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Hospital
news for the medical staff
Citywide disaster drill
Texas Children’s Hospital participated in a three-day State-Wide
Hurricane Evacuation and Sheltering Exercise on May 2, 2006,
which proved that we are on the right track as we continue to
refine our emergency preparedness process. As a reminder, the
Texas Children’s Physician Hotline number 832 824-DOCS will be
used for physician-specific updates in times of emergency.
New code of conduct policy
In response to a new focus by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO), the Peer
Review Subcommittee has developed a Code of Conduct Policy
MS100-04, which was approved by the Medical Executive Committee
on May 9, 2006. This policy was developed in a manner that will
encourage collegial intervention and response to physician
behavioral issues. This policy can be viewed on the Texas
Children's Hospital Intranet, Physician Resource Page, or by clicking on:
http://intranet.tch.tmc.edu/TCH/audit/pol_proc/Med%20Staff/Medical%20Staff%20P&P%20T-O-C.htm
Changes to rules and regulations
Please note changes to the Rules and Regulations that were
approved by the Medical Executive Committee and the Board of
Trustees. These changes require that all H&Ps be updated (or a
note stating that no change in status has occurred) at the time
of admission or prior to a procedure. These changes result from
recent revisions to JCAHO standards becoming effective on July
1, 2006.
Changes to B-6 reflect the need to include a direct contact
number (i.e., pager, phone number) when signing your name to
facilitate improved communication among caregivers.
Full text of the Medical Staff Bylaws, Rules and Regulations,
and Policies and Procedures are available on the Physician’s
Resource Page.
B-1. The attending physician shall be responsible for the
preparation of a complete and legible medical record. Its
contents shall be pertinent and current. The record for
inpatients shall include identification data, complaint,
personal history, family history, history of present illness,
physical examination, appropriate physiological parameters,
special reports such as consultations, clinical laboratory and
diagnostic imaging services and others, provisional diagnosis,
medical or surgical treatment, operative report, pathological
findings, progress notes, final diagnosis, condition on
discharge, summary or discharge note, evidence of known advance
directives, where applicable, and autopsy report when performed.
Documentation of outpatient encounters (i.e., in clinics, same
day surgery, emergency center and observation units) must
include the reason for the encounter, pertinent history and
physical examination findings, and the provider’s impression and
plan of care. The outpatient medical record includes
documentation of other outpatient services including operative,
laboratory, and diagnostic imaging reports. A summary list is
also part of the outpatient medical record and should be
initiated no later than the patient’s third visit in any single
clinic and updated as clinically appropriate by that clinic on
subsequent visits. The summary list contains the following
information, as assessed by the responsible provider/clinic:
significant diagnoses and conditions, significant operative and
invasive procedures, all known adverse and allergic drug
reactions, and all known long-term medications, including
current prescriptions, over the counter drugs and herbal
preparations.
B-2. A complete inpatient admission history and physical
examination shall be recorded within 24 hours of admission. This
report shall include the reason for admission, a complete
medical history and a physical examination and the provider’s
impression and plan of care. “Complete” means “inclusive of all
data pertinent to the encounter.” If a history and physical
examination meeting these requirements was recorded within seven
days prior to admission, it may be used in lieu of the above
report. However, documentation that there has been no change in
the H&P or an update to the H&P that includes all additions to
the history and any subsequent changes in the physical findings
must always be recorded within 24 hours of admission and prior
to procedure.
In addition, an assessment of airway, pulmonary and
cardiovascular status is specifically required immediately
before sedating (moderate/deep) or anesthetizing a patient.
B-3. a) Patients who are to have a same day surgical procedure
or outpatient surgery must have a complete history and physical
examination recorded in the medical record which has been
performed not more than 30 days prior to the procedure. If the
H&P was not performed within 24 hours of the procedure,
documentation that there has been no change to the H&P or an
update that includes all additions to the history and any
subsequent changes in the physical findings must be recorded
prior to the procedure.
b) When the history and physical examination are not recorded
before an operation or any potentially hazardous diagnostic
procedure, the procedure shall be canceled, unless the attending
physician states in writing that such delay would be detrimental
to the patient.
B-6. All clinical entries in the patient's medical record shall
be accurately dated and authenticated as follows:
a) Paper records must include a handwritten or rubber stamped
signature and professional credential, as well as a contact
number (i.e., pager or direct contact phone number).
b) Electronic records must include an approved electronic
signature/computer key.
The rubber stamp signature or computer key is used only by the
authorized individual. Rubber stamps may not be used to
authenticate orders for drugs and biologicals. Any document for
file in a patient's paper medical record shall be the original
or a copy legible in its entirety with an original signature
affixed after the reproduction was made.
New clinic/service chiefs named
Please note the following appointments:
Marianna Sockrider, M.D. has been named the chief of the
Pulmonary Clinic.
Aloysia Schwabe, M.D. has been named the chief of the Physical
Medicine and Rehabilitation Service.
Annual medical staff meeting date change
The annual meeting of the medical staff, normally held on
Tuesday, Aug. 8, 2006, has been changed to Monday, Sept. 18,
2006, and will be held at the Medical Center Marriott Hotel.
Please mark your calendar and plan to attend.
Important news from the Texas Department of Insurance
The Texas Department of Insurance (TDI) has revised the Texas
Standardized Credentialing Application. The new form can be
obtained from Medical Staff Services or the
TDI Web site.
Conversion to this revised form is required by the state of
Texas immediately, and will be requested at the time of your
next reappointment cycle. |
