(b) The medical staff shall adopt and enforce bylaws and rules to carry out its responsibilities. These bylaws and rules shall:
(3) include, but not be limited to, the following:
(A) A description of the medical staff organizational structure. If the organization calls for an executive committee, a majority of the members shall be physicians on the active medical staff.
(B) Meeting requirements of the staff.
(C) A provision for maintaining records of all meetings of the medical staff and its committees.
(D) A procedure for designating an individual physician with current privileges as chief, president, or chairperson of the staff.
(E) A statement of duties and privileges for each category of the medical staff.
(F) A description of the medical staff applicant qualifications.
(G) Criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges.
(H) A process for review of applications for staff membership, delineation of privileges in accordance with the competence of each practitioner, and recommendations on appointments to the governing board.
(I) A process for appeals of decisions regarding medical staff membership and privileges.
(J) A process for medical staff performance evaluations based on clinical performances indicated in part by the results of quality assessment and improvement activities.
(K) A process for reporting practitioners who fail to comply with state professional licensing law requirements as found in
IC 25-22.5, and for documenting appropriate enforcement actions against practitioners who fail to comply with the hospital and medical staff bylaws and rules.
(L) A provision for physician coverage of emergency care that addresses at least
the following:
(i) A definition of emergency care to include, but not be limited to,
the following:
(AA) Inpatient emergencies. and
(BB) Emergency services emergencies. and
(ii) A timely response.
(M) A requirement that a complete physical examination and medical history be performed:
(i) on each patient admitted by a practitioner who has been granted such privileges by the medical staff;
(ii) within seven (7) days prior to date of admission and documented in the record with a durable, legible copy of the report and changes noted in the record on admission; or
(iii) within forty-eight (48) hours after an admission.
(N) A requirement that all physician orders shall be:
(i) in writing or acceptable computerized form; and shall be
(ii) authenticated by the responsible individual in accordance with hospital and medical staff policies.
(O) A requirement that all verbal orders must be
repeated and verified and that the repetition and verification be documented in the patient's medical record signed and dated by the authorized health care professional that took the order. If there is no repetition and verification of the verbal order the prescribing physician/practitioner shall authenticate authenticated by the responsible individual in accordance with hospital and
medical staff policies. The individual receiving a verbal order shall date,
time, and sign the verbal order
in accordance with hospital policy. Authentication of a verbal order must occur within forty-eight (48) hours
unless a repeat and verify process described under items (i) and (ii) is utilized. If a patient is discharged within forty-eight (48) hours of the time that the verbal order was given, authentication shall occur within thirty (30) days after the patient's discharge.
(i) As an alternative, hospital policy may provide for a repeat and verify process for verbal orders. Any repeat and verify process must require that the individual receiving the order shall immediately repeat the order to the ordering physician or other responsible individual who shall immediately verify that the repeated order is correct.
(ii) The individual receiving the verbal order shall document in the patient's medical record that the order was repeated and verified. Where the repeat and verify process is followed, the hospital shall require authentication of the verbal order not later than thirty (30) days after the patient's discharge.
(P) A requirement that the final diagnosis be documented along with completion of the medical record within thirty (30) days following discharge.
