The Role of the St. Dominic's Practitioner

Expectations

This is merely a highlighted and non inclusive list.

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.

Dictation Instructions

For dictation, dial 601-200-5808.
When prompted, enter your 4 digit ID number.
When prompted, enter the work type followed by the # key.

Work types:
1# H&P
2# Consults
3# Operative Notes
4# Discharge Summary
5# EEG
6# Progress note
* STAT/Priority

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.

Informed Consent

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

Medication Reconciliation

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

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:

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.

The mark:

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:

For complete documentation requirements and suspension process, see Medical Staff Polices, Medical Staff Suspension Process and St. Dominic Hospital Medical Staff Rules and Regulations.