California Code of Regulations
Title 22 - Social Security
Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies
Chapter 1 - General Acute Care Hospitals
Article 6 - Supplemental Services
Section 70651 - Standby Emergency Medical Service, Physician on Call, General Requirements

(a) Written policies and procedures shall be developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration. Policies shall be approved by the governing body. Procedures shall be approved by the administration and medical staff where such is appropriate.

(b) The responsibility and the accountability of the emergency medical service to the medical staff and administration shall be defined.

(c) There shall be a roster of names of physicians and their telephone numbers who are available to provide emergency service.

(d) A communication system employing telephones, radiotelephone or similar means shall be in use to establish and maintain contact with the police department, rescue squads and other emergency services of the community.

(e) The emergency medical service shall have a defined emergency and mass casualty plan in concert with the hospital's capabilities and the capabilities of the community served.

(f) The hospital shall require continuing education of all emergency medical service personnel.

(g) Medical records shall be maintained on all patients presenting themselves for emergency medical care. These shall become part of the patient's hospital medical record. Past hospital records shall be available to the emergency medical service.

(h) An emergency room log shall be maintained and shall contain at least the following information relating to the patient: name, date, time and means of arrival, age, sex, record number, nature of complaint, disposition and time of departure. The name of those dead on arrival shall also be entered in the log.

(i) Each standby emergency medical service shall be identified to the public by an exterior sign, clearly visible from public thoroughfares. The wording of such signs shall state STANDBY EMERGENCY MEDICAL SERVICE, PHYSICIAN ON CALL.

(j) Standardized emergency nursing procedures shall be developed by an appropriate committee of the medical staff.

(k) A list of referral services shall be available in the emergency service. This list shall include the name, address and telephone number of the following:

(l) Periodically, an appropriate committee of the medical staff shall evaluate the services provided and make appropriate recommendations to the executive committee of the medical staff and administration.