The Role of the St. Dominic's Practitioner
This is merely a highlighted and non inclusive list.
- Provide the highest quality care using scientific evidence
- Use best practice protocols
- Utilize computerized physician order entry systems
- Support Core Measures
- Abide by National Patient Safety Goals
- Follow Infection Control Protocols and Guidelines
- Communicate directly with attending and consulting physicians
- Avoid verbal and telephone orders whenever possible
- Write legibly
- Never utilize unapproved abbreviations
- Sign, date, and time all entries in the medical record
- Document H&P within 24 hours of admission and before any operative or invasive procedures
- Dictate operative/procedure note immediately after a procedure
- Complete all medical records within 30 days of discharge
Emergency Medical Screening
When an individual comes to St. Dominic’s and a request is made on his/her behalf for an examination or treatment for a medical condition, or a prudent layperson observer would believe that the individual presented with an emergency medical condition, an appropriate medical screening examination, within the capabilities of the hospital’s emergency department (including ancillary services routinely available and the availability of on-call physicians), shall be performed by an individual qualified to perform such an examination to determine whether an emergency medical condition (EMC) exists or, with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC.
If an EMC is determined to exist the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as required by Emergency Medical Treatment and Active Labor Act (EMTALA). Such stabilization treatment shall be applied in a nondiscriminatory manner.
For dictation, dial 601-200-5808.
When prompted, enter your 4 digit ID number.
When prompted, enter the work type followed by the # key.
3# Operative Notes
4# Discharge Summary
6# Progress note
When prompted, enter the patient’s seven (7) digit account number followed by the # key. If you do not know the patient’s account number enter 1234567.
Timeliness of Physician Visits
All critical/unstable patients admitted to the adult critical care areas must be seen as soon as possible by the admitting physician or his designee. All patients admitted to the critical care areas must be seen by the admitting physician or his designee within four (4) hours of admission, or sooner, if the patient’s condition warrants.
Any patient admitted to an ICU area after a code will be seen by the attending physician or his designee within one (1) hour.
All other patients must be seen within 24 hours of admission. The attending physician shall have the overall responsibility for the care of the patient. The admitting/attending physician shall make rounds on a daily basis and enter a progress note in the record. Overall care of the patient shall not be delegated to non-physician providers.
The on-call practitioner is expected to respond to pages and phone calls promptly; the on-call practitioner shall respond within thirty (30) minutes. Hospital arrival time will be dictated by the needs of the patient and requested physician. An on-call practitioner must be able to physically present to the emergency department of the hospital within thirty minutes of being called/paged.
For more information, please refer to the Medical Staff Rules and Regulations.
The physician who performs the procedure or operation must provide information to the patient regarding any treatment, procedure or operation planned during the hospital stay. Informed consent must be obtained prior to procedures, and the physician must explain the following information:
Nature of the operation/procedure
- Possible risks, benefits, and side effects of the operation/procedure
- Any potential problems during the recuperation
- Possible risks, benefits and side effects related to the alternate methods or treatment
- Possible risks related to not receiving the proposed operation/procedure
All patient medications must be reconciled upon admission, inpatient transfer, and before discharge. Reconciliation involves comparing the patient’s list of medications to the physician’s admission, transfer, and/or discharge orders. Discharge dictation and computerized discharge patient medication instructions should always match.
For further information contact Pharmacy Services at extension 6000.
Documentation of Orders
- All entries in the record shall be dated, timed and authenticated.
- All orders for treatment shall be written legibly, including date and time, and signed by the ordering physician his/her authorized house staff, or appropriately privileged and credentialed designee.
- Signatures may be accompanied by block print name stamp to enhance readability and clarification of orders; however signature stamps are not allowed as the sole documentation of the signature.
- Admission orders shall be entered into the patient’s medical record within two (2) hours of admission.
- Specific pediatric orders should include the mg/kg does to assure proper doses are communicated to staff.
- Physicians are required to write all orders in the patient’s record when in person in the hospital except in urgent/emergent situations or during a procedure. • All telephone/verbal orders shall be subsequently countersigned and dated within 24 hours.
For more information see St. Dominic Hospital’s Medical Staff Rules and Regulations.
You must sign, time and date all entries in the medical record!
Telephone/verbal orders must be signed, dated and timed within 24 hours of giving them.
Electronic Medical Record - Portal
Dictated medical record documents can be signed electronically by using Portal. To register for Portal, contact Medical Staff Services.
To electronically sign your documents via the Internet, login to Portal at https://www.portal.stdom.com. Or if you are inside our facility, you can access the Portal icon on the computer desktop.
Some reports that are available for electronic signature:
- History and Physical
- Operative reports
- Discharge Summary
- Procedure Notes
- Emergency Room Reports
- Cardiac Cath
Surgical Site Markings
The site must be marked by a licensed independent practitioner or other provider who is privileged or permitted by the hospital to perform the intended surgical or non-surgical invasive procedure. This individual will be involved directly in the procedure and will be present at the time the procedure is performed.
The site will be marked before the patient is moved to the location where the procedure will be performed, and marking takes place with the patient involved, awake and aware, if possible.
- Will be his/her initials.
- Will be made at or near the procedure site or the incision site.
- Will be made with or without a line representing the proposed incision.
- Will be made using a marker that is sufficiently permanent to remain visible after completion of the skin prep and sterile draping and adhesive site markers will not be used as the sole means of marking the site.
- Will be positioned to be visible after the patient has skin prepped, is in a final position, and sterile draping is completed.
For spinal surgeries, in addition to preoperative skin marking of the general spinal region, special intraoperative radiographic techniques will be used for marking the exact vertebral level.
Site marking is not required when the individual doing the procedure is continuously with the patient from the time of the decision to do the procedure through to the performance of the procedure.
Site marking is not required for midline, single organ procedures, endoscopies, and for procedures in which there is no predetermined site of insertion such as cardiac catheterization and other interventional radiology procedures.
Suspension process for delinquent medical records
Failure to maintain timely records can be detrimental to patient care, compensation, and legal issues, and may endanger the physician’s privileges and possibly licensure. Failure to complete medical records within the specified time frame shall result in a delinquent episode unless the physician has given prior notice to the Health Information Management Department of a vacation, illness or other valid reason for not completing records.
A delinquent record is any medical record that does not contain:
- History and physical within 24 hours of admission
- Operative note written immediately after a procedure
- Dictated operative report within 24 hours of the procedure
- Discharge summary within 30 days of discharge
- Any other required elements not completed within 30 days of discharge or date of service
For complete documentation requirements and suspension process, see Medical Staff Polices, Medical Staff Suspension Process and St. Dominic Hospital Medical Staff Rules and Regulations.