Provision for routine examination of all patients upon admission and recording of the preoperative diagnosis prior to surgery;
A stipulation that a surgical operation is permitted only with the consent of the patient or the patient's legally authorized representative except in emergencies;
Statements concerning the request for and performance of consultations, and instances in which consultations are required; and
A statement specifying categories of personnel duly authorized to accept and implement medical staff orders. All orders shall be recorded and authenticated. All verbal and telephone orders shall be authenticated by the prescribing member of the medical staff in writing within 24 hours of receipt.
The medical staff shall have the numbers and kinds of officers necessary for the governance of the staff.
Officers shall be members of the active staff and shall be elected by the active staff, unless this is precluded by hospital by-laws.
(a) Number and frequency.
The number and frequency of medical staff meetings shall be determined by the active staff and clearly stated in the by-laws of the medical staff.
Attendance records shall be kept of medical staff meetings. Attendance requirements for each individual member shall be clearly stated in the by-laws of the medical staff.
Full medical staff meetings shall be held to conduct the general business of the medical staff and to review the significant findings identified through the quality assurance program.
Adequate minutes of all meetings shall be kept that are sufficient to document for those members who did not attend the meeting the general nature of the business conducted, the decisions reached, and the findings and recommendations of the medical staff.
The medical staff shall establish committees of the medical staff and is responsible for their performance.
(b) Executive committee.
The medical staff shall have an executive committee to coordinate the activities and general policies of the various departments, act for the staff as a whole under limitations that may be imposed by the staff, and receive and act upon the reports of all other medical staff committees.
Hospitals may create services to fulfill medical staff responsibilities. Each autonomous service shall be organized and function as a unit.
(b) Chief of service.
Each service shall have a chief appointed in accordance with the medical staff by-laws. The chief of service shall be a member of the service and be qualified by training and experience to serve as chief of service. The chief of service shall be responsible for:
Making recommendations to the hospital's administrative staff and governing board concerning the qualifications of the members of the service;
Making recommendations to the hospital's administrative staff regarding the planning of hospital facilities, equipment, routine procedures and any other matters concerning patient care;
Arranging and implementing inpatient and outpatient programs, which include organizing, engaging in educational activities and supervising and evaluating the clinical work;
Cooperating with the hospital's administrative staff on purchase of supplies and equipment;
Representing the service in a medical advisory capacity to the hospital's administrative staff and governing body.
DHS 124.12 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88.
The nursing service shall be directed by a registered nurse with appropriate education and experience to direct the service. A registered nurse with administrative authority shall be designated to act in the absence of the director of the nursing service. Appropriate administrative staffing of the nursing service shall be provided on all shifts.
There shall be a written plan showing the flow of administrative authority throughout the nursing service, with delineation of the responsibilities and duties of each category of nursing staff.
The delineation of responsibilities and duties for each category of nursing staff shall be in the form of a written job description for each category.
An adequate number of registered nurses shall be on duty at all times to meet the nursing care needs of the patients. There shall be qualified supervisory personnel for each service or unit to ensure adequate patient care management.
The number of nursing personnel for all patient care services of the hospital shall be consistent with nursing care needs of the hospital's patients.
The staffing pattern shall ensure the availability of registered nurses to assess, plan, implement and direct the nursing care for all patients on a 24-hour basis.
All nursing care shall be planned and directed by registered nurses. A registered nurse shall be immediately available to give direct patient care when needed.
A registered nurse who is not occupied in the operating room, delivery room or emergency room shall be available at all times to render direct care.
A registered nurse shall assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the preparation and competence of the available nursing staff.
The ratio of registered nurses to patients and the ratio of registered nurses to other allied health care personnel shall be determined by the seriousness of patient illness or injury, the patient census, and the complexity of care that must be provided, and shall be adequate to provide proper care and supervision of staff performance.
A registered nurse shall plan, supervise and evaluate the care of all patients, including the care assigned to other nursing personnel.
There shall be other nursing personnel in sufficient numbers to provide nursing care not requiring the services of a registered nurse.
Individuals selected for the nursing staff shall be qualified by education, experience, and demonstrated ability for the positions to which they are appointed.
The educational and experiential qualifications of the director of nursing, the director of nursing assistants and nursing supervisors shall be commensurate with the scope and complexity of the services of the hospital.
The functions and qualifications of nursing personnel shall be clearly defined in relation to the duties and responsibilities delegated to them.
Personnel records, including application forms and verifications of credentials, shall be on file.
Nursing management shall make decisions about the selection and promotion of nursing personnel based on their qualifications and capabilities and shall recommend termination of employment when necessary.
There shall be a procedure to ensure that hospital nursing personnel for whom registration, a license or other approval is required by law have valid and current registration, licensure or other approval.
There shall be a comprehensive and thorough job orientation program for all nursing service personnel. The facility shall provide orientation to nursing service personnel before they provide care to patients.
There shall be appropriate, ongoing training programs available to all nursing service personnel to augment their knowledge of pertinent new developments in patient care and to maintain current competence.
The nursing service shall have well-established working relationships with the medical staff and with other hospital staffs that provide and contribute to patient care.
Hospital policies affecting the nursing service shall be developed and reviewed with the participation of the director of nursing or designee. The nursing service shall be represented on hospital committees that affect patient care policies and practices.
Nursing care policies and procedures that reflect optimal standards of nursing practice shall be in writing and shall be reviewed and revised as necessary to keep pace with current knowledge. Written nursing care policies and procedures shall be available on each nursing unit.
There shall be a written nursing care plan for each patient which shall include the elements of assessment, planning, intervention and evaluation.
Documentation of nursing care shall be pertinent and concise and shall describe patient needs, problems, capabilities and limitations. Nursing interventions and patient responses shall be noted.
Meetings of the registered nursing staff shall be held at least bimonthly to discuss patient care, nursing service problems and administrative policies. Minutes of all meetings shall be kept and shall be available to all staff members.
The nursing service director shall ensure that there is ongoing review and evaluation of the nursing care provided for patients and shall ensure that nursing care standards and objectives are established and met.
When the nursing department is decentralized into clinical departmental services or clinical programs are established, the hospital shall have one administrator to whom the nursing directors shall be accountable and who has the responsibility for maintenance of one standard of nursing practice within the organization.
DHS 124.13(7)(a)(a) Definition.
In this subsection, “circulating nurse" means a registered nurse who is present during an operation or infant delivery to provide emotional support to the patient, assist with the anesthesia induction and, throughout the surgical procedure or delivery, to coordinate the activities of the room, monitor the traffic in the room and maintain an accurate account of urine and blood loss and who, before the surgical procedure or delivery is completed, informs the recovery room of special needs and ensures that the sponge, needle and instrument counts have been done according to hospital policy.
Every patient admitted in labor shall be assessed initially by a registered nurse. There shall be a circulating nurse at every infant delivery.
A qualified registered nurse shall function as the circulating nurse in the surgical and obstetrical room whenever general anesthesia is used and on all local cases involving a high degree of patient risk. Individual surgical technologists and licensed practical nurses may function as assistants under the direct supervision of a qualified registered nurse.
When temporary nursing personnel from outside registries or agencies are used by the hospital, the nursing service shall have a means for evaluating the credentials and competence of these personnel. Temporary nursing personnel shall function under the direction and supervision of a qualified registered nurse from the hospital nursing staff. The temporary nursing personnel shall have at least a minimum, formal orientation to the facility.
If private duty nursing personnel are employed by the patients, the nursing department shall have a means for evaluating the credentials and competence of these personnel. The hospital shall have policies regarding use of these personnel in the facility.
Medications may not be prepared by nursing personnel on one shift for administration during succeeding shifts.
The hospital shall have effective policies and procedures for reporting transfusion reactions, adverse drug reactions, accidents and medication errors.
DHS 124.13 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88.
A medical record shall be maintained for every patient admitted for care in the hospital. The record shall be kept confidential and released only in accordance with ss. 51.30
, or 252.15
, Stats., and ch. DHS 92
, as appropriate.
(a) General requirement.
The hospital shall have a medical records service with administrative responsibility for all medical records maintained by the hospital.