Transcription
MEDICAL STAFFBYLAWS, RULES ANDREGULATIONSINDEX – Pages 2-6BYLAWS – Pages 7 - 34RULES AND REGULATIONS – Pages 34 – 51
Abbreviations. RR4.9Active Medical Staff. 4.2Admitting CriteriaIntensive Care. RR3.1Mental Health. RR3.2Neonatal . RR1.2.1.6Obstetrical . RR1.2.1.4Pediatrics . RR1.2.1.5Admitting Priorities . RR1.1.7Admitting PrivilegesActive Staff . 4.2Associate Staff . 4.3Consulting Staff . 4.4Courtesy Staff. 4.5Honorary Staff. 4.6Adoption ofBylaws. 17.0Rules and Regulations . 17.0Agreement of Compliance. 3.2.2.2.5Allied Health Professionals . 5.0; RR7.6Alternate Physician Coverage . 3.2.2.4; RR1.1.5AmendmentsBylaws. 15.0Rules and Regulations . 16.0Anesthesia Privileges. RR7.2.3Appeal of Summary Suspension . 8.1.3Appellate Review . 9.1; 9.6Applicant for Staff Membership . 6.1AppointmentApplication. 6.0; RR7.1Chair Clinical Departments . 11.2Duration - Medical Staff . 3.3Process . 6.2Provisional . 3.3.2Temporary. 7.2Termination. 6.3.3Associate Medical Staff. 4.3Authentication, Medical Records . RR4.3; RR4.8Autopsy . RR1.3.3Board Certification . RR7.2.1; RR7.2.2; RR7.3.1;RR7.3.2Bylaws Committee . RR5.2Cancer Committee . RR5.6Chair--DepartmentResponsibilities . 11.2.1Termination. 11.2.3Qualifications. 11.2.2Clinical Departments . 11.0Clinical PrivilegesDental . 7.1.4; RR2.72
Emergency . 7.3Initial . 7.1.2Reappointment . 6.3Allied Health Professionals . 5.2Qualifications. 5.1; RR7.0Temporary. 7.2Clinical Psychologist . RR7.6.6Committees - Appointment . 10.6.1.4; 12.1Committees - Vacancies . 12.1.3Committees/Service Lines. 12.0; RR5.0Conduct of Care . RR2.0Confidentiality . RR4.13Conflict Resolution 20.0ConsentRelease of Information. RR4.12Agreement . RR1.1.11Consultant . RR2.8Consulting Medical Staff. 4.4Consultation Reports . RR4.6Consultation, Required . RR2.6;RR2.7;RR2.8; RR3.2.1.2Continuing Medical Education. 2.3; 6.3.2Contracted or Hospital Based Physicians--Terminationof Contract . 3.3.7of Staff Privileges . 3.3.6Corrective ActionActivities and conduct . 8.1.1DEA . 8.3.2OIG Sanctions . 8.3.4Procedure . 8.1; 8.5Professional Liability . 8.3.3State License Suspension/Revocation . 8.3.1Counsel During Hearing and Appellate Review . 9.5.5Countersignatures, Medical Records. RR4.3Courtesy Medical Staff . 4.5Coverage, Emergency Department . RR3.3.1Credentials/Bylaws Committee . RR5.2Current Competence . RR5.2.2Definitions . 14.1Dental/Oral Surgery Staff . 7.1.4; RR2.7Dental Patient, Responsibility For. 7.1.4; RR2.7Department, Chair . 11.2.1Department, Vice Chair . 11.2.4Departments . 11.0Surgery . RR7.2Medicine . RR7.3Determination of Death . RR1.3.2Diagnosis, Final . RR4.10Disaster Plan . RR3.3.5Discharge . RR1.3Diagnosis. RR4.11Summary . RR4.11Timing of Completion . RR4.173
Disciplinary Action--See Corrective ActionElection of Staff Officers. 10.3Emergency Care . RR3.3Emergency Medicine Privileges. RR7.3.5Emergency Privileges . 7.3Ethical & Religious Directives . AttachedEthical Pledge . 3.2.3Executive Committee . 12.2Expedited Privileging .6.2.11Final Diagnosis . RR4.10Professional Practice Evaluation (PPE) Requirements . 3.4Forms, Medical Staff . RR7.1.1HearingCommittee .9.4Conduct Of .9.5Notice .9.3Officer.9.4Request .9.2Right 9.1History & Physical. RR4.2; RR4.3Honorary Medical Staff . 4.6Immediate Past President . 10.6.3Immunity From Liability . 14.4Incomplete Records as Grounds for Corrective Action . RR4.5; RR4.17Insurance Coverage . 3.2.2.1Leave of Absence . 7.4Liability, Immunity From . 14.4Locum Tenens . 7.2.2Medical Education . 2.2; 2.4; 6.3.2Medical Records . RR4.0Access.RR4.14Completion Requirements.RR4.17Confidentiality of .4.13Release.RR4.12Medical Screening Examination . 5.4Meeting, Annual Medical Staff . 13.0Meeting Attendance as Grounds for Corrective Action . 13.4MeetingsAttendance Requirements .13.4Committee/Service Lines .13.0Department .11.2.6Staff .13.0Membership—Committee/Service Line Appointment Of . 10.6.1.4; 12.1Mental Health Patients . RR3.2Nurse Anesthetist. RR7.6.1Nurse Practitioners . RR7.6.2Nurse Midwife . RR7.6.4Nondiscrimination in Appointments . 3.3.5Obstetrics & Gynecology Privileges . RR7.2.5OfficersDuties . 10.6Election . 10.34
Nomination--Method of. 10.3.1Qualifications . 10.2Vacancies . 10.2Term . 10.4Termination/Removal . 10.5Operative Report. RR4.5Optometrist . RR7.6.7Oral & Maxillofacial Surgery and Dentistry Privileges. RR7.2.6OrdersDischarge . RR4.11Legibility . RR2.3Routine . RR4.16Stop Orders . RR2.4Verbal . RR4.16.1Outpatient Testing . 3.1.1Past President . 10.6.3Pathology Privileges . RR7.4.1Pediatric Privileges . RR7.3.4Physician Assistant . RR7.6.3Podiatry, Surgical . RR7.2.7Policies . 18.0Prenatal Record. RR4.7President . 10.6.1President-Elect . 10.6.2Privileges .5.2Professional Practice Evaluation .3.4Progress Notes . RR4.4Provisional Appointment. 3.3.2Psychologist, Clinical . RR7.6.6Purpose of Organization . 2.0Qualifications for Clinical PrivilegesAllied Health Professionals . 5.1General . RR7.1.3Anesthesia . RR7.2.3Emergency Medicine . RR7.3.5Medicine . RR7.3.3Obstetrics & Gynecology . RR7.2.5Oral & Maxillofacial Surgery and Dentistry . RR7.2.6Pathology . RR7.4.1Pediatrics . RR7.3.4Radiation Medicine . RR7.4.3Radiology . RR7.4.2Residents . RR7.5Surgery - Core . RR7.2.4Surgery - General . RR7.2.4.1Qualifications for Initial AppointmentMedical Staff Membership . 3.2Allied Health Professional . 5.1Quorum . 13.3Radiation Medicine Privileges . RR7.4.3Radiology Privileges . RR7.4.2Release of Medical Information . RR4.125
Residents . RR7.5Responsibilities of Allie
locum tenens for a member of the Medical Staff to practice in the Medical Center provided the locum tenens applicant has submitted a complete application and the application has been processed in the same manner as a permanent staff member
