Rules and Regulations


1. Admitting, Discharge, and Transfer of Patients 2


Eligibility to Admit  


Provisional Diagnosis  


Control of Admitting, Discharge and Transfer  


Appropriateness of Patients  


Responsibility for Patient Care  


Patient Consent for Diagnosis and Treatment  


Information Required Upon Admission  


Specialty Care Units: ICU, CCU, and PCCU  


Triage From Special Care Areas  


Discharge of Patients  


Patients Admitted to the Teaching Services  
2. General Conduct of Patient Care 5


Medical Records  


Orders for Out-Patient Testing  




Preprinted Orders  


Expiration of Orders Upon Transfer  


Pharmaceutical Related Matters  


Use of Consultants  




Pre-Operative Evaluation  


Required Pre-Operative Documentation  


Invasive Procedures, Required Documentation  


Specimens Removed  


Assistants at Surgery  


Practitioner Punctuality  


Patient Resuscitation Classification  




Patients Leaving the Hospital Against Medical Advice  


Treatment of Mass Casualties  


Care in the Emergency Department.  
3. Human Experimentation and Research Activities 17
4. Medical Students 18
5. Adoption 19

1.    Admitting, Discharge, And Transfer Of Patients.           (return to top)

1.1    Eligibility to Admit.  A patient may be admitted to the Hospital only by an Active, Courtesy Staff member or Nurse Practitioners with admitting privileges in good standing. In the event the admission is arranged by a podiatrist, oral surgeon, dentist, or Nurse Practitioners with admitting privileges, the following conditions shall be met:

1.1.1    That specific professional shall be responsible for documenting an assessment of the reason for admission from the perspective of his professional discipline and for management of the admitting problem(s) and clinical activity shall be restricted thereto.

1.1.2    That specific professional shall arrange for a history and physical to be performed by a practitioner eligible to do so. Qualified oral surgeons who have been granted the privilege to do so, may perform histories and physical examinations on their own patients in the absence of any coexisting medical problems.

1.1.3    A staff practitioner or other appropriate consultant shall be responsible for the management of any other medical problem not within the clinical privileges of the specific professional arranging the admission.

1.2    Provisional Diagnosis.  Except in an emergency, no patient shall be admitted to the Hospital until a provisional diagnosis has been stated by a member of the Medical Staff. The admission is to be consistent with the policies of the Hospital. In case of emergency, this provisional diagnosis shall be stated as soon after admission as possible.

1.3    Control of Admitting, Discharge and Transfer.  All practitioners shall be governed by the official admitting transfer, discharge and triage policies of the Hospital.

1.4    Appropriateness of Patients.  The Hospital shall admit only that type of case consistent with the policies of the Professional Staff and the Board of Trustees.

1.5    Responsibility for Patient Care. 

1.5.1    The admitting practitioner is that member of the staff who makes the arrangements for the patient’s hospitalization. The admitting practitioner (the attending practitioner ) is responsible for the patient until the patient is discharged, or until such time as the admitting practitioner  transfers the care of the patient, through a written order on the chart, to another practitioner  (who becomes the attending practitioner ), who has agreed in writing to assume responsibility for the care of the patient.

      1.5.2    As part of the responsibility of patient care; he or she shall also be responsible to respond to any hospital page/call within 30 minutes.  Initial Call and response times shall be documented within the Medical Record.  Each member of the Professional Staff who is not available for the care of his/her patient shall name a member of the Medical Staff with appropriate privileges who is available and who will accept responsibility for continuing care of the staff member’s patient in the Hospital, including discharge or transfer when medically indicated. In case of a failure to name such a staff member, the Chief of Staff or appropriate department chairman shall have the authority to call any member of the staff to provide the necessary care.

      1.5.3    When a supervising or collaborating practitioner  is required by licensing or privileging, Mid Level Providers shall identify the collaborating or supervising practitioner.

1.6    Patient Consent for Diagnosis and Treatment.  A general consent for diagnosis and treatment signed by, or on behalf of, every patient admitted to the Hospital shall be obtained at the time of admission.

1.7    Information Required Upon Admission.  Practitioner admitting patients shall be responsible for providing the Hospital any available information as may be necessary to protect other patients and staff.

1.8    Specialty Care Units: Intensive Care Unit, Coronary Care Unit and Post-Critical Care Unit.  Admission, discharge and transfer from the Critical Care Areas shall be governed by such criteria as is developed from time to time and approved by the appropriate Professional Staff department or hospital unit or cluster.

1.9    Triage From Special Care Areas (ICU, CCU and PCCU).   The triage to and from special care areas shall be consistent with the guidelines as developed by the appropriate Professional Staff department or hospital unit or cluster. The triage officer shall have the authority to arrange transfer of patients without the necessary consent of the attending practitioner  if a situation arises that requires application of the admitting and transfer criteria for the special care area involved.

1.10    Discharge of Patients.  Patients shall be discharged only upon the written order of the attending practitioner  except under the disaster conditions set forth in the Hospital disaster manual.

1.11    Patients Admitted to the Teaching Services.  All patients admitted to the teaching service shall be admitted through the appropriate resident practitioner, as outlined under the regulations of the Tucson Hospitals Medical Education Program, Inc., and as approved by the Medical Executive Committee.

2.    General Conduct of Patient Care.        (return to top)

2.1    Medical Records.

2.1.1    Custody of Medical Records. The medical record is the property of the Hospital and is maintained for the benefit of the patient, the practitioner and the Hospital. No record shall be removed from the premises without court order, subpoena, or to meet other statutory requirements. The Hospital shall safeguard the information contained in the records against loss, effacement, tampering, alteration, or use by unauthorized persons.

2.1.2    Access to Medical Records. Free access to medical records of all patients shall be accorded duly constituted committees of the Professional Staff for the purpose of medical care evaluation and review of utilization. In the case of readmission of the patient, all previous records shall be available to the attending staff member. Professional Staff members in good standing shall have access to the medical records of all patients for bonafide study and research upon the recommendation of the Medical Executive Committee. Written consent of the patient is required for the release of information from the medical record to persons not otherwise authorized to receive this information.

2.1.3    Medical Record Preparation. The attending practitioner, even when house staff is participating in the care of the patient, shall be held responsible for the preparation of a complete medical record of each patient. This record shall contain:    Identification data.    Medical history:    Chief complaint;    Details of present illness;    Relevant past, social and family histories;    Inventory by body systems;    Pediatric/adolescent records must include the patient’s development age, immunization status, and the family’s involvement in the care of the patient. Obstetric records must include prenatal information.    Physical examination.    Conclusions/impressions from the admission history and physical.    Course of action planned for the patient.    Diagnostic and therapeutic orders.    Evidence of appropriate informed consent.    Clinical observations.    Progress notes.    Consultation reports, if applicable. All responses to a request for consultation shall show evidence of a review of the patient’s record by the consultant, pertinent findings on examination of the patient, and the signed opinion and recommendation of the consultant.    Reports of procedures and surgical operations.    Reports of tests and their results.    Discharge/death summary:    Principal and other relevant diagnoses;    Principal and additional procedures;    Reason for hospitalization;    Significant findings;    Condition of patient on discharge;    Specific instructions given to patient/family;    Autopsy report, if applicable.    No medical record shall be filed until it is complete. Incomplete records, under unusual circumstances, may be filed at the discretion of the MEC.

      2.1.4    Entries in the medical record, including telephone orders, may be made by members of the Professional Staff or house staff and, when relevant to their respective discipline, by hospital employees acting within the scope of their job description and certain third party health care providers specifically authorized by the Hospital and within their realm of certification, licensure or registration.  All entries (including practitioner orders) in the medical record require a legible printed name, as well as the time and date of each entry and must be authenticated.  A signature stamp is acceptable only if signature is on file in the Professional Staff Office and the person whose signature is on the stamp keeps the signature stamp in possession.
2.1.5    All orders dictated over the telephone shall be read back by the person authorized to receive them and signed by that authorized person with the name of the Practitioner dictating.  Telephone orders for behavioral health patients in a behavioral health setting must be countersigned by the ordering practitioner within 48 hours.  All other telephone orders must be countersigned by the ordering practitioner within 72 hours.  Authentication of Medical Records is the responsibility of each medical staff practitioner.  Unless otherwise required by law or regulation, authentication may occur as follows:    Authentication of medical record entries by a practitioner means:    Entries shall be deemed authenticated when the practitioner's name or initials and title are recorded on the entry.    The practitioner understands and acknowledges his/her responsibility for the content of the entry.    The practitioner has not countermanded the noted entry.    If a computer key is used to authenticate entries, the practitioner using the computer key is the only one with knowledge of the user code to assign the computerized signature, and the Professional Staff Office has a letter on file verifying this.    All orders dictated over the telephone shall be repeated by the person authorized to receive them and signed by that authorized person with the name of the practitioners who dictated the orders.

2.1.6    Timely Completion of Medical Records. An admission note shall be completed within 24 hours of the admission of the patient. It shall contain a provisional diagnosis, pertinent physical findings, and a plan of care. A report of History and Physical examination shall be available in the chart or clinical viewer within 24 hours of admission.  A History and Physical completed within thirty (30) days of admission is acceptable.  However, if it is completed more than seven (7) days prior to admission, an updated entry by the practitioner is required at the time of admission.  Updates should indicate any significant changes that may have occurred in the patient's condition.  If no change has occurred, state that there is no significant change in condition, and date and sign.  If the time frame exceeds thirty (30) days from admission, a current History and Physical exam shall be available in the chart or clinical viewer.  An interval History and Physical is acceptable if the patient is readmitted within thirty (30) days of discharge from this Hospital.  If the patient is admitted for an entirely different diagnosis, a current history and physical exam shall be available in the chart or clinical viewer.

2.1.7    Delinquent Medical Records. A practitioner with delinquent medical records shall be refused permission to book patients for admission or surgery until all such delinquent records have been completed. This restriction on admissions shall not relieve the delinquent practitioner of his responsibilities for ER call. Admissions or operations previously scheduled will be honored. A delinquent record is defined as:    Any record lacking a history and physical report more than 24 hours after admission.    Any record lacking an operative report more than 24 hours after procedure.    Any Discharge Diagnosis Form incomplete more than 24 hours after discharge.    Any record incomplete more than thirty days from the date the record is made available for completion.    Except when a provider currently has incomplete records, providers will not become delinquent during an extended absence from town if the Medical Records Department receives advance signed notice from the practitioner indicating the dates he/she will be absent.  Provider will have a 3-day grace period after scheduled return to complete all medical records.

2.1.8    Incorporation of Regulatory Requirements.  In the event the requirements of any regulatory or accrediting body differ from those set forth in these Rules and Regulations, such requirements shall be deemed incorporated herein by reference.

2.2    Orders for Out-Patient Testing.  Licensed practitioners, oral surgeons, dentists, podiatrists, or Mid Level Providers may order out-patient tests consistent with their license to manage the care identified by way of the results of the test, but need not be members of the Professional Staff.
2.3    Orders.

2.3.1    Orders Requiring Authentication Signatures.    Admission order;    Medication;    Treatments;    Operative orders;    Discharge orders;    Resuscitation status;    Diagnostic studies requiring practitioner interpretation, i.e., pathology reports or EKGs;    Restraints or seclusion.

2.3.2    The attending practitioner is not compelled to sign any order not given by him, or any order not at his direction; but may sign the following, if he elects to do so:    Orders written by an associate or other designee on his patient during the attending’s absence;    Orders written on his patient by a resident practitioner.

2.4    Preprinted Orders.  Preprinted order sets are formulated and approved by the Professional Staff in consultation with The Orders/Protocols Review Committee.  All orders are reviewed and updated as necessary.   No preprinted order shall replace or override those orders written for a specific patient.
2.5    Standing Orders.  Standing Order sets are formulated and approved by the Professional Staff and finalized by the Orders and Protocols Review Committee.  Standing Orders must be applied to all patients meeting the criteria.

2.6    Expiration of Orders Upon Transfer.  All orders for patient care shall be canceled at the time of surgery, or change in level of care, i.e., on transfer to or from the Intensive Care Unit or Coronary Care Unit. It shall be the responsibility of the attending practitioner to initiate or renew orders promptly for the continuation of patient care.

2.7    Pharmaceutical Related Matters.
2.7.1    Hospital Formulary. A Hospital formulary shall be maintained by the Pharmacy under the direction of the Pharmacy and Therapeutics Committee. The formulary restricts the drugs that are listed and inventoried. Substitution by the pharmacist of an equivalent drug from a different manufacturer shall be permitted, unless otherwise specifically indicated by the practitioner.

2.7.2    Content Medication Order: The prescribing practitioner shall include the following in any order for medication: medication name, dose, frequency, route, and the indications for PRN medications.

2.7.3    Duration of Medication Order. The prescribing practitioner may order medication for a specific number of days or for the duration of the patient’s stay or a specific number of doses.    The following time periods shall govern obligatory re-evaluation of certain medication orders:    Narcotics and other Class I controlled substances - 72 hours;    Barbiturates and other Class III controlled substances - 72 hours;    Anticoagulants - 72 hours;    Antibiotics: Empiric-72 hours; Therapeutic-7 days; Prophylactic-48 hours;    Steroids - 7 days;    All other drug orders and reorders of all existing drug orders - 10 days.    Medications Brought to the Hospital by the Patient. Patient’s personal medications may be self-administered only following identification by the Hospital pharmacy, with practitioner order in patient’s name, including medication name, dose, frequency, route and indications for PRN orders. The patient must understand the administration schedule and the patient must sign a hospital release from responsibility. This shall be permitted only after the patient signs a release from responsibility. All such dosing shall be recorded on medication forms by nursing.

2.8    Use of Consultants.

2.8.1    Practitioners will seek consultation for levels of care which are not covered by the category of clinical privilege granted to them.

2.8.2    Consultations on critically ill patients shall be requested as deemed necessary from time to time for sound medical practice, as may be defined and approved by the department of the Professional Staff.

2.8.3    The attending practitioner is primarily responsible for requesting consultation when indicated and for selecting the qualified consultant.

2.8.4    A consultant is a practitioner well qualified to give an opinion in his area of expertise.

2.8.5    All consultations shall be requested in writing, timed, and dated by the requesting practitioner, and shall include the indications or purpose for the consultation.  The order for consultation shall include the following:  The consultant's full and correct name and specialty;  Specify what is requested of the consultant (procedure to be performed, consultation and treatment, or consultation only, etc.) with a specific reason for consultation;  Clearly explain any qualifying data with respect to patient's requests, insurance requirements or other stipulations;  Specify a requested time for completion (routine, urgent or emergent);  The requesting practitioner must leave his/her most accessible call back number.

2.8.6   Consultation response times are defined as follows:  Routine-performed within twenty-four (24) hours; Urgent-performed within twelve (12) hours; and Emergent-performed within four (4) hours.  If the consultation request is urgent, the ordering practitioner will communicate with the consultant via a telephone call or face-to-face meeting.

2.8.7   If the requesting practitioner is unable to procure an emergency consultation for an in-house patient, the practitioner on call for the emergency room in the appropriate specialty must perform the consultation and respond in a timely fashion.  If consulting doctor(s) refuse to consult, they should be reported to the Chief of Staff and the Chief Medical Officer for review.

2.8.8    In all cases where the action of the Medical Executive Committee, Professional Affairs Committee, or the Board of Trustees requires consultations as a requirement of observation, the consultant shall perform his consultation without charge.

2.9    Consents.  In addition to the general consent for diagnosis and treatment signed at the time of admission, each staff member shall obtain additional informed consents signed prior to diagnostic, therapeutic, or operative procedures which entail significant risk. In the case of emergencies involving a minor or a patient who is unconscious or otherwise incompetent to render an informed consent, or when a patient’s life is in jeopardy and suitable consent cannot be obtained, the circumstances shall be fully recorded on the medical record. In such instances, when time permits, a consultant’s opinion is desirable.
2.10    Pre-Operative Evaluation.  The time limit for pre-operative laboratory testing will be left to the judgment of the attending practitioner and the anesthesiologist.
2.11    Required Pre-Operative Documentation.  It is presumed that laboratory, x-ray and other studies ordered pre-operatively are essential for the diagnosis and definite treatment of the patient. Therefore, except when a delay would be detrimental to the patient, no operation will be performed unless the following are recorded in the patient’s record:

2.11.1    A dictated or hand-written history and physical, including:   Chief complaint;   Details of present illness;   Relevant past social and family histories;   Inventory of body systems;   Pediatric/adolescent records must include the patient's developmental age, immunization status, and the family's involvement in care of the patient.  Obstetric records must include prenatal information.;   Physical exam;   Conclusions and impressions from the history and physical;   Course of action planned for the patient.

2.11.2    All patients having a planned procedure will have a dictated or written History and Physical exam in accordance with Section 2.1.6.

      2.11.3    A short history and physical examination form may be acceptable for outpatient procedures, procedural sedation, or procedures with a less than 48 hour hospitalization.  The short history and physical examination should contain the same elements as the routine history and physical examination but may be focused on the problem for which the patient is receiving treatment. Patients undergoing surgery by a Dentist, Oral Surgeon or Podiatrist shall have a history and physical examination performed by a practitioner (M.D., D.O., or Oral Surgeon, when credentialed to perform the history and physical to those patients admitted by him).

      2.11.4   Any patient scheduled for any invasive procedure without an H&P on the chart prior to the procedure or a procedure involving moderate or deep sedation will have the procedure postponed until the documentation is completed.

2.12    Invasive Procedures, Required Documentation.   Immediately after the completion of all invasive procedures, a brief operative note shall be placed in the medical record. The performing practitioner must provide a full description of all invasive procedures, and such record should be completed immediately following the procedure, but no later than 24 hours after the procedure.
2.13    Specimens Removed. 

2.13.1    All tissues or foreign bodies removed during any invasive procedure shall be sent to the Department of Pathology for examination except the following:    Specimens that by their nature or condition or situation do not permit productive examination such as a cataract, orthopedic appliance, foreign body, or portion of rib removed only to enhance operative exposure;    Therapeutic radioactive sources, the removal of which is guided by radiation safety monitoring requirements;    Traumatically injured members that have been amputated and for which examination for either medical or legal reasons is not deemed necessary;    Foreign bodies (e.g., bullets) that, for legal reasons, are given directly in the chain of custody to law enforcement representatives;    Specimens known to rarely, if ever, show pathological change, and removal of which is highly visible postoperatively, such as the foreskin from a circumcision of a newborn infant, providing removal of such normal tissue is widely accepted procedure;    Placentas that are grossly normal and have been removed in the course of operative and non-operative obstetrics;    Teeth, provided the anatomic name or anatomic number of each tooth, or fragment of each tooth, is recorded in the medical record;    IUDs;    Scar tissue.

      2.13.2    All tissue or foreign bodies removed during any invasive procedures shall be documented as to their disposition in the operative report or on the operating room record. Surgeons shall be specific as to the types of studies to be performed on the tissue sent to the Department of Pathology.

2.14    Assistants at Surgery.  Assistants at surgery shall be either practitioners with Category II, III, IV surgical privileges, or members of an approved residency program qualified to assist at surgery under their privileges and professional guidelines.
2.15    Practitioner Punctuality.  For all procedures which require scheduling, promptness will be expected. Tardiness without reason will be dealt with through departmental rules or action.
2.16    Patient Resuscitation Classification.  Prior to any invasive procedure, all attending practitioners will indicate the level of resuscitative effort appropriate for the patient, should the need arise. In the absence of such orders and in the absence of an applicable advanced directive, all patients shall be classified as Category A, and full resuscitative measures will be initiated.
2.17    Deaths/Autopsies.  A deceased patient shall be pronounced dead by the attending practitioner or his designee, who shall be a member of the Medical Staff or house staff. In the case of hospice patients where the death is anticipated, two registered nurses may pronounce death in the absence of the attending practitioner. The body shall not be released until a signed entry is made in the record. Every member of the Medical Staff shall be actively interested in securing meaningful autopsies whenever a death occurs. No autopsy shall be performed without the written consent of the nearest relative or legal guardian. All autopsies shall be performed by a member of the Department of Pathology or by a practitioner so designated by that department. Release of the body shall conform to the statutes of the State of Arizona and the policies of the Hospital. The statutes of the State of Arizona shall apply in the retention or transfer of anatomical organs. The attending practitioner shall obtain the necessary authorization forms.

2.17.1    Criteria for securing an autopsy:    Unanticipated deaths;    Deaths in which exact cause of death is not known (cause is sufficiently obscure to delay completion of death certificate);    Deaths related to genetically inheritable condition (for purposes of genetic counseling);    Intra-operative or intra-procedural death (usually OME cases);    Deaths in which autopsy would meaningfully augment medical knowledge;    Potentially iatrogenic deaths (within 48 hours of surgery or invasive diagnostic procedure, with deep venous lines or intubation or other life support mechanisms, etc.);    Death incident to or within 7 days of pregnancy;    Death occurring in patients on experimental therapy, if autopsy results are considered helpful to evaluation of experimental regimen;    Accidental deaths (usually OME cases).

2.17.2    To ensure that autopsy findings have meaningful clinical impact, all autopsies will be reviewed by the appropriate chart review committee as determined by Medical Records.

2.17.3    In all autopsies, provisional anatomic diagnoses will be recorded in the medical record within three (3) working days.  The completed autopsy protocol will be made a part of the medical record within 30 days.

2.17.4    There will be a spot check analysis of autopsies by the Pathology Department to determine whether or not the clinical diagnoses are addressed appropriately in the clinical correlation and to give an overall review of the quality of the pathologic report.  These will be discussed at a group meeting.

2.18    Patients Leaving the Hospital Against Medical Advice.   Patients refusing treatment or hospitalization may be discharged against medical advice after the Hospital attempts to secure their signature on a release relieving the Hospital and the attending practitioner of any further responsibility for their medical condition.
2.19    Treatment of Mass Casualties.  When conditions arise which make it necessary to put the Hospital’s disaster plan into effect, all practitioners who have been assigned to Hospital posts will be responsible for reporting to their assigned places. The Chief of Staff or the Hospital Medical Director will have the authority, or may delegate it to another staff member, to order the discharge or transfer of any patient in the Hospital to provide beds for disaster patients, or to order the evacuation of the entire Hospital. All members of the staff agree to accept such orders and so advise their patients should the question ever arise. The occurrence of a disaster or implementation of the disaster plan shall not absolve the attending practitioner of his responsibility to see that all the medical records of his patients are completed in a timely and orderly fashion.
2.20    Care in the Emergency Department.

2.20.1    The medical staff through its Emergency Department practitioners, and its Active and Courtesy staff shall ensure compliance with the Emergency Treatment and Labor Act.  All patients presenting to the Emergency Department shall recieve an Emergency Screening Examination and either stabilization of the patient's emergency medical condition or transfer to a more appropriate facility.    Any patient who presents himself to the Emergency Services Department for care and who also does not specify or request a private attending practitioner is automatically the responsibility of the Emergency Services Practitioner for care. The patient will be referred to the appropriate specialty practitioner from the list of "on-call" practitioners for follow-up or continuing care. If a patient requests the services of a practitioner with whom the patient has no prior medical relationship, that practitioner has no responsibility to accept the care of the patient unless the practitioner is the "on-call" practitioner. A copy of the emergency medical record of the patient should be forwarded to the practitioner who ultimately accepts responsibility for care, either initially or as follow-up care.    When a patient presents himself/herself to the Emergency Services Department for care and specifies a specific private attending practitioner, that practitioner shall be consulted as to the treatment of the patient. The private attending practitioner may request a specialist or staff practitioner of his choice (call or non-call), unless the patient states a preference. The private attending practitioner is responsible for the care of the patient until a referral practitioner has agreed to accept and continue the care of the patient. A copy of the emergency medical record of the patient should be forwarded to the responsible private attending practitioner.

2.20.2    Any refusal by an on-call list practitioner or private attending practitioner with a prior medical/patient relationship to accept care of the patient will be referred to the appropriate clinical department for remedy.

2.20.3    Any staff member assigned to Emergency Department Call may arrange for a colleague to cover this duty, either permanently or intermittently. It is, however, the individual practitioner who must make such arrangements, and he should then so notify the Hospital.

2.20.4    The practitioner on-call in the Emergency Department will be called a second time if he fails to respond to the first call.    If there is still no response at the end of an hour, or more rapidly if the medical situation so warrants, the attending second-call practitioner will be called and asked to make a disposition of the case.    In any such instance, the Emergency Department record will be forwarded to the department of the attending practitioner who did not respond to the emergency call, and that department will evaluate the incident and implement the appropriate corrective action.


3.    Human Experimentation and Research Activities.         (return to top)

The Hospital shall do all in its power to foster research consistent with adequate safeguards for the patient and potentially meaningful advances in medical science:

3.1    All clinical research studies impacting patient care must be reviewed and approved by the Human Research Committee (IRB).

3.2    Investigational clinical studies shall be conducted only under the direction and supervision of the practitioner responsible for the use of the investigational drug, device or protocol in this institution. The supervising practitioner shall be a member in good standing of the Hospital’s Professional Staff and shall assume the burden of securing the necessary consent.

3.3    The pharmacy shall be the storage area for investigational drugs.

3.4    The patient will be given a protocol, information, and a consent form to sign at the beginning of investigational clinical study.

3.5    Administration of an investigational drug, or application of an investigational device shall be the direct responsibility of the practitioner supervising the study at this Hospital.

3.6    When nurses are called upon to administer investigational drugs or devices, they shall have available to them basic information concerning such drugs or devices including: dosage forms, strengths available, actions and uses, side effects, symptoms of toxicity, operating procedures and maintenance, etc.


4.    Medical Students.         (return to top)

4.1    Medical students are not licensed practitioners and, therefore, all their work with patients must be reviewed, amended as necessary and countersigned by a practitioner legally entitled to care for patients.

4.2    Medical students are permitted to perform histories and physical examinations for evaluation by the house and attending staffs, but these are not acceptable as part of the official record. The Medical Records Department shall not accept material dictated by medical students with the exception that fourth year medical students can dictate History and Physicals, which must be signed by the attending practitioner.

4.3    Medical students are permitted to write orders in the chart provided they are countersigned, or given telephone approval, by the appropriate practitioner at the time of writing. Such orders will be written with both the student’s and the practitioner’s names attached (e.g., "V. Smart, M.D. per I.M. Green, MSIII"). Nurses are not to carry out student orders until a practitioner’s signature is attached to the order or telephone permission obtained from the practitioner.

4.4    Students cannot sign out-patient prescriptions without the signature of a practitioner.

4.5    Pelvic examinations may be performed by medical students but only when approved by the practitioner and in the presence of a nurse.

5.    Adoption.         (return to top)

Professional Staff.  This Rules and Regulations Manual was adopted by the MEC in accordance with and subject to the Professional Staff Bylaws.

Chief of Staff

Date June 14, 2004

10/8/01 - 2.1.5
9/9/02 - 2.7.7
10/13/03 - 2.1.6, 2.10.1 thru 2.10.4, and 4.2
3/8/04 - 2.1.6 and 2.10.2
6/14/04 - 2.1.4