RULES AND REGULATIONS OF THE MEDICAL STAFF
UNIVERSITY OF COLORADO HOSPITAL
I.
PREAMBLE .............................................................................................................................................................. 2
II.
INDIVIDUAL RESPONSIBILITIES ................................................................................................................................ 2
A. CARE OF PATIENTS..................................................................................................................................................... 2
B. ANESTHESIA AND SEDATION ...................................................................................................................................... 5
C. EMERGENCY CARE...................................................................................................................................................... 6
D. MEDICAL RECORDS..................................................................................................................................................... 7
E. RIGHTS OF PATIENTS .................................................................................................................................................. 9
F. PROFESSIONAL LIABILITY CLAIMS............................................................................................................................. 11
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RULES AND REGULATIONS OF THE MEDICAL STAFF
The Medical Staff shall adopt such Rules and Regulations as may be necessary for proper conduct of the work
of the Medical Staff. Such Rules and Regulations shall be attached to and become a part of these Bylaws of the
Medical Staff. Rules and Regulations may be amended as provided in Article XIV of the Bylaws of the Medical
Staff.
I. PREAMBLE
The purpose of the Rules and Regulations of the Medical Staff of the Hospital is to assure: 1) equal and
appropriate care of all patients: inpatient, ambulatory, and emergency; 2) that the rights of the patient are
preserved; 3) attainment of excellence in education and research; 4) reasonableness of costs and effective
utilization of facilities; 5) provision for auditing care and peer review; 6) achievement of the appropriate
ethical and moral standards of practice; 7) compliance with existing Bylaws of the Medical Staff of the
Hospital, applicable laws of the State of Colorado and federal laws, adherence to the requirements of the
Joint Commission (“TJC”), and directives of the Social Security Administration, the Department of Health
and Human Services and other appropriate agencies and governmental bodies. These rules may apply to
the care of any patient as appropriate to the setting of the patient’s care, treatment and services.
II. INDIVIDUAL RESPONSIBILITIES
All clinicians accepting Medical Staff appointment must assume responsibility for support of the policies of
the Medical Staff and the Hospital, including these Rules and Regulations.
A. CARE OF PATIENTS
1. The admission of all patients to the hospital shall be in accordance with severity of illness and
intensity of service criteria and in accordance with appropriate state laws, rules and regulations,
and policies of the Hospital.
2. Any member of the Medical Staff can apply for admission privileges. An attending provider shall
be clearly identified at the time of admission for each patient. The attending provider shall be
notified in a timely manner of all patients for which the attending provides coverage.
3. The attending provider is responsible for all care delivered by residents or other trainees to
patients on the service for which the attending provides coverage.
4. It shall be the responsibility of the attending provider to inform the nursing unit and the
Administrator-on-Call if the patient’s condition is such as to create an unusual hazard to other
individuals and/or to the patient.
5. Non-physician Attending Providers:
a. Psychologists holding medical staff privileges (1) carry out psychological evaluation, treatment
and clinical research; (2) write orders for psychosocial aspects of patient care (e.g.,
occupational therapy, patient privileges, nursing care); (3) supervise psychological and
psychosocial treatment and evaluation by Housestaff and other students and trainees to
assure that care meets a proper level of quality; (4) participate in the treatment plan according
to written policies of the multidisciplinary treatment team; and (5) practice in a manner
consistent with their delineated hospital privileges.
b. Nurse midwives may: (1) admit patients as provided by state law; (2) perform and record the
history and physical examination; and (3) practice normal obstetrics and gynecology in a
manner consistent with their delineated hospital privileges in accordance with his/her
collaborative practice agreement, and all applicable policies and procedures of the
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Department of Obstetrics and Gynecology.
c. The practice of Podiatry is limited to “the treatment of the foot” as defined by Colorado law
and delineated hospital privileges. The practice of Podiatry is performed under the supervision
of the Chairperson of the Department of Surgery (Division of Vascular Surgery) or the
Department of Orthopedics, or their designees. A podiatrist holding staff privileges may: (1)
admit patients to the clinical units in association with a physician member of the medical staff;
(2) be responsible for that part of the patient’s history and physical exam related to podiatry.
The history and physical exam will be done by a member of the Medical Staff with privileges to
perform history and physical exams; and (3) practice in a manner consistent with their
delineated hospital privileges.
d. Oral and maxillofacial surgeons may; (1) apply for and be granted privileges to admit patients
without other relevant medical problems to inpatient services for oral and maxillofacial
surgery; (2) perform and record the history and physical examination if privileged to do so; (3)
assess the medical risk of an operative procedure; and (4) practice in a manner consistent with
their delineated hospital privileges.
e. A dentist holding medical staff privileges may: (1) admit dental patients to the Hospital in
association with a physician member of the Medical Staff. The history and physical exam will
be done by a member of the Medical Staff with privileges to perform history and physical
exams and; (2) practice in a manner consistent with their delineated hospital privileges.
6. Physician Attending Providers:
a. A history and physical examination (H&P) will be performed and documented for every patient
no more than thirty (30) days prior to admission or within twenty-four (24) hours of admission,
except that patients residing at CeDAR will have a history and physical examination performed
and documented within seven (7) days of admission to CeDAR. When the history and physical
examination is performed within thirty (30) days before admission, an interval H&P note
documenting an examination for any changes in the patient’s condition will be completed
within twenty-four (24) hours of admission and prior to any surgery or procedure. If the
admission is a re-admission within a month’s time for the same condition, the previous history
and physical with an interval H&P note will suffice.
b. Surgical patients must have a history and physical examination documented in the medical
record prior to surgery or any procedure requiring anesthesia. In the event the surgeon
believes performing the history and physical would cause a delay that would be harmful to the
patient, the surgeon must make note of this fact in the patient’s record.
c. Medical Staff members who are not privileged to perform general physical assessments but
who provide elective surgery may arrange for a history and physical exam by a qualified
medical practitioner. In addition, they should provide a pre-operative assessment specific to
the condition necessitating the operation. When a practitioner other than the one performing
surgery performs this H&P, the practitioner performing surgery must document his/her review
of this information and confirm the appropriateness of the procedure. Patients must have an
interval H&P note before going to surgery.
d. The attending provider must review, sign, and assume responsibility for any history and
physical examination prepared by Housestaff or medical students.
e. Review the patient’s history, the record of examinations and tests in the institution, and make
daily reviews of the patient’s progress.
f.
Confirm or review the diagnosis and determine the course of treatment to be followed.
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g. Either perform the services required by the patient or supervise Housestaff, according to
written Departmental guidelines, so as to assure that Housestaff provides appropriate
treatment and services and that the care meets a proper quality level.
h. Ensure the acquisition of an informed consent from patients (or legal representatives of
incompetent patients) undergoing a diagnostic or therapeutic procedure that involves the
invasion or disruption of the integrity of the body (excepting venipuncture for peripheral
venous access). Such informed consent shall include documentation of the patient’s
awareness of the likely results if the procedure is not performed, alternative procedures, the
possible risks or injuries associated with the procedure and each alternative procedure, and
the likelihood that the procedure will result in no improvement or worsening of the patient’s
condition. The informed consent must be documented on the approved hospital form and in
accordance with the informed consent policy. No examination or treatment shall be
undertaken in the Hospital without informed consent from the patient or his/her legal
representative unless the circumstance is emergent and the patient or representative is
unable to give consent. If the circumstance warrants proceeding without proper consent, the
attending physician or their designee shall make a note in the chart on the approved Hospital
form. The surgical/procedural consent is permissible if acquired within 90 days prior to the
surgical/procedure date.
i.
When a Physician Assistant is providing services to hospitalized patients, the licensed
supervising physician shall review the quality of medical services rendered every two working
days by reviewing and signing the medical records to assure compliance with the physicians’
directions. Inpatient history and physical exam reports and discharge summaries documented
by a Physician Assistant must also be reviewed and co-signed by the attending physician. The
Physician Assistant’s performance of a delegated medical function shall comply with the
board’s regulations and any restrictions and protocols of the licensed supervising physician
and hospital.
j.
Inpatient histories and physicals and discharge summaries performed by a certified advanced
practice nurse (NP) must be co-signed by an attending physician. For histories and physicals
completed by the advanced practice nurse prior to an inpatient admission, the attending
physician may complete an Interval H&P note at the time of admission.
k. When more than one member of the medical staff is treating the patient, the attending
provider is responsible for coordination of care and designation of responsibility.
7. Drugs used shall be (1) those approved by the Pharmacy and Therapeutics Committee and listed in
the Hospital Formulary, or (2) investigational drugs approved for research by the Colorado
Multiple Institutional Review Board (COMIRB) and Pharmacy and Therapeutics Committee.
8. Clinical research projects are to be encouraged and supported. However, no patient is to be
involved in a research project unless and until he/she has signed an informed consent form that
has been approved along with the project protocol by COMIRB. The project burden to the
departments must be disclosed pursuant to Hospital policy and approved by the Hospital prior to
the initiation of the research project.
9. Abortions will be performed in accordance with existing state and federal law, and University of
Colorado Hospital policies.
10. When patient restraint or seclusion is necessary, a physician order must be written in accordance
with the policies of the Hospital.
11. All other special treatment procedures, including restraint, seclusion, or behavior modification
procedures shall be documented in the medical record.
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12. All Medical Staff members privileged to treat patients shall be allowed to provide analgesia.
13. Any physician who has privileges to write orders may order respiratory care or rehabilitation care
services as long as the practitioner is responsible for the care of the patient. Nurse Practitioners,
Physician Assistants, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, or Certified
Nurse Midwives who are privileged and practicing either independently or under a supervisory
agreement may order respiratory care or rehabilitation care services within his/her scope of
practice.
14. Verbal orders can be given only in emergency situations. Verbal orders can be given when a
practitioner has no computer access. Verbal orders in an emergency situation should be carried
out immediately and can be entered into the order system at a later time.
Telephone orders can be given when a provider is off campus and has no computer access. When
the provider is giving a telephone order he/she must stay on the phone while the accepting staff
member writes down the order and reads the order back to the provider for verification. For
telephone orders immediately entered into the EMR, the provider must remain available to
respond to all clinical decision support alerts.
Verbal orders, including telephone orders, may be received by the following professionals:
registered nurses, certified physician assistants, physical therapists, occupational therapists,
speech language pathologists, respiratory therapists, registered dietitians, and pharmacists. In
radiology, for the purposes of scheduling only, verbal orders may be received by radiologists,
radiology technologists, radiology medical secretaries, and medical assistants.
In the ambulatory care settings, where no Registered Nurse or Certified Physicians Assistant is
available, medical orders (including telephone and verbal orders) may be accepted by other clinical
staff who provide care to patients in that ambulatory area and who have demonstrated
competence to accept medical orders within the scope of their practice. The professional person
receiving the order shall document and sign the order with the name of the clinician who gave the
order by the professional person’s own name.
B. ANESTHESIA AND SEDATION
1. Anesthesia: A history and physical is required before any procedure requiring anesthesia. All
anesthesia is planned and given under the direction and supervision of a privileged
anesthesiologist. Certified Registered Nursing Anesthetists (CRNA) and Anesthesiologist Assistants
(AA) may administer anesthesia under supervision of the anesthesiology attending physician who
is immediately available if needed. In the absence of an emergency situation, patients must
provide informed consent for anesthesia prior to administration of anesthesia. A pre-anesthesia
assessment can be performed by any practitioner privileged to administer anesthesia and must be
performed within 48 hours prior to the administration of anesthesia. A patient assessment must
be performed immediately before induction. An intraoperative anesthesia record must be
documented and maintained as part of the patient’s medical record. A post-anesthesia evaluation
can be completed by any practitioner privileged to administer anesthesia and must be performed
no later than 48 hours after the surgery/procedure requiring anesthesia. The post-anesthesia
assessment must include current respiratory function, cardiovascular function, mental status, body
temperature, pain level, if nausea and vomiting exist, and post-operative hydration.
2. Sedation: All sedation is given under the direction of an attending physician who has been
privileged to direct sedation. Patients must provide informed consent for sedation prior to
administration of sedation. Patients undergoing sedation must have a pre-sedation assessment
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including a focused history, physical assessment related to sedation, airway assessment, ASA
classification and plan for sedation. Documentation of sedation must be in compliance with
hospital policy.
C. EMERGENCY CARE
1. Emergency Admissions: For patients admitted under emergency conditions without an admitting
diagnosis, a diagnosis must be given to the Admitting Office within twenty-four (24) hours.
2. Emergency care shall be provided for patients through the services of the Emergency Department
of the University of Colorado Hospital. Emergency Department patients shall be given written
recommendations regarding follow-up care. A copy of such recommendations shall be maintained
in the patient’s medical record. The patient’s condition on release from Emergency Department
shall be documented in the EHR.
3. Emergency Medical Treatment and Active Labor Act Regulations (EMTALA):
a. Transfer of Patients: By federal law and in accordance with the University of Colorado
Hospital’s policy on Medical Screening Examinations, Stabilizing Treatment and Appropriate
Transfers, a patient who comes to the Hospital or outpatient facilities and requests
examination or treatment of a possible emergency medical condition1 has the right to receive,
within the capabilities of the Hospitals’ staff and facilities and regardless of diagnosis, financial
status, race, sex, color, age, religion, national origin, handicap, veteran status, sexual
orientation, or individual disabilities, the following:
i. An appropriate medical screening examination to determine if the patient has an
emergency medical condition. Physicians and nurse practitioners may perform an MSE if
they have been approved to do so by their department. Additionally, registered nurses
and paramedics may perform a medical screening exam in the Emergency Department if
they have been approved to do so by Emergency Department administration. Nurse
Practitioners, Registered Nurses, and Paramedics must have three years of clinical
experience and have completed the Emergency Department triage training program
before they may qualify to perform medical screening examinations. Approval by the
Emergency Department Medical Director and Nursing Director is also required. In
addition, a psychiatric screening examination to determine whether a patient has an
emergency psychiatric condition may be performed by psychologists, psychiatric social
workers, psychiatric clinical nurses (registered nurses), licensed marriage and family
therapists, and licensed professional counselors. Registered nurses in the Labor &
Delivery Unit may do the medical screening examination on a pregnant patient for the
limited purpose of determining whether or not the patient is in labor. If the medical
screening examination is performed by a non-physician, a physician must be reasonably
available onsite when needed. In off-site outpatient clinic areas, a medical screening
examination may be initiated by clinic personnel in consultation with an emergency
department physician in accordance with established protocols for the handling of
individuals with potential emergency conditions at off-campus departments.
ii. Treatment which is necessary to stabilize the patient’s emergency medical condition,
including treatment for an unborn child. There shall be a list of physicians, including
specialists and subspecialists, who are on call to provide further evaluation and/or
treatment necessary to stabilize an individual with an emergency medical condition. The
1
An emergency medical condition is one that, without immediate medical treatment, is likely to seriously jeopardize the health of the patient (or of an
unborn child), or is likely to result in serious impairment to bodily functions. With regard to a pregnant woman who is having contractions, an
emergency medical condition exists if there is not time to safely transfer her to another hospital before delivery, or transfer would pose a threat to the
health or safety of the woman or the unborn child.
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on-call physicians shall respond within a reasonable period of time, not to exceed fifteen
(15) minutes, and shall provide such further examination and treatment.
iii. If necessary, an appropriate transfer to another medical facility.
iv. Neither the screening nor any necessary treatment may be delayed in order to inquire
about the person’s insurance status or how they are going to pay.
b. The University of Colorado Hospital may not transfer an unstabilized patient to another facility
unless the patient or his/her representative, after being informed of the Hospital’s obligations
to provide stabilizing treatment and of the risk of transfer, requests in writing to be transferred
to another facility, or a physician signs a certification that, on the basis of the information
available at that time, the medical benefits expected from the treatment at the other facility
outweigh the increased risks to the individual (including the risks to an unborn child) from
making the transfer. In addition, the transfer must be “appropriate”, which means that:
i. The transferring hospital, within its capacity, must provide treatment to minimize the
risks of transfer;
ii. The receiving hospital must have space and qualified personnel to treat the patient, and
must have agreed to the transfer;
iii. The transferring hospital must send the patient’s medical records related to the
emergency to the receiving hospital; and
iv. The transfer must be made using qualified personnel, appropriate transportation, and
any necessary life-support measures.
Patients who present to Hospital ambulatory clinics seeking emergency treatment shall be
treated in accordance with established protocols for the handling of individuals with potential
emergency conditions at off-campus departments.
For further information about these requirements, the University of Colorado Hospital policy
as referenced above should be consulted.
D. MEDICAL RECORDS
1. The attending provider has the responsibility for preparation of a complete medical record for
each patient. The Hospital Department Chairperson has ultimate responsibility for the completion
of medical records.
2. The record shall include, as appropriate to the care, treatment and services provided:
identification data; reason(s) for admission, care, treatment or services; history and physical
examination including conclusions or impressions; allergies; special reports such as consultation,
clinical laboratory, x-ray, and others; provisional diagnosis; medical or surgical treatment;
operative report; pathological findings; orders and progress notes; final diagnoses; condition on
discharge; disposition; summary or discharge note, if applicable Transfer notes and off-service
notes, of appropriate content, summarizing care to that point should be written for inpatients and
outpatients. E-mails between hospital staff, patients or physicians deemed to be important to
patient care should be incorporated into the medical record. The medical record must include
statements describing the patient’s status at discharge, including degree of disability, potential for
and plans for rehabilitation, capacity for self-care, and plans for follow-up care.
3. All paper medical record entries must be dated, timed and authenticated by the individual making
the entry or responsible for the care.
4. Histories and physicals shall be completed within twenty-four (24) hours of admission and, except
for emergent cases should be on the record prior to procedures being performed. A history &
physical performed within thirty (30) days of admission may be accepted if an interval H&P note
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documenting an examination for any changes in the patient condition is completed and signed by
the attending physician. If it is a readmission within a month’s time for the same condition, the
previous history and physical with an interval note will suffice. The history should include chief
complaint, relevant history, past medical history and a review of systems.
5. Operative reports must be dictated within twenty-four (24) hours after surgery. A postoperative/post-procedure note will be entered in the medical record immediately after surgery or
high-risk procedure, such as general anesthesia or monitored anesthesia, unless the complete
operative report has been immediately entered. The post-operative/post-procedure note will
include the name of the primary surgeon(s), assistant(s), procedure performed, a description of
each procedure, findings, estimated blood loss, specimens removed, and postoperative diagnosis.
Complete operative reports must be dictated or entered into the record within twenty-four (24)
hours after surgery.
6. The medical record shall be completed within ten (10) days of discharge.
7. The Patient Record System Policy shall be followed and all paper original medical records
(including inpatient, outpatient and emergency room) shall be housed in the Health Information
Management Department. The Clinical Informatics Committee (CIC) must authorize any
exceptions.
8. Abbreviations on the UCH Unapproved Abbreviations List are not to be used in any medical Record
documentation.
9. Signature stamps are not to be used at any time.
10. No medical record shall be filed until complete, except on order from the CIC.
11. All medical records, including shadow records, are the property of the University of Colorado
Hospital and shall not be removed from the Hospital except through appropriate legal action.
Paper records must be reviewed in the Health Information Management department. They may
only leave the department for patient care purposes or regulatory investigations. No record may
be removed from any area to which it has been signed out without proper notification to Health
Information Management Department. No records or portions of records may be removed to any
areas of the Hospital, e.g., offices, sleeping quarters, etc., or sequestered in places so that they are
unavailable for use in patient care. All previous records shall be available for use by the attending
provider for approved purposes.
12. Medical records should always be transferred within the institution by courier, or standard means,
UNLESS, in the opinion of the medical staff member, the patient’s medical care would be
compromised by the time required transferring records in this way. The Health Information
Management Department must be notified of the transportation of records.
13. Portions of inpatient records that are paper must be available for Health Information Management
the morning following the patient’s discharge. Records for patients undergoing autopsies must be
returned to Health Information Management within (3) days.
14. The attending provider must review, co-sign and assume responsibility for any history and physical
examination prepared by Housestaff or medical students.
15. All written diagnostic and therapeutic orders, even if preprinted, shall be in writing and shall be
signed, dated and timed. Housestaff may write orders under the supervision of a member of the
Medical Staff.
a. Preprinted orders may be developed by the respective Hospital Departments in conjunction
with the Hospital Department Chairperson. They must be reviewed and approved by
appropriate hospital departments.
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b. Verbal orders, including telephone orders, may be received by the following professionals:
registered nurses, certified physician assistants, physical therapists, occupational therapists,
speech language pathologists, respiratory therapists, registered dietitians, and pharmacists. In
radiology, for the purposes of scheduling only, verbal orders may be received by radiology
technologists and medical sonographers.
c. In the ambulatory care settings, where no Registered Nurse or Certified Physicians’ Assistant is
available, medical orders (including telephone and verbal orders) may be accepted by other
clinical staff who provide care to patients in that ambulatory area and who have demonstrated
competence to accept medical orders within the scope of their practice. The professional
person receiving the order shall document and sign the order with the name of the clinician
who gave the order by the professional person’s own name.
d. Verbal and telephone orders, must be countersigned as soon as possible but no later than ten
(10) days after discharge/visit/procedure by the ordering practitioner or anther physician. Any
clinician who has privileges to write orders may countersign a verbal order if they have
knowledge of the patient’s hospital course, medical plan of care, condition and current status.
e. New orders must be written or acknowledged in the EHR when there is a change in the level of
care or when the medical service changes.
16. Ambulatory visit documentation must be completed within ten (10) days of the patient visit.
17. Physician Assistant records must be reviewed and signed by the supervising attending physician
every two (2) working days in the inpatient setting. Inpatient history and physical exam reports
and discharge summaries documented by a Physician Assistant or Nurse Practitioner must also be
reviewed and co-signed by the supervising attending physician.
18. In the ambulatory setting, physician assistant records must be reviewed and signed by the
supervising attending physician as follows:
a. For new physician assistant graduates: within seven (7) days of the patient encounter for the
first six (6) months of employment and a minimum of 500 patient encounters;
b. For experienced physician assistants new to a practice setting: within fourteen (14) days of
the patient encounter for the first three (3) months of employment and a minimum of 500
patient encounters:
c. All other physician assistants: no co-signature required.
19. The attending physician at the time of discharge is responsible for the completion of the discharge
summary. The discharge summary should encompass the patient’s entire stay and contain the
final diagnosis, reason for hospitalization, procedures performed, care, treatment and services
provided, the patient’s condition and disposition at discharge, and information provided to the
patient and family and provisions for follow-up care.
E. RIGHTS OF PATIENTS
No listing of rights can guarantee for the patient the kind of treatment he/she has a right to expect,
nor can a listing of rights supersede state and/or federal laws and regulations. A hospital has many
functions to perform, including the prevention and treatment of disease, the education of health
professionals and patients, and research. All of these activities must be conducted with an overriding
concern for the patient and, above all, respect of the patient’s dignity as a human being. The University
of Colorado Hospital’s policy on Patients’/Parents’ Rights and Responsibilities delineates specific rights
of patients including those which are required by TJC. The University of Colorado Hospital has many
policies which impact patients’ rights including Consent for Medical Care and Procedures, Advance
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Directives, and Refusal to Permit Blood or Blood Component Administration. Patients’ rights, which
may be included in any University of Colorado Hospital policy, are incorporated into these Rules and
Regulations by this reference. It should be understood that, if the patient is a minor, his or her parent
or legal guardian is included in those rights relating to information, communication and consent,
except in those cases listed in the policy on Consent for Medical Care and Procedures.
Some of these rights are:
1. Patients have the right to considerate, respectful care at all times and under all circumstances,
regardless of race, creed, color, religion, age, gender, national origin, sexual orientation, veteran
status, or individual disability, and with recognition of his/her personal dignity.
2. The patient has the right to know the identity and professional status of individuals providing
service to him/her, and to know which physician or other practitioner is primarily responsible for
his/her care. The patient also should be informed of means of staff identification (e.g., different
uniforms, badges, etc.).
3. The patient has the right to receive from his/her physician complete, current information
concerning his/her diagnosis, treatment and prognosis in terms the patient can be reasonably
expected to understand. When it is not medically advisable to give such information to the
patient, the information should be made available to an appropriate person in his/her behalf.
4. In accordance with 1.g.5 of these Rules and Regulations, the patient has the right to receive from
his/her physician information necessary to give informed consent prior to the start of any
procedure, sedation, and/or treatment. In addition, the patient has the right to refuse treatment
to the extent permitted by law and to be informed of the medical consequences of that refusal.
5. The patient has the right to every consideration of his/her privacy concerning his/her own medical
care program. Case discussion, consultation, examination, and treatment are confidential and
should be conducted discreetly and in surroundings designed to assure reasonable audiovisual
privacy. This includes the right to have a person of the same sex present when an examination or
procedure is conducted by a health professional of the opposite sex, and the right not to be
disrobed any longer than is medically necessary. Those not directly involved in the patient’s care
must have the permission of the patient to be present.
6. The patient has the right to expect that all communications and records pertaining to his/her care,
including the source of payment for such care, will be treated as confidential.
7. The patient has the right to request treatment; however, this does not mean that the Hospital is
obligated to provide treatment that is deemed medically unnecessary or inappropriate, or for
which the Hospital determines that they do not have the resources to provide.
8. When medically permissible, a patient may be transferred to another facility only after he/she has
received complete information and explanation concerning the need for such a transfer and
information concerning the alternatives to the transfer. The institution to which the patient is to
be transferred must first have accepted the patient for transfer.
9. The patient has the right to be advised if the Hospital proposes to engage in or perform human
experimentation affecting his/her care or treatment. Participation by the patient in research
and/or educational projects is voluntary, after full disclosure of all relevant information, including
any risks, and execution of the approved consent form. Patients also have the right to know that
refusal to participate will not compromise their access to care.
10. The patient has the right to expect reasonable continuity of care and to know in advance what
appointment times and physicians are available and where. The patient has the right to expect
that the Hospital will provide a mechanism whereby he/she is informed by his/her physician or a
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delegate of the physician of the patient’s continuing health care requirements following discharge.
11. The patient has the right to examine and receive an explanation of his/her bill, regardless of source
of payment.
12. The patient has the right to know what Hospital rules and regulations apply to his/her conduct and
rights as a patient, as well as the procedures, which are available for addressing patient complaints
or grievances.
13. The patient has the right to receive information tailored to his/her language and ability to
understand including access to interpreting and translation services.
Each Medical Staff Member should become familiar with the Hospital’s policy on Patients’/Parents’
Rights and Responsibilities, as well as the other policies noted above. Those policies contain a more
extensive listing and explanation of the rights of patients within the Hospital.
F. PROFESSIONAL LIABILITY CLAIMS
Any Medical Staff member who is named in a professional liability claim or action shall report the
circumstances of the claim or action to his/her Hospital Department(s), to the Medical Staff Office, and
to the Office of Professional Risk Management. Reporting shall occur at the time of notification of the
claim or action, and at a minimum, the Medical Staff member shall also report final judgments or
settlements. There shall be adherence to the requirements of the National Practitioner Data Bank and
to the State of Colorado reporting requirements.
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