Minnesota Administrative Rules

4675.0500 MEDICAL STAFF.

The medical director and the medical staff shall be responsible to the governing body for patient and staff policies and for medical procedures and services relative to admission, treatment, and related emergency treatment. The medical staff shall:

A.

Establish written policies for the admission and treatment of patients for surgery, including but not limited to:

(1)

Requirements for preoperative history, physical examinations, and diagnostic procedures.

(2)

Preparation for and administration of anesthesia. Only an anesthesiologist or qualified physician and/or anesthetist shall administer anesthetics other than local infiltration anesthetics.

(3)

Postoperative patient observation and care.

(4)

Discharge examinations by physician.

(5)

Safe transfer to home and follow-up services.

B.

Establish written policies for surgical procedures to be performed.

C.

Establish written policies for the creation and maintenance of a program for infection control.

D.

Provide for orientation and in-service programs for all center personnel as related to their activities, including medical emergency procedures.

E.

Provide for emergency care procedures in the event of surgical complications.

F.

Establish policies for transfer of patients needing hospital care.

G.

Maintain medical records on each patient accepted for treatment. Each patient record shall include: the patient's name, address, and telephone number; the operating physician, admission and discharge notes and dates; a signed consent form; pertinent medical history; tests and examinations; admitting diagnosis; surgical procedure and anesthesia report; pathology report where indicated; patient aftercare instructions; prescribed medications; and other progress notes. Surgery-related or anesthesia-related complications which result in morbidity or mortality of a patient shall be recorded in detail. Patients' records shall be made available for inspection by the department and be preserved in accordance with Minnesota Statutes, sections 145.30 to 145.33.

H.

Develop and maintain a system for professional peer review.

I.

Assure that all employees, prior to employment and at least annually thereafter show freedom from tuberculosis by means of a standard Mantoux tuberculin test and/or a chest X-ray test as medically indicated. The results shall be reported in writing and made a part of each employee's personnel record.

Statutory Authority:

MS s 144.56

Published Electronically:

January 21, 2000