Current through September 2, 2024
All hospitals who provide emergency medical care in a specific area of the facility shall have an organized plan for emergency care based upon current community needs and the capability of the hospital.
01.
Policies and Procedures. The emergency room of every hospital shall have written policies and procedures. These shall be in conformance with state and local laws. The procedures shall be approved by the hospital administration, medical staff, and nursing service. The policies shall be approved by the governing body. The policies and procedures shall include but are not limited to, the following:
a. Policies and procedures for handling accident victims, rape victims, contagious disease, persons suspected of criminal acts, abused children or adults, emotionally disturbed persons, persons under the influence of drugs and/or alcohol, persons contaminated by radioactive materials, and patients dead on arrival; and
b. Medical responsibility shall be delineated regarding emergency care (including levels of care relating to clinical privileges and specialty areas) and shall specify a method to insure staff coverage; and
c. Procedures that can/cannot be performed in the emergency room; and
d. Policies and supporting procedures for referral and/or transfer to another facility; and
e. Policies regarding instructions to be given patients requiring follow-up services; and
f. Policies and supporting procedures for storage of equipment, medication, and supplies; and
g. Policy and supporting procedures for care of emergency equipment; and
h. Instructions for procurement of drugs, equipment, and supplies; and
i. Policy and supporting procedures involving toxicology; and
j. Policy and supporting procedures devised for notification of patient's physician and transmission of reports; and
k. Policy involving instructions relative to disclosure of patient information; and
l. A policy for integration of the emergency room into a disaster plan.
02.
Staffing. There shall be adequate medical and nursing personnel to care for patients arriving at the emergency room. Minimum personnel and qualifications of such personnel shall be as follows:
a. A physician in the hospital or on call twenty-four (24) hours a day and available to see emergency patients as needed.
b. A qualified licensed registered nurse shall be on duty in the facility and available to the emergency room at all times.
03.
Staff Roster. A written roster shall be available with the names of all physicians on call and where they can be located if there is no physician on duty.
04.
Records. Medical records shall be kept on every patient who presents himself for treatment in the emergency room of the hospital.
a. The record shall contain at least the following:
i. Patient identification; and
ii. Time of arrival; and
iii. Description of illness or injury; and
iv. Clinical, laboratory and x-ray findings as appropriate; and
v. Diagnosis, physician orders, medication, and treatment given; and
vi. Condition of patient on discharge or transfer; and
vii. Final disposition and time of day; and
viii. Instructions for follow-up care; and
ix. Signature of attending physician and nurse for all treatments and medications provided.
b. Emergency room records shall be filed with inpatient records when appropriate.
05.
Retention, Filing, and Indexing Records. The retention, indexing and filing of emergency room records shall be the responsibilities of the medical records service.
06.
Emergency Room Register. There shall be an emergency room register containing name of patient, age, physician, and diagnosis.
07.
Equipment and Supplies.
a. Parenterals, drugs, instruments, equipment, and supplies shall be readily available to the emergency room for use.
b. Emergency drugs shall be available based upon a formulary designed by medical staff and pharmacy staff.
08.
Minor Elective Surgical Procedures. A record shall be maintained for all patients seen in the emergency room for minor elective surgical procedures. The record shall contain the following:
a. Short medical history and record of physical; and
b. Reports of diagnostic tests; and
c. Tissue report; and
d. Description of procedure performed; and
e. Discharge instructions for patient.
Effective March 17, 2022
