period will be reported as delinquent.
All physicians and non‐physician practitioners will be notified of their incomplete medical records weekly. Any physician or non‐physician practitioner with more than 3 delinquencies on the monthly Medical Record Delinquency report will be reported to the Medical Executive Committee for
consideration of disciplinary action which can include suspension.
Any physician or non‐physician practitioner with more than 25 delinquent records on the monthly Medical Record Delinquency report for two consecutive months will be reported directly to the Medical Director for consideration of immediate disciplinary action which may include suspension.
Report will follow to the Medical Executive Committee.
When the decision to suspend a physician or non‐physician practitioner is enacted, the suspended practitioner will not be permitted to report to work for regularly scheduled hours in any department, schedule procedures, perform consults, admit, or assign patients to observation, or accept a transfer of a case unless authorized by the President of the hospital or the Medical Director. Existing admissions will not be affected by the suspension.
All suspensions will be reported to the Medical Executive Committee on a monthly basis for consideration of additional disciplinary action and renewal of privileges.
ARTICLE X PRIVILEGES OF INFORMATION AND RELEASE
All information on medical records is held to be privileged communication and is not to be released out side to parties or institutions without written permission of the patient, except in cases of subpoena, court order, or statute, in accordance with the law. All records are the property of the Hospital and shall not be released except by subpoena, court order, state and federal statute. In the case of
readmission of a patient, all previous records shall be available for the use of the attending physician.
This shall apply whether the patient is attended by the same physician or by another physician.
Unauthorized removal of charts from the Hospital is grounds for suspension of the physician for a period to be determined by the Executive Committee of the Medical Staff. Free access to all medical records of all patients shall be afforded to members of the Medical Staff for bonafide study and research consistent with preserving the confidentiality of personal information concerning the individual patients. All projects shall be approved by the Medical
Executive Committee of the Medical Staff before records can be studied. Subject to the discretion of the Administrator, former members of the Medical Staff shall be permitted free access to information from the medical records of their patients covering all periods during which they attended such patients in the Hospital. Medical Staff access to patient medical records shall coincide with HIPAA regulations.
ARTICLE XI MEDICAL COVERAGE OF EMERGENCY ROOM
Medical coverage in the Emergency Services Department is furnished by St. Luke’s Physician Group.
Physicians being provided must be credentialed in the usual manner of credentialing before staff approval. ED Physicians are credentialed to provide services in the Emergency Department only.
ED Physicians will only respond to situations in Acute Care and Nursing & Rehabilitation Center that involve
cardiopulmonary arrest and require the presence of a physician to direct resuscitation. (1/03)
Monitoring of physician services is the responsibility of the Emergency Services Section Director with reports sent to the Medical Executive Committee via quality assurance reviews. The duties and responsibilities of all personnel serving patients within the emergency area shall be defined in a procedure manual relating specifically to this outpatient facility. The contents of such a manual shall be developed by a multi‐specialty committee of the medical staff including representatives from nursing service and hospital administration. It shall be approved by the medical staff and by the governing body.
ARTICLE XII DISASTERS
All physicians shall be assigned to posts and it is their responsibility to report to their assigned stations.
The chief of the clinical services in the hospital and administrator of the hospital will work as a team to coordinate activities and directions. In cases of evacuation of patients from one section of the hospital to another, or evacuation from the hospital premises, the chief of the clinical services during the disaster will authorize the movement of patients.
All policies concerning direct patient care will be a joint responsibility of the department chairman and administrator of the hospital.
ARTICLE XIII MEDICAL STAFF FILES
Responsibility: All requests for medical staff files and/or records shall be made to and recorded and approved by the medical staff services coordinator according to the medical staff bylaws. The medical staff services coordinator will refer requests requiring further consideration to the chief of staff and/or legal counsel whenever necessary. Removal or copying will be upon permission of the chief of staff and /or as specified in this policy. The medical staff services coordinator and officers of the medical staff shall be responsible for preserving the confidentiality of the records in accordance with this policy.
Members of the medical staff recognize the importance of preserving confidentiality of all information obtained in connection with responsibilities as medical staff members.
Access by persons performing official hospital or medical staff functions are defined as follows:
1. Medical staff officers
2. Medical staff services coordinator 3. Department chairman
4. Section directors
5. Medical staff committee members 6. Consultants
7. Medical Director
8. Chief Executive Officer: The CEO or his designee shall have access to the information contained in a physician’s credentials and/or peer review file.
Access by medical staff members will be processed as follows:
1. Credentials and Peer Review Files: Review of the file can only be carried out by the individual physician in the presence of the medical staff services coordinator or his designee. The physician shall have a right to copies of documents submitted by him. A request form will be signed by the requesting physician and the chief of staff authorizing each request.
a) Examples:
b) Application and reapplication c) Delineation of privileges forms d) Licensure
e) Malpractice Insurance f) DEA Registration
g) Correspondence from him or addressed to him.
Committee/Department Records: Review may be carried out by all committee or department members of their respective committees or department minutes and correspondence after these documents have been approved by the chairman of the department or committee. Copying and distribution of minutes and/or correspondence will be at the discretion of the department chairman and/or chief of staff. All committee members are copied for distribution to the Medical Executive Committee after approval.
Access by persons or organization outside the hospital system will be processed as follows:
1. Credentialing or Peer Review at Other Hospitals: Routine written requests for information will be completed by the department chairman, chief of staff, medical director, CEO, in‐house departments if requested in these specialties, or the medical staff services coordinator. All request must be accompanied by written authorization for release of information from the involved physician prior to completion of such request.
2. Other Requests: All requests must be submitted in writing and reasons for the request provided. These requests by persons or organizations outside of the hospital for information contained in the medical staff files and/or committee/department minutes will be reviewed by the medical staff services coordinator and completed at the discretion of the chief of staff.
3. Subpoenas: All subpoenas of medical staff files/records shall be referred to the chief of staff and legal counsel prior to responding to the order.
Filing: All medical staff credential files and records are maintained in a locked file cabinet in a secure and locked area as follows:
1. Physician Credential Files: Physician credential files shall contain all credentialing information and other miscellaneous correspondence directly related to the individual physician.
2. Physician Peer Review Files: A Peer Review file is maintained in a separate file in a locked and secured area. Physicians will be notified of information recommended to be placed in their files and given the opportunity to review or dispute such information in accordance with medical staff bylaws.
3. Minutes: All minutes will be filed upon completion and final approval by the chairmen of the respective committee/department along with attached supporting documentation and filed with the MEC Minutes in the Office of Medical Staff Services.
4. Correspondence: All correspondence will be filed as completed and maintained in
chronological order within a binder in the Office of Medical Staff Services with any correspondence relative to department/committee meetings attached to minutes and filed accordingly.
Computer Access: Employees of Medical Staff Services are designated as having access to medical staff files/records contained in the Medical Staff Information System computer system. Release of this information will be kept in accordance with above guidelines. Computer disks, backup files, etc, are kept in a locked storage area.
ARTICLE XIV GENERAL PRINCIPLES OF PATIENT, PRACTITIONER AND HOSPITAL RELATI