 After 24 hours, before writing a new order for the use of seclusion or restraint for the management of violent or self-destructive behavior, a Physician or other licensed independent Practitioner who is responsible for the care of the patient and who is authorized to order seclusion and restraint by Hospital policy in accordance with the law of the State of Illinois, must see and assess the patient.

3.4.6 Each order for restraint used to insure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by Hospital policy.

3.4.7 Seclusion or restraint must be discontinued at the earliest possible time, regardless of the length of time identified in the order.

3.5 Monitoring of Patients in Seclusion or Restraint

3.5.1 The condition of the patient who is restrained or secluded must be monitored by a Physician; other licensed independent Practitioner or trained Staff that have completed the training criteria outlined in Hospital policy.

3.5.2 When seclusion or restraint is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a Staff member, or others, the patient must be seen face-to-face within one (1) hour after the initiation of the intervention by a Physician or other licensed independent Practitioner; or registered nurse or physician assistant who has been trained in seclusion and restraint in accordance with Hospital policy, to evaluate the patient’s immediate situation; the patient’s reaction to the intervention; the patient’s medical and behavioral condition; and the need to continue or terminate the seclusion or restraint. If the face-to-face evaluation is conducted by a trained registered nurse or physician assistant, the trained registered nurse or physician assistant must consult the Attending Physician or other licensed independent Practitioner who is responsible for the care of the patient as soon as possible after the completion of the one (1) hour face-to-face evaluation.

3.5.3 Simultaneous seclusion and restraint use is only permitted if the patient is continually monitored face-to-face by an assigned, trained Staff member; or by trained Staff using both video and audio equipment, which must be in close proximity to the patient.

3.6 Documentation of Seclusion and Restraint

3.6.1 When seclusion or restraints is used there must be documentation in the patient’s medical record of the following:

3.6.1.1 The 1 hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior;

3.6.1.2 A description of the patient’s behavior and the intervention used;

3.6.1.3 Alternatives or other less restrictive interventions attempted (as applicable);

3.6.1.4 The patient’s condition or symptom(s) that warranted the use of the seclusion or restraint; and

3.6.1.5 The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention.

3.6.1.6 The patient has the right to safe implementation of restraint or seclusion by trained staff.

3.6.1.7 Deaths associated with the use of seclusion or restraints must be reported to CMS by telephone, facsimile, or electronically as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death. Reporting includes each death that occurs while a patient is in restraint or seclusion; each death that occurs within 24 hours after the patient has been removed from restraint of seclusion; and each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume the use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint or seclusion used on the patient during this time.

ARTICLE IV – MEDICAL RECORDS

4.1 Medical Records

4.1.1 A medical record must be maintained for every individual evaluated or treated (inpatient and outpatient) in the hospital. Medical Records must be accurately written, promptly completed, properly filed and retained and accessible. The Hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. The Hospital must have a procedure for ensuring the confidentiality of patient records.

Content of the Medical Record:

The medical record must include evidence of informed consent for procedures, interventions, care plans, diagnosis, orders, medical history, progress notes, treatments, test results and documentation that justifies admission, and supports the diagnosis, describes the patient’s response to treatment and provides a discharge summary. Include clinical evaluation information obtained from post-discharge follow-up telephone calls; care provided and the patient’s response to treatments and interventions. The term “medical record” includes at least written documents, computerized electronic information, radiology film and scans, laboratory reports and pathology slides, videos, audio recordings, final diagnosis and other forms of information regarding the condition of the patient. The Medical Record must reflect the patient’s entire care during his or her inpatient or outpatient treatment. The Medical Record must contain information to justify admission, continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and treatment services.

Responsibility for Preparation of the Medical Record:

The Attending Physician shall be responsible for the preparation of a medical record for each patient according to regulatory guidelines. All patient medical record entries must be accurate, legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided, consistent with Hospital policies and procedures. Advanced Practice Nurses (Nurse Practitioners, CRNA’s and APN Nurse Midwife) do not require medical record entries to be countersigned with the exception of the Discharge Order. All Certified Physician Assistants who are employed by a medical staff member must have any and all medical record entries, including but not limited to Progress Notes; History and Physical Examinations; and any and all orders such as pharmaceutical orders; laboratory orders; and diagnostic imaging orders, countersigned by their sponsoring physician. All Certified Physician Assistants who are employed by the hospital must have any and all medical record entries, including but not limited to Progress Notes; History and Physical Examinations; and any and all orders such as pharmaceutical orders; laboratory orders; and diagnostic imaging orders, countersigned by a physician member of the Medical Staff with comparable clinical privileges. Symbols and abbreviations may be used only when the have been approved by the Medical Staff. An official record of the annually approved abbreviations and explanations will be on file in the Medical Records Department.

4.1.2 All medical records must document the following, as appropriate:

Evidence of:

(i) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration. Documentation of the updated examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services;

(ii) Admitting diagnosis;

(iii) Results of consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient;

(iv) Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia;

(v) Properly executed informed consent forms for procedures and treatments specified by the Medical Staff, or by Federal or State of Illinois law if applicable, to require written patient consent;

(vi) All practitioners’ orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition;

(vii) Discharge Summary with outcome of hospitalization, disposition of case, and provisions for follow-up care;

(viii) Final diagnosis with completion of medical records within 30 days following discharge.

(ix) If an autopsy is performed, provisional anatomic diagnoses are recorded in the medical record within three (3) days, and the complete protocol is included in the record within sixty (60) days.

4.1.3 Each medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and responses to medications and services. The medical record should contain, at a minimum, information as it relates to the patient’s admission or episode of care: identification data; date; name of any legally authorized representative; the patient’s communication needs, including preferred language; complaint, personal history; family history; history of illness; history of allergies, current medication, physical examination findings; treating or admitting diagnosis; laboratory and radiological data; hospital acquired infections; and unfavorable reactions to drugs and anesthesia; medical and surgical treatment; anesthesia record; pathological findings; progress notes; final diagnosis; condition on discharge, discharge summary and care plan; discharge instructions to patient; and when performed, results of autopsy. When an autopsy is performed, provisional anatomic diagnoses are recorded in the medical record within three (3) days, and the complete protocol is included in the record within sixty (60) days.

4.1.4 The medical record shall contain evidence of the patient’s Informed Consent for any procedure or treatment, including the use of investigational drugs, or any special diagnostic or therapeutic radiology procedure and any special ambulatory care or emergency care. It should also include the following: (i) identity of individual(s) performing procedures or administering treatment; (ii) authorization for anesthesia and/or administration of blood or blood components; (iii) indications that alternate means of therapy and possible risks or complications have been explained to the patient; (iv) authorization for disposition of any tissue or body parts; and (v) authorization for photographs and/or videotaping.

4.1.5 Each medical record shall contain evidence of a critical review of the patient’s written record by the Attending Practitioner.

4.1.6 Medical History and Physical Examinations. A medical history and physical examination must be completed and documented for each patient no more than 30 days prior to or 24 hours after hospital admission or registration, but prior to surgery or a procedure requiring anesthesia services. The Medical History and Physical Examination must be completed and documented by a physician (as defined in Section 1861(r) of the Act (Social Security Act), oral maxillofacial surgeon, or other qualified licensed individual in accordance with State of Illinois Scope of Practice law and hospital policy and who are formally authorized by the hospital to conduct an H & P and who have been credentialed and granted clinical privileges by the Board of Trustees to perform an H & P. Other qualified licensed individuals are those licensed practitioners who are authorized in accordance with their State of Illinois scope of practice laws or regulations to perform an H & P and who are formally authorized by the hospital to conduct and H & P and have been credentialed and granted clinical privileges by the Board of Trustees to perform an H & P. Other qualified licensed practitioners would include Nurse Practitioners and Physician Assistants. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration. The Medical Staff is responsible for specifying the minimal content of medical histories and physical examinations, which may vary by setting or level of care, treatment and services and defines when a medical history and physical examination must be validated and countersigned by a Practitioner with appropriate privileges. The quality of all medical and physical examinations are monitored by the Medical Staff.

An Advanced Practice Nurse (APN) or a Physician Assistant (PA) may perform the history and physical examination if they have been credentialed and privileged to do so by the Board of Trustees. If the performance of the H&P is delegated to an APN or PA, the APN or PA must have delegated authority from their collaborating physician or their supervising physician respectively, and this must be located in written form in APN or PA’s credentialing file located in the Medical Staff Office.

History and physical examinations completed by medical students are for educational purposes only and do not meet the required H&P standards, even if authenticated by a medical staff or house staff physician.

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