Date



INSTRUCTIONSPlease read the application carefully and following the instructions for each section. ALL SECTIONS MUST BE COMPLETED OR LABELED “NOT APPLICABLE.”Review Management of HyperglycemiaReturn the following documents as a complete package:Application and ConsentCME certificatesExplanation of Professional Liability Actions Conflict of Interest StatementRestraint and Seclusion Quiz Fire Safety for Physicians and Allied Health ProfessionalsDues - $300 – made payable to HealthAlliance Hospitals Medical StaffIf you have any questions regarding this application, please call Amaris Berrios at 845-334-2704 or Brigid Chauncey at 845-943-6014.MEDICAL / DENTAL / PODIATRIC / ALLIED HEALTH STAFF REAPPOINTMENT APPLICATION PLEASE COMPLETE THE FOLLOWING:Name: FORMTEXT ?????Contact Email: FORMTEXT ?????Office Address: FORMTEXT ?????Office Phone: FORMTEXT ?????Office Fax: FORMTEXT ?????Home Address: FORMTEXT ?????Home Phone: FORMTEXT ?????Cell Phone: FORMTEXT ?????Office Manager/contact: FORMTEXT ?????IN THE LAST TWO YEARS:Has your license to practice medicine in any State or jurisdiction been involuntarily revoked, suspended (to include those stayed), restricted, subject to any other penalty of misconduct (censure, reprimand, probation, fine, community service, etc.) or been involuntarily or voluntarily surrendered, irrespective of reinstatement?YES FORMCHECKBOX NO FORMCHECKBOX Has your license to practice as a Physician been denied in any State or jurisdiction?YES FORMCHECKBOX NO FORMCHECKBOX Are there any charges currently pending against your license in any State or jurisdiction?YES FORMCHECKBOX NO FORMCHECKBOX Has your DEA registration been involuntarily suspended, revoked, placed under probation, or been involuntarily or voluntarily modified, irrespective of reinstatement?YES FORMCHECKBOX NO FORMCHECKBOX Are there any charges currently pending against your DEA registration in any State or jurisdiction?YES FORMCHECKBOX NO FORMCHECKBOX Has your training, employment, association, or clinical privileges at any hospital or health care facility been denied, revoked, suspended, diminished, modified to require consultation, been subject to probation, monitoring or continuing medical education requirements or not renewed or been involuntarily or voluntarily reduced or withdrawn?YES FORMCHECKBOX NO FORMCHECKBOX Are you currently the subject of an investigation or corrective or disciplinary action concerning your association or clinical privileges at any hospital or healthcare facility?YES FORMCHECKBOX NO FORMCHECKBOX Are there any charges currently pending against your training, employment, association, or clinical privileges at any hospital or health care facility in any State or jurisdiction?YES FORMCHECKBOX NO FORMCHECKBOX Have you ever voluntarily or involuntarily resigned or withdrawn, limited, reduced or lost your association or clinical privileges at another hospital or health care entity, irrespective of reinstatement or withdrawal of an application for Medical Staff membership, prior to final action by the hospital or health care entity?YES FORMCHECKBOX NO FORMCHECKBOX Have you ever been denied professional liability insurance, in whole or part, or has your policy ever been cancelled, involuntarily restricted, denied renewal, or has a surcharge been assessed because of the nature or volume of claims against you? If “Yes” please explain on separate sheet. YES FORMCHECKBOX NO FORMCHECKBOX Are there any pending professional medical misconduct proceedings concerning you in this State or any other jurisdiction?YES FORMCHECKBOX NO FORMCHECKBOX Have you ever been convicted of a crime (i.e., a misdemeanor or a felony) regardless of whether sentence was imposed or subsequently vacated? This does not include minor traffic or parking violations.YES FORMCHECKBOX NO FORMCHECKBOX Since your last appointment, have you been the subject of a report to the National practitioner Data Bank?YES FORMCHECKBOX NO FORMCHECKBOX Are you involved in any pending medical malpractice action in this State or any other State or jurisdiction? If “Yes” complete Attachment B for each case.YES FORMCHECKBOX NO FORMCHECKBOX Have there been any findings (judgments or settlements) of medical malpractice proceedings or actions in this State or any other State or jurisdiction? If “Yes” complete Attachment B for each case.YES FORMCHECKBOX NO FORMCHECKBOX Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings in any medical organization, professional society, or specialty board?YES FORMCHECKBOX NO FORMCHECKBOX Have you ever been suspended, sanctioned, or otherwise restricted from participating in any private, state, or federal health insurance program (i.e. Medicaid, Medicare)? YES FORMCHECKBOX NO FORMCHECKBOX NEW AFFILIATIONS ONLY (last two years)HOSPITAL NAMEADDRESSPHONE AND FAX OF MEDICAL STAFF OFFICEPhone:Fax: Contact:Phone:Fax: Contact:Phone:Fax: Contact:HEALTH STATUSDo you have a physical or mental condition which would affect your ability to exercise the clinical privileges requested or which would require an accommodation in order for you to exercise the privileges requested safely and competently? If YES please provide an explanation.YES FORMCHECKBOX NO FORMCHECKBOX Do you have a physical, mental, or emotional condition or substance abuse problem that could affect your ability to exercise the clinical privileges requested or that would require a reasonable accommodation for you to exercise those privileges safely and competently?YES FORMCHECKBOX NO FORMCHECKBOX BOARD CERTIFICATIONSince your last reappointment, has there been any change to your certification status, i.e., have you become board eligible, board certified, or have you recertified? FORMTEXT ????? Yes FORMTEXT ????? NoAmerican Board of FORMTEXT ?????Date of Certification: From FORMTEXT ????? to FORMTEXT ?????Are you meeting Maintenance of Certification (MOC) requirements: FORMTEXT ?????Yes FORMTEXT ????? No (if yes, please include MOC transcript) If no, are you in the certification process? FORMTEXT ?????Yes FORMTEXT ?????No If yes, anticipated date of completion: FORMTEXT ?????.CLINICAL PEER REFERENCEIf you are a Dentist, Podiatrist, or Allied Health Professional, please provide a peer reference name, address, and contact information below for a peer who can give you a clinical reference. Please notify the named individual that this reference must be received in order to move your reappointment forward.NAME OF PEER REFERENCE: FORMTEXT ?????ADDRESS : FORMTEXT ?????PHONE: FORMTEXT ????? (required)FAX: FORMTEXT ????? (required)EMAIL ADDRESS: FORMTEXT ????? (required)CONTINUING MEDICAL EDUCATIONPlease check all that apply and provide evidence of 50 CME, 75% of which pertain to your specialty, earned within the last two (2) years.I have attached documentation for the following CME’s: FORMTEXT ?????No. of Hours - Specialty Specific (Certificate Attached) FORMTEXT ????? Online Education FORMTEXT ????? Class/Ground Rounds/Meeting FORMTEXT ?????No. of Hours - Specialty Specific Journal Articles (Certificate Attached) FORMTEXT ?????No. of Hours - Non-specialty CME (Attach Certificate and/or copy of Article) FORMTEXT ?????Online Education FORMTEXT ?????Class/Ground Rounds/Meeting FORMTEXT ????? Journal Articles PRIVILEGE ATTESTATIONYour current privileges were sent to you via email with notification of your reappointment.Please review and keep in mind your clinical practice pattern. If you have not used a procedure in several years, you might wish to relinquish this privilege. If you request additional privileges or procedures, please enclose documentation of additional education, training, and current clinical competence in the specific privileges requested. Privileges relinquished during the reappointment process are not reportable; Privileges denied at reappointment are reportable. FORMTEXT ????? I have reviewed my clinical privileges and request that my clinical privileges remain unchanged. FORMTEXT ????? I have reviewed my clinical privileges and request to relinquish the following privileges: __________________________________________________________________________________ FORMTEXT ????? I have reviewed my clinical privileges and request additional privileges. Please go to the website and complete a new privilege form for your specialty. NOTE: All requests for new privileges must be accompanied by a documentation of training and/or clinical activity report from another facility where you have been practicing the privilege(s) in order for this request to be considered. NOTE: Current Nitrous Oxide Training required for Anesthesia and OB with reappointment.PROCEDURAL (CONSCIOUS) SEDATION FORMTEXT ????? I do not have Conscious Sedation Privileges FORMTEXT ?????I wish to retain my privileges in Conscious Sedation. If yes, please complete the quiz below and return with this application. Current ACLS is required for this privilege. FORMTEXT ?????I wish to relinquish my privileges in Conscious Sedation. FORMTEXT ?????I wish to obtain privileges in Conscious Sedation. If yes, please complete the quiz attached and return with this application. Current ACLS is required for this privilege.PROCEDURAL SEDATION FOR THE NON-ANESTHESIOLOGISTASSESSMENT TESTPlease write the correct answer to each question below. To receive a successful score on this Assessment Test, you may not get more than two incorrect answers.1) Objectives of Conscious Sedation include all of the following except:Answer: FORMTEXT ?????a.Anxiolysisb.Amnesiac.Cooperation during procedured.Decreased pain thresholde.Stable vital signs2) Flumazenil (Romazicon) reverses the effects of Midazolam (Versed):Answer: FORMTEXT ?????a.Trueb.False3) The recommended initial dosage of Versed is:Answer: FORMTEXT ?????a.1 – 2.5 mgb.5 mgc.7 mgd.10 mg4) Moderate Sedation:Answer: FORMTEXT ?????a.Allows protective reflexes to be maintained by the patientb.Pertains to the patient that is unconscious or in a state of depressed consciousnesswhere the patient cannot respond purposefully to verbal or physical stimulic.Requires mask ventilation to maintain respirationsd.Requires the use of Naloxone at the end of the procedure5) Monitoring parameters include:Answer: FORMTEXT ?????a.Heart rate, blood pressure, respirationsb.Heart rate, blood pressure, and oxygen saturationc.Heart rate and rhythm, blood pressure, respirations, oxygen saturation, and level of consciousnessd.Heart rate and rhythm, blood pressure, respirations, and oxygen saturatione.Heart rate, blood pressure, respirations, and oxygen saturation6) What of the following information is needed in the history of a patient undergoing Conscious sedation:Answer: FORMTEXT ?????a.Allergiesb.Past experiences with anesthetic drugsc.NPO statusd.Pregnancy or menstrual historye.All of the above7) Moderate sedation, a medically controlled state of depressedConsciousness allows protective reflexes to be maintained:Answer: FORMTEXT ?????a.Trueb.False8) If you find a patient has ceased breathing, which of the following is to be done first?a. IntubateAnswer: FORMTEXT ?????b.Place an oral airway b.Perform head tilt/jaw thrustc.Call Anesthesia9) The most common cause of airway obstruction is the tongue:Answer: FORMTEXT ?????a. Trueb.False10) Prior to administering sedation for any procedure, documentationAnswer: FORMTEXT ?????Should include:a.History and Physical (H&P)b.Baseline vital signsc.Age and weightd.NPO statuse.Evidence of informed consentf.Results of pregnancy test (if warranted)g.All of the above11) During the procedure the vital signs should be taken and documented:Answer: FORMTEXT ?????a.Pre and post procedureb.Every five (5) minutesc.Every ten (10) minutesd.Every fifteen (15) minutese.As the physician feels necessary.12) The RN monitoring the patient receiving conscious sedation:Answer: FORMTEXT ?????a.May be the charge nurseb.May also circulate in the room and get equipmentc.May not apply oxygen if neededd.May not be engaged in any other activity during this periode.Should do the preoperative history and physical prior to the procedure.13) A patient currently undergoing bronchoscopy has received Versed for Answer: FORMTEXT ?????sedation and within a few minutes, the oxygen saturation has begun to drop. You should:a.Halt the procedureb.Increase FiO2 (Oxygen) deliveryc.Check for respirationd.Arouse the patiente.All of the above14) The following may be an indication of a difficult airway, except :Answer: FORMTEXT ?????a.Large Neck circumference b.Edentulous mouth c.Mallampati score of III or greaterd.Limited Neck and Jaw range of motione. Short thyromental distance (receded jaw)Answer True or False15) Conscious Sedation would be appropriate for patients needing pain control Answer: FORMTEXT ?????or mechanical ventilation.16) The goal of conscious sedation is to produce a depressed level of consciousness without the loss of protective airway reflexes.Answer: FORMTEXT ?????17) The monitoring RN is permitted to leave the room at the discretion of the physician.Answer: FORMTEXT ?????18) Post procedure monitoring must continue every five (5) minutes until vital signs have returned to the pre-procedure range, protective reflexes are intact, O2 saturation is > 92% on room air (or at pre-procedure level), there is age-appropriate verbalization response.Answer: FORMTEXT ?????19) An out-patient may be discharged to his own care if his mental status has returned to its baseline level (scheduled/planned out-patient procedure)Answer: FORMTEXT ?????20) Ketamine is restricted to Anesthesiologist and Emergency Departmentuse ONLY.Answer: FORMTEXT ?????21) Benzodiazepines will not amplify the respiratory depressanteffects of narcotics.Answer: FORMTEXT ?????Match the ASA classification to each of the following patients. Place the corresponding letter on the line provided below:A)ASA Class IB)ASA Class IIC)ASA Class IIID)ASA Class IVE)ASA Class V22)Answer: FORMTEXT ????? A patient with marked signs of cardiac insufficiencyAnswer: FORMTEXT ????? A normal, healthy patientAnswer: FORMTEXT ????? A patient not expected to survive twenty four (24) hoursAnswer: FORMTEXT ????? A patient with well-controlled essential hypertensionAnswer: FORMTEXT ????? A morbidly obese patientATTESTATIONBy applying for reappointment to the Medical or Allied Health Staff of WMC Health | HealthAlliance, I hereby agree to abide by the bylaws, rules and regulations of the medical staff to which I am appointed; and as a member of a particular department and/or committee where information of a privileged and confidential nature is discussed, such information shall be held in strict confidence and not be divulged. I further agree that I am obligated to promptly notify the facilities if any of the information provided changes at any time in the future. In addition, if the hospital(s) activates their Incident Command Program for a disaster, I agree, if called upon, to confirm my availability to provide care within the scope of my privileges and competency. Updated 7.29.14I acknowledge that I have read the training module on the Management of Hyperglycemia in the Noncritical Care Setting.I hereby attest that all information submitted by me in this application for reappointment is complete, true and accurate to the best of my knowledge, and I have not requested privileges for which I am not qualified. By signing this document you consent to allow centralized information gathering for reappointment of medical staff privileges.THIS IS A LEGAL DOCUMENT. BEFORE SIGNING THIS APPLICATION PLEASE REVIEW IT CAREFULLY, REGARDLESS OF WHO COMPLETED THE APPLICATION, AS YOU ARE ATTESTING TO ITS ACCURACY AND ARE RESPONSIBLE FOR ITS CONTENT.Applicant’s Printed Name: FORMTEXT ????? Signature: FORMTEXT ?????Please include with your application your Medical Staff Dues of $300 for two years. Please make checks payable to “HealthAlliance Hospitals Medical Staff.”CONSENT FOR RELEASE OF INFORMATIONI understand and agree that I, as an applicant for reappointment for Medical Staff membership and/or privileges, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications. I further agree that this application will not be processed until it is deemed complete by the each facility. I have not requested privileges for any procedures for which I am not qualified. I am familiar with the laws of the State governing the practice of Medicine/Dentistry/Podiatry/Allied Health Professionals and pledge to abide by these laws. I further understand that any significant misstatement in or omissions from this application constitute cause for denial of appointment or cause for summary dismissal from the Medical Staff. All information submitted by me in this application (including attachments) is true to my best knowledge and belief and I agree to update this application should there be any change in the information provided.In making this application for reappointment to the Medical Staff, I hereby give my consent to the disclosure, inspection and copying of information and documents relating to credentials, health status, and qualifications. I signify my willingness to appear for the interviews in regard to my application, authorize the facilities, their Medical Staff and their representatives to consult with administrators and members of medical staff of other hospitals or institutions with which I have been associated and with others, including but not limited to past and present malpractice carriers, professional societies, specialty boards and professional schools and training programs who may be material to an evaluation of my professional qualifications and competence to carry out the clinical privileges requested as well as my moral and ethical qualifications for staff membership.I hereby release from liability all representatives of the facilities and their Medical Staff for their acts performed in good faith and without malice in connection with evaluating my application and my credentials, qualifications, and competence and in the process of Focused Professional Practice Evaluation or Ongoing Professional Practice Evaluations. I hereby release from any liability any and all individuals and organizations who provide information to the facilities, or their Medical Staff, in good faith, without malice, and in accordance with current Federal and State laws, and I hereby release from liability the facilities, their Medical Staff and their authorized representatives to the full extent permitted by law for so doing. Nothing in this document shall be construed as limiting or superseding any immunities otherwise provided by law.I understand that, although the Medical Staff of the facilities will make a recommendation concerning my application for reappointment, the facilities Governing body(ies) retains the final authority to determine whether my reapplication will be accepted, and if accepted, what privileges will be granted to me.I understand that I will notify the Hospital Administration, in writing, of any voluntary or involuntary termination or reduction of clinical privileges at this hospital or any other health care facility, as well as any action taken by a regulatory agency.In signing this Attestation and Consent, I acknowledge that I agree to abide by the Medical Staff Bylaws, Rules and Regulations and policies for all facilities concerned. I agree to be bound by the terms thereof, if I am granted membership or clinical privileges in all matters relating to the consideration of my application for appointment, and I further agree to abide by such hospital and staff rules and regulations, which may be from time to time enacted. By signing this document you consent to allow centralized information gathering for reappointment of medical staff privileges.Signature: FORMTEXT ????? Date: FORMTEXT ?????Name: FORMTEXT ?????ATTACHMENT BEXPLANATION OF PROFESSIONAL LIABILITY ACTIONS Please copy and complete for each claim/suitApplicant’s name: FORMTEXT ?????Name of Patient: FORMTEXT ?????Date of Incident: FORMTEXT ?????Date Lawsuit Filed: FORMTEXT ?????What was/is your status: FORMTEXT ?????Sole defendant FORMTEXT ?????Co-defendant FORMTEXT ?????other: ____________________________________________________Nature of Claim: FORMTEXT ?????Status of Case (with reference to you, specifically) FORMTEXT ?????Pending FORMTEXT ?????Dismissed FORMTEXT ?????Closed without payment / Date: FORMTEXT ????? FORMTEXT ?????Pre-trial settlement: $ FORMTEXT ????? FORMTEXT ?????Verdict for defendant FORMTEXT ?????Verdict for plaintiff $ FORMTEXT ?????CONFLICT OF INTEREST DISCLOSURE STATEMENTInstructionsThis Conflict of Interest Disclosure Statement must be completed by all “Personnel” of HealthAlliance of The Hudson Valley, its subsidiaries and affiliated entities (Organization) who are covered by the Conflict of Interest Policy (as defined below).A.Personnel Covered by the Conflict of Interest Policy. This Policy applies to the following “Personnel” of the Health Alliance of the Hudson Valley, its subsidiaries and affiliated entities (Organization): members of the Board of Trustees, Officers, “Leadership Management” (defined to be the President and Chief Executive Officer, Senior Vice Presidents and Vice Presidents), Assistant Vice Presidents, Department Heads, and other employees (including physicians) who are in a position to influence any substantive business decision between the Organization and a Vendor. Such business decisions include, but are not limited to, the decision to purchase goods or services for the Organization and any other decision affecting the course of a business transaction being considered or entered into by the Organization. This Policy applies to “immediate family” members of such Personnel.B.Immediate Family. The term “immediate family” includes your spouse, siblings, children, parents, or in-laws of any of them.C.Vendor. The term “Vendor” includes all vendors, suppliers, consultants, and other third parties seeking to do or currently engaged in business with the Organization.D.Discloseable Interest. Personnel have a discloseable “interest” if he/she has a contractual or an employment relationship with a Vendor, or he/she is a member, owner, director, trustee or officer of a Vendor; or he/she has any other financial interest in a Vendor:(i)from which the Organization purchase or lease equipment, services, or supplies, or that provides services that compete with the organization.(ii)with which the Organization negotiate real estate transactions (such as the leasing of space), and which either benefits from the real estate transactions or competes with the Organization in the leasing or purchase of real estate; or(iii)which renders directive, managerial, or consulting services to any organization that does business with, or competes with, the Organization in providing services.An “interest” in a Vendor also includes any service as a member of the governing board or officer of another healthcare organization licensed, registered or approved under Articles 28, 28A, 36, or 44 of the New York Public Health Law.An “interest” also includes the employment by or contracting with the Organization of a Personnel’s immediate family.If the financial interest is the ownership of securities which are publicly traded, such interest does not have to be disclosed, unless the combined holdings of the securities of both the person and his or her immediate family constitute 5% or more of the outstanding securities of the Vendor.CONFLICT OF INTEREST DISCLOSURE STATEMENTIf the answer to any of the following questions is YES, please explain in the space provided below or attach additional information, as needed:1.I, or a member of my immediate family, have a discloseable interest in a Vendor which either conducts business or is seeking to conduct business with the Organization. FORMTEXT ?????Yes FORMTEXT ????? No2.A member of my immediate family is employed by or has a compensation arrangement with the Organization. FORMTEXT ?????Yes FORMTEXT ?????No3.I, or a member of my immediate family, hold a financial interest aggregating more than five percent (5%) of publicly traded securities in a Vendor doing or seeking to do business with the Organization. FORMTEXT ?????Yes FORMTEXT ?????No4.I, or a member of my immediate family, serve as a member of the governing board or officer of another healthcare organization licensed pursuant to Articles 28 (Facility), 28A (Facility), 36 (Home Health Agency) or 44 (Health Maintenance Organization) of the Public Health Law which does business or is affiliated with the Organization. FORMTEXT ?????Yes FORMTEXT ?????No5.I, or a member of my immediate family, am involved in any other activity, except as disclosed above, which raises a potential conflict of interest for the Organization. FORMTEXT ?????Yes FORMTEXT ?????No6.Identify any instance in which you or any member of your immediate family has rendered or is rendering directive, managerial, or consultative services to any outside concern that competes with the services of the Organization.7.Identify any instance in which you or any member of your immediate family has accepted or is accepting a gift, gratuity, or entertainment from any outside concern that does, or is seeking to do business with or is a competitor of, the Organization or its affiliates under circumstances from which it may be reasonably inferred that such an act involves interest that could result in a conflict..8. Identify any instance in which you or any member of your immediate family has disclosed or used or is disclosing or using information relating to the Organization’s or its affiliate’s business for personal profit or advantage to you or the member of your immediate family.(This does not apply to information that is or will generally become available to the general public)Explanation FORMTEXT ?????ATTESTATION AND ACKNOWLEDGMENTI attest that my answers to the above questions are true and accurate to the best of my knowledge. I further acknowledge that I understand that if I believe a transaction may involve a potential or actual Conflict of Interest, I shall advise in writing, the Compliance Officer, or such other person designated by the President, of such potential or actual Conflict of Interest prior to the consummation of the transaction.I further understand that I am required to revise, in writing, my Conflict of Interest Statement to reflect any changes which occur during the year.NAME: FORMTEXT ?????SIGNATURE: FORMTEXT ?????DATE: FORMTEXT ?????Department/Specialty: FORMTEXT ?????Contact Phone Number: FORMTEXT ?????Contact Email Address: FORMTEXT ?????_______________________________Reviewed ByRestraint and Seclusion QUICK REFERENCE SHEET : PHYSICIANS, LIP’s, PA’s HealthAlliance supports the patient’s right to be free from restraints or seclusion of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff. Less intrusive and least restrictive measures must be considered before the initiation of any restraint. Despite all efforts, restraint may be necessary to protect the patient from injury to himself or others. As per CMS guidelines, physicians/LIP’s and all mid-level practitioners will have a working knowledge of the hospital policy regarding the use of restraints and seclusion. Physicians/LIP’s and PA’s, upon appointment and upon reappointment, will be educated to the policy content via an on-line Quick Reference/Overview and a related quiz, distributed by the Medical Staff/Credentialing Office. Once completed, the quiz will be returned to that office. The following behavior scale will be used to assess patient behaviors when chemical or 4 point restraint or the use of seclusion are necessary ScoreTermDescription+4CombativeOvertly combative, violent, immediate danger to staff+3Very agitatedPulls or removes tube(s) or catheters(s), aggressive+2AgitatedFrequent non-purposeful movement, fights ventilator+1RestlessAnxious but movements not aggressive, vigorous0Alert and calm-1DrowsyNot fully alert, but has sustained awakening (eye-opening/eye contact) to voice (>10 seconds)-2Light sedationBriefly awakens with eye contact to voice (<10 seconds)-3Moderate sedationMovement or eye opening to voice (but no eye contact)-4Deep sedationNo response to voice, but movement or eye opening to physical stimulation-5UnarousableNo response to voice or physical stimulation Richmond Agitation-Sedation Scale (RASS)See the grid below for guidelines for the use of restraints for violent and non-violent patients. Actions needed for the use of restraint or seclusion Nonviolent Patient 2 soft restraints, Geri Chair, Full Side Rails Violent Patient 4 Point Restraint or Chemical Restraint (RASS +4)Violent Patient Seclusion (RASS +4)Applicable CaregiverObtain order from the attending physician/LIP or PA Order is preferably obtained prior to initiating a restraint but can be provided immediately following the application of 2 point restraints and other devices when urgent need necessitates application. Telephone orders are acceptable, when necessary. PRN orders are permissible for Geri-chairs and full side rails [only] for non-violent patients. Order will preferably be provided after the practitioner assesses the patient and prior to initiating restraints these types of restraints. Same requirements as noted in the column to the left for a violent patient. MD/LIP, PAA Rapid Response will be called when the patients attending physician is not readily available and a patient is exhibiting violent or self destructive behavior. When absolutely necessary, telephone orders are acceptable for physical or chemical restraints but must be authenticated within 30 minutes, never to exceed one hour. PRN Orders are never accepted Frequency of order renewalEvery 24 hours while devices are in use. Geri-chair and full side-rail are a one-time order do not require renewal. All orders for chemical restraints are considered one-time orders. Successive orders qualify as a new one-time order. Renewals for continued need for 4-point restraints or seclusion must occur at the following times. Med Surg patients - 4 hrs for adult s(18 and up) Med/Surg patients- 2 hrs for adolescents (9-17)Med Surg patients- 1 hr-child (less than 9) Total maximum time allowed for restraint = 24 hours. Restraints used for greater than 24 hours defines “prolonged restraint” and must be reported to the CMO (if used in the mental health units) and the Quality Management Committee for all other settings. MD/LIP, PAActions needed for the use of restraint or seclusionNonviolent Patient 2 soft restraints, Geri Chair, Side RailsViolent Patient4 Point Restraint or Chemical Restraint (RASS +4)Violent Patient Seclusion (RASS +4)Applicable CaregiverThe patient’s attending physician must be notified when the initial order was not obtained from that attending physician(i.e., a Hospitalist provided the restraint order during a Rapid Response, the patient was not admitted to their service) As soon as possible As soon as possible Immediately, or as soon as possible when the patient is safeRN or the practitioner who ordered chemical or 4 point restraints, or seclusion When a PA orders a chemical or 4 point restraint, or seclusion, she/he must consult the attending physician responsible for the care of the patient as soon as possible after the completion of the assessment. The attending is not required to come to the hospital but can determine the need to assess the patient based on symptoms, condition and history. Initial Face-to-face physical assessment must occur for all episodes of restraint for the violent patient. This will be documented on the Post Restraint Progress Note for all episodes of chemical restraint, 4 point restraint, and seclusionNot required Within 30 minutes, never to exceed one hour. The physician/LIP or PA who ordered restraint or seclusion via telephone order, must authenticate the order and assess the patient within 30 minutes, never to exceed 1 hour.MD/LIP, PA Note: when a PA conducts the one hour face to face assessment, once completed, the attending must be notified. Ongoing Face-to-face physical assessment. Minimally, every 24 hoursMinimally, every 24 hours and as necessary, and before a new order is written. MD/LIP, PA, or NPDiscontinuation Restraint may only be employed while the unsafe situation continues. Once the unsafe situation ends, the use of restraint (any type) or seclusion must end.As soon as possible and when interventions requiring restraint have been discontinuedAs soon as possible and when the patient’s unsafe behavior ends. 4 hours (unless patient is sleeping). A new seclusion episode may only be reinitiated if the patient continues to remain a harm to self or others and a new order is obtained. MD, PA, NP, or RN*Once discontinued, a new order for re-application is required. Otherwise, this would constitute a PRN order which is unacceptable. Restraint and Seclusion Quiz CMS guidelines require physicians/LIP’s and all mid-level practitioners to working knowledge of the Restraint/Seclusion policy. Upon initial appointment and with each reappointment, practitioners will review the Restraint/Seclusion quick reference guide and will complete the related quiz. True/False FORMTEXT ?????When ordering physical or chemical restraints for patients with violent behavior, a face to face assessment must be completed within 30 minutes to one hour and will be documented on the Post Restraint Progress Note. True/False FORMTEXT ?????PRN orders are not allowed for chemical restraints, 4 point physical restrain, or seclusion. True/False FORMTEXT ?????A Rapid Response will be called for any patient exhibiting violent or self-destructive behavior, unless the patients attending physician is readily available. True/False FORMTEXT ?????Once the unsafe situation ends, the use of 4 point restraint or seclusion will be discontinued, regardless of the length of time identified in the current order. A new order is required if restraints must be re-applied. True/False FORMTEXT ????? For non-violent patients in restraint (i.e., 2 point soft restraints), an assessment must occur minimally, every 24 hours, and before a new order is written. True/False FORMTEXT ?????NAME: FORMTEXT ?????SIGNATURE: FORMTEXT ?????DATE: FORMTEXT ?????FIRE SAFETY FOR PHYSICIANS AND ALLIED HEALTH PROFESSIONALSPlease read and comply with the following fire regulations for our hospitals. Fire drills will be conducted on a regular basis and physicians will be expected to participate.Report every fire regardless of its size. Under no circumstance consider a fire to be easily controllable.Rescue patients in the immediate area of the fire or smokePull fire alarm and call emergency number (4911) to give exact location. CODE RED is the alert to be called.Close all doors to rooms and corridors and windows If you are in the patient’s room when a fire starts, do the following:Remove all portable gases, and place in a safe area.Turn off all medical gas and electrically operated equipment and valves.Leave all lights on.Turn off all x-ray equipment machines and mainline switches for all equipment.Extinguish the fire with fire extinguisher only when safe to do so. Evacuate if necessary.Ambulatory patients should be escorted by a staff member to the closest safe area, usually through one set of fire doors. A staff member should stay with the group of patients.Non-ambulatory patients should be placed in wheelchairs or on stretchers and moved to the closest safe area, usually through one set of fire doors.I acknowledge that I have received training in Fire Safety Regulations and will comply with these regulations when I am present in any of the HealthAlliance facilities.NAME: FORMTEXT ?????SIGNATURE: FORMTEXT ?????DATE: FORMTEXT ????? ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download