RULES & REGULATIONS TABLE OF CONTENTS MEDICAL STAFF RULES AND REGULATIONS ............................................................................................ 7 DEFINITIONS .............................................................................................................................................................. 7 ADMISSION AND DISCHARGE OF PATIENTS ............................................................................................................... 8 GENERAL CONDUCT OF CARE .................................................................................................................................. 10 EMERGENCY SERVICES............................................................................................................................................. 12 DISASTER PLAN ........................................................................................................................................................ 13 RESIDENTS/FELLOWS IN TRAINING.......................................................................................................................... 14 MEDICAL RECORDS POLICIES ON COMPLETION OF MEDICAL RECORDS .................................................................. 15 INPATIENT AND OUTPATIENT RECORDS .................................................................................................................. 16 RESPITE CARE ........................................................................................................................................................... 16 HISTORY AND PHYSICAL ........................................................................................................................................... 17 CONSULTATION REPORTS ........................................................................................................................................ 18 OPERATIVE/PROCEDURE REPORTS .......................................................................................................................... 18 PROGRESS NOTES .................................................................................................................................................... 19 DISCHARGE SUMMARY / FINAL PROGRESS NOTE .................................................................................................... 21 DIAGNOSTIC REPORTS ............................................................................................................................................. 21 EMERGENCY ROOM RECORD ................................................................................................................................... 22 MEDICAL RECORD REVIEW ...................................................................................................................................... 22 RETIRE INCOMPLETE RECORDS ................................................................................................................................ 22 SUSPENSION ............................................................................................................................................................ 23 COMMITTEES ........................................................................................................................................................... 24 CONFLICT RESOLUTION ........................................................................................................................................... 31 DEPARTMENT RULES AND REGULATIONS AND CLINICAL DELINEATION OF PRIVILEGES ......... 33 DEPARTMENT OF ANESTHESIA .................................................................................................................. 33 RULES AND REGULATIONS ....................................................................................................................................... 33 PRIVILEGES .......................................................................................................................................................... 39 CORE I ANESTHESIA ................................................................................................................................................. 39 CORE I ANESTHESIA PRIVILEGES .............................................................................................................................. 40 CORE IA ANESTHESIA PRIVILEGES ............................................................................................................................ 40 CORE II ANESTHESIA PRIVILEGES ............................................................................................................................. 40 CORE II ANESTHESIA PRIVILEGES ............................................................................................................................. 40 CORE IIA ANESTHESIA PRIVILEGES ........................................................................................................................... 41 DEPARTMENT OF DENTISTRY ..................................................................................................................... 42 RULES AND REGULATIONS ....................................................................................................................................... 42 DELINEATION OF PRIVILEGES ................................................................................................................................... 42 DEPARTMENT OF EMERGENCY MEDICINE ............................................................................................... 46 RULES AND REGULATIONS ....................................................................................................................................... 46 DELINEATION OF PRIVILEGES ................................................................................................................................... 47 REQUIREMENTS FOR ULTRASOUND PRIVILEGES: .................................................................................................... 48 CORE I EMERGENCY MEDICINE DELINEATION OF PRIVILEGES ................................................................................. 49 CORE I PRIVILEGES IN EMERGENCY MEDICINE ......................................................................................................... 50 CORE II EMERGENCY MEDICINE DELINEATION OF PRIVILEGES ................................................................................ 51 CORE II PRIVILEGES IN EMERGENCY MEDICINE ........................................................................................................ 52 CORE IIA PRIVILEGES ................................................................................................................................................ 53 CORE II PRIVILEGES IN EMERGENCY MEDICINE ........................................................................................................ 54 TRAINING, EDUCATION, EXPERIENCE AND COMPETENCY REQUIREMENTS FOR ULTRASOUND PRIVILEGES .......... 54 ALLIED HEALTH PROFESSIONALS IN THE EMERGENCY DEPARTMENT ..................................................................... 56 DELINEATION OF REQUIREMENTS AND FUNCTIONS ............................................................................................... 56 Parkview Medical Center Medical Staff Rules & Regulations 05.28.2019 2 DEPARTMENT OF FAMILY PRACTICE ........................................................................................................ 58 ALLIED HEALTH PROFESSIONALS ............................................................................................................................. 61 DELINEATION OF PRIVILEGES ................................................................................................................................... 61 CORE I ...................................................................................................................................................................... 61 CORE II ..................................................................................................................................................................... 62 CORE II PROCEDURE CHECKLIST ............................................................................................................................... 63 CORE III .................................................................................................................................................................... 64 DEPARTMENT OF MEDICINE ........................................................................................................................ 65 RULES AND REGULATIONS ....................................................................................................................................... 65 DELINEATION OF PRIVILEGES ................................................................................................................................... 66 ALLIED HEALTH PROFESSIONALS ............................................................................................................................. 67 INTERNAL MEDICINE DELINEATION OF PRIVILEGES ................................................................................................. 67 CORE I PRIVILEGES IN INTERNAL MEDICINE ............................................................................................................. 68 CORE II PRIVILEGES IN INTERNAL MEDICINE ...........................................................................................................