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the Orientation Handbook.

1. Hospitalist Office at GBMC 15 located on the main floor of the hospital in Suite 3808 Miscellaneous e daily contact list of hospitalists caring for a specific patient is faxed to each hospital floor e Hospitalists can see patients in any inpatient unit of the hospital as well as PACU Sherwood Surgical Center and the Wound Care Center 02 25 13 Inpatient Mid Level Team Services A dedicated mid level team is available to provide on site support for community physicians who choose to manage their patients hospitalizations Inpatient Attention While You Stay in the Office The team is available for care when you most need to be available at your office practice This service designed to assist you in caring for your patients when they are hospitalized is available 24 7 by calling 443 849 7925 You can request on site hospital care for a patient arriving via direct admission or through the emergency service As a reminder when calling please leave your pager number Services Provided The team s specific role 1s to Manage patient care in conjunction with the attending physician once the patient has arrived on a hospital unit either from the emergency department or directly from your office Provide on site coverage and communication with the admitting physician on non urgent treatment changes Consult regularly with the nursing team on the day to day care provided to the patient ensuring that treatment
2. f to report a safety ewent that affected a Visitor Visitor Track My Event Pear Review Protection Statement Event ID Pursuant to Maryland Health Occupatons Artide Section 1 401 proceedings records of fles of medical review committee such as managerent utilization ravigw committee ara rot discoverable and are not admisshle m evidence in any action This information 16 protected and confidential This rfarmanon wil be used by professional heabicare orceidars far purposes inducing evaluation and improvement of the quality and effinieney of services ordered or parfomed by healthcare providers evaluation of the need for care and the level of perfomance of heath care providers and comaliance with the standards set by healthcare provider associadons and apalicable laws rules and regulations and other aporcunate safety and quality of cara standarde Every employee having access to this system canjuncion with the Systems risk managemert program shall with the Ersurance Partehility and Accountability Act of 1996 Privacy amp Sacurty Regulations HIPAA and al applicable state and Federal privacy laws ducing HITECH usa disdosura of Probarted Haakh Crformation this system for purposes beyond complianca with tha 5 internal isk management program and which is not spechically authormed is strictly prohibited and ma
3. completed within 24 hours of admission work type 6 See History amp Physical Format Consultations work type 3 Date consultation is performed Name of physician requesting consult Reason for consultation Past medical history Physical examination of patient Assessment diagnostic impression of care treatment recommendations Data Quality Coding Office 443 849 3509 The basic role of the coder is to translate what the physician has documented on his patient s record into ICD9cm and CPT codes Coders can only code what 1s stated explicitly and not is what is implied This 1s the reason why physicians are queried retrospectively regarding diagnoses which they alluded to but did not state An example of this is Patient had surgery lost 1100ccs of blood transfused 2 units for a hematocrit of 24 It is obvious to the coder that the patient has blood loss anemia but unless the physician uses those very words this diagnosis cannot be coded The following are examples of common documentation issues coders encounter frequently which result in either a Coder Physician Query or an incomplete patient profile Acute Myocardial Infarction State the site and whether or not it is subendocardial or involves the full thickness of heart Sepsis If patient has this condition use this terminology Urosepsis is translated into a UTI in ICD9cm bacteremia 1s considered the presence of bacteria in the blood Pneumonia
4. if previous patient at GBMC Type of bed requested Present location of patient office home etc Estimated time of arrival if bed available Condition of patient ambulatory or wheelchair and Whether patient will be accompanied by family members that can assist patient to lab or X Ray if ordered or will need GBMC transport assistance Administrative Coordinator will secure bed and provide the physician s office with bed assignment After orders have been received Physician will write Admission orders and fax the orders to the Administrative Coordinator at 443 849 6933 The orders need to be received prior to the patient arriving Labs and X ray orders should be written STAT e A physician telephone number or pager should be provided on the orders for any questions The patient should go directly to the Admission Desk the Main Lobby Patient will be registered for Admission 100 Procedures for Medical Attending Daytime Direct Admissions Page 2 6 10 11 12 13 The patient s family will be provided with the option to either escort the patient to the lab and or X Ray or have GBMC Transport accompany the patient and family If a transporter is required Admitting will page the transporter STAT for transportation of the patient The transporter will have a Patient Flow Sheet that will list the areas to which the patient is to go and the patient room assignment The transporter will remain with the p
5. uncomplicated large bowel obstruction appendicitis w perforation sepsis acute biliary sepsis with orwithout obstruction chalangitis or unstable acute cholecystitis abscess drainage any location or wound debridement w sepsis stable intestinal ischemia glaucoma emergency retinal detachment urgent open fracture any location major joint dislocation acute septic joint iexduding total joint replacement esophageal leak or perforation mediastinitis uncontrolled bronchopleural fistula vulvar abscess with sepsis infected pelvic mass tubo ovarian abscess deep space vascular infection acute peripheral nerve compression urinary obstruction wy sepsis penile fracture paraphimosis patent ductus arteriosus PDA premature infant Section Il Pre S urgical Testing Pre Surgical Testing Department Our goal is to ensure safe and efficient surgical care by partnering with you to have all required pre surgical testing requirements before the day of surgery Department Hours e Pre Surgical Testing Department answers calls from 7 30 a m to 4 30 p m Monday through Friday You may leave a voice mail message before or after our normal hours of operation VVe endeavor to return ALL calls within 24 hours of receipt except for calls received on the weekends Patients can be scheduled for Pre Surgical Testing appointments with our Nurse Practioner from 8 00 a m t
6. Surgical Posting Department answers calls from 7 30 a m to 5 00 p m Monday through Friday You may leave a voice mail message before or after our normal hours of operation We endeavor to return ALL calls within 24 hours of receipt Your case is not officially posted until you receive confirmation from the Posting Office Who to Call for Scheduling Add on and Emergent Urgent Cases Posting Department takes call during normal hours of operation as above for elective case posting AS WELL AS calls up to 2 00 p m for add on cases for the following day The General Operating Room GOR Control Desk takes calls to post SAME DAY emergent urgent cases AND takes calls after 2 00 p m for add on cases for the following day Staff Contacts e Roberta RN RNFA Posting Manager telephone 443 849 3442 Names of staff members Suzie Whitaker Tracy Joyner Darlene Johnson Deborah Cox Main Telephone 443 849 6700 46 MAIN TELEPHONE 443 849 6700 PHONE CHANGES ONCE THE MESSAGE COMES ON YOU CAN IMMEDIATELY PRESS THE NUMBER FOR YOUR SERVICE IF SCHEDULER IS ON ANOTHER LINE YOU WILL BE DIRECTED TO HER VOICEMAIL AND YOU WILL RECEIVE A CALL BACK PHONE OPTIONS PRESS 1 CHANGES TO NEXT DAY SCHEDULE PRESS 3 BARIATRICS DARLENE JOHNSON FAX 443 849 3911 PRESS 4 SUZIE WHITAKER ENT HEAD amp NECK ORAL SURGERY amp PEDIATRIC GENERAL SURGERY FAX 443 849 3916 PRESS 5 TRACY JOYNER ORTHO N
7. All anti inflammatory medications e g Ibuprofen Advil Motrin Naproxen etc MUST be stopped 48 hours prior to plastic or retinal surgery All herbal medications and non vitamin supplements MUST be stopped SEVEN days prior to your surgery Diet medications MUST be stopped SEVEN days prior to surgery Birth control pills continue day of surgery Eye drops continue day of surgery Narcotic pain medications continue day of surgery Antiseizure medications continue day of surgery Steroids oral and inhaled continue day of surgery Statins Zocor Lipitor continue day of surgery Cardiac medications Digoxin continue on day of surgery Blood pressure medication and diuretics continue on morning of surgery COX 2 inhibitors Celebrex Vioxx continue day of surgery Thyroid medication continue day of surgery Heartburn or reflux medication such as acid blockers Zantac Pepcid Axid Prilosec Propulsid Reglan SHOULD be taken on the morning of surgery to reduce the risk of pneumonia However antacids such as Maalox Tums or Carafate SHOULD NOT be taken because they contain particulate material that may damage the lungs if aspirated MINIMAL PREOPERATIVE REQUIREMENTS BY AGE PEDIATRIC 0 6 MONTHS PEDIATRIC 6 MTHS 18 YRS amp P HCT History and Physical Only Exception tonsillectomy requires HCT menstruating females need HCT amp HCG ADULT MALES lt 40 ADULT MALES 40 69 ADULT MALES 70 and over History and Physic
8. 34 Organizational Chart Department of Pathology Greater Baltimore Medical Center Laboratory Quality Improvement Committee Pathologists Administrative Director Laboratory Managers Quality and Education Coordinator QUALITY AND EDUCATION MANAGER OF PHLEBOTOMY COORDINATOR SERVICES Aimee Lopez Lois Lorenz LABORATORY INFORMATION SYSTEMS CUSTOMER SERVCE Agnes Masucol ANATOMIC PATHOLOGY CLINICAL LABORATORIES SURGICAL PATHOLOGY HISTOLOGY CYTOLOGY PATHOLOGY OFFICE CORE CLINICAL LABORATORY Lab Manager Alan Graham Supervisor Manju Kaushal Histology Specialist Pathology Office Manager Suzy Beck Laboratory Clinical Specialists Chemistry Jesse Nasby Hematology Christine Drummond Immunology Sue Mann Evening Supervisor Tom Barlow Point of Care Coordinator Debra PATHOLOGISTS Gurney BLOOD BANK upervisor Sue Erickson Nathan Dunsmore M D Blood Bank Onc gt Services MICROBIOLOGY Laboratory Personnel Policies Philip McDowell M D Hematology per visor Gail Szyman Team Steven Pearlman M D Immunohistochemistry Beth Schwartz M D Cytopathology Administrative Director Howard Siegel M D Immunology Phlebotomy Services Manager Dr Palermo Microbiology Chemistry Surgical hee ae ih Laboratory Management Team Supervisors Pathology TET Administrative Assistant Nikki Chilcoat Administrative Director Medical Director Labora
9. Pespirations percussion breath Heart PMI rhythm ectopics Peripheral Vascular For Abdomen Tenderness Extremities Edema varicosities cote Neuro Motor sensory orientation Other Pertinent Findings impression 60 GBMC 6701 North Charles Street Baltimore Maryland 21204 CONSENT TO DIAGNOSTIC OPERATIVE THERAPEUTIC BLOOD TRANSFUSION AND PHARMACOLOGICAL PROCEDURE Date of Procedure PM Name of Patient type or print 1 I consent to the performance of the following procedures upon the Patient under the direction of Dr as the physician in charge these procedures may be performed by him her or anyone whom he she may designate a Physical examinations other routine diagnostic procedures and routine medical treatment b The following operative special diagnostic or therapeutic procedures injection or other administration of the drugs or other substances incidental to any procedure described in subparagraph a above d Any other procedure related or incidental to those enumerated above if within a reasonable degree of medical certainty the procedure 15 necessary to avoid a substantial risk of death or immediate and serious harm to my health and someone authorized to give consent on my behalf 1s not reasonably available to make the decision e option of my surgeon the videotaping or photographing of any surgical procedure for diagnostic purposes or for educ
10. Summary Sheet Process Forms Falls Policy and Pain Assessment Pediatric Crash Carts in Outpatient Settings Medication Management and Suicide Risk Protocol Ophthalmology Otolaryngology 68 Improve Accuracy of Patient Identification Use TWO patient identifiers NAME AND DOB when administering medications collecting blood samples and other specimens for clinical testing when giving blood doing procedures treatments transporting or providing meals The patient s room number or physical location is not used as an identifier e Must use active communication Please TELL ME your NAME and DOB 1 v A Policy Patient Identification 69 Universal Protocol Make sure that the correct surgery is di on the correct patient and at the correct place on the patient s body Mark the correct place on the patient s body where the surgery 1s to be done EVERYONE Pauses before the surgery to make sure that a mistake 1s not being made Document the Time Out Policy Universal Protocol 70 Improve Communication Purpose To communicate critical results to the licensed caregiver so that action may be taken to prevent avoidable delays in treatment or response GBMC will be proactive in its approach to communicating critical results throughout the organization Person receiving the call from the lab regarding a critical laboratory result is to call the licensed caregiver within 60
11. a zero before a decimal point Trailing zero X 0 mg and Lack of leading zero X mg Magnesium Sulfate Mistaken for each other Magnesium Sulfate Morphine Sulfate Morphine Sulfate 29 GBMC HEALTHCARE DEPARTMENT OF PATHOLOGY Customer Services For Clinical Laboratory Results 24 hours day 7 days week To speak to a Customer Service Specialist Phone 443 849 2314 Fax 443 849 6741 For Anatomic Pathology Results 7 30 a m 5 00 p m Monday Friday To speak to a Pathology Secretary Phone 443 849 2233 Fax 443 849 3016 Customer Service Specialists Clinical Laboratories will Call all outpatient critical results to the physician s office Process requests for add ons to existing orders and provide follow up Investigate and resolve problems and then provide appropriate follow up Assist with specific requirements for special laboratory tests Print and ensure delivery of outpatient requisitions for private physician offices Set up special research protocols Pathology Secretaries Anatomic Pathology will e Provide Anatomic Pathology results to physicians if requested by fax e Obtain pathology materials from outside institutions for review by GBMC Pathologists e Provide patients with materials needed to obtain second opinions Outpatient Service Centers Available Services The GBMC Patient Service Center provides specimen procurement services for laboratory testing EKGs and Autologous and T
12. sur Earn eo EEUH wae doe Ue Raten Pot RU EP QUU dd eH 53 Perioperative Surgical side eie aa vet eut dA ERE 56 Pre Surgical Testing Consent 0 0 ccc ccc ceee eee eeeeee eee e eens 59 Iraportant CODICIS ii 63 QUALITY AND PATIENT SAPE LY oit 66 QUOS extre r ext is robs 75 GBMC Clinical Policy Restraints amp Seclusion eee e eee 8 90 SURGICAL ORIENTA TION 97 DAYTIME DIRECT ADMISSIONS ccccccccccccccccccccccccccsccsccscsssseees 98 DIRECT LATE ADMISSIONS 100 THE JOINT COMMISSION 102 Compliance and Internal Audit 0c cece ccc cee e ence 103 OTHER REFERENCES e At A Glance Card e Provider Service Quick Reference GBMC Campus Map e MD Today Greater Baltimore Medical Center DEPARTMENT CHAIRMEN AND DIVISION HEADS ANESTHESIOLOGY Ext 2202 Fax 3241 DIAGNOSTIC RADIOLOGY Ext 2935 Fax 2866 Diagnostic Radiology Interventional Radiology Neuroradiology Special Imaging EMERGENCY MEDICINE Ext 2323 Fax 2526 FAMILY MEDICINE 410 771 9220 Fax 410 771 9301 GYNECOLOGY Ext 2382 Fax 8068 Gyn Oncology Reproductive Endocrinology Urogynecology MEDICINE Ext 2680 Fax 6812 Cardiology Dermatology Endocrinology Gastroenterology Hematology Infectious Disease Internal Medicine Medical Oncology Nephrology Neurology Pulmonary Diseases Rheumato
13. 3 Consultation 8 Priority Consultation 4 ER Admission Note 9 ER Note 5 History and Physical 10 Interim Summary Because the system has built in VOR Voice Operated Record you may begin your dictation and the recorder will automatically start recording When you stop talking or pause the recorder will automatically stop and the low continuous tone will return The touch tone commands are as follows 1 Listen Dictate VOR Operation 3 Rewind will rewind approximately 15 words and then automatically begin playback 4 Pause you can pause for approximately 2 minutes before being disconnected 18 9 End of Document This separates your reports Touch this after each report to re enter your personal ID number then enter the new work type number patient number and begin dictation Go to End of Dictation After touching this the recorder will instantly place you at the end of your dictation You may then begin dictating Fast Forward After touching this key the recorder will fast forward and stop at the end of your dictation Go to Beginning of Dictation The recorder will instantly place you at the beginning of the document being dictated Touch 1 to listen Touch 2 to dictate Manual Disconnect Depress this key before hanging up Multiple Dictations To dictate multiple reports depress 5 This re enters your personal five digit ID number then enter the work type number and patient ID numb
14. 8 hrs 24 hrs same MRI day 1day 7days 1 5 hr 8 hrs 24 hrs within PET CT 24hrs 1 7 days 1 5 hr 8 hrs 24 hrs 3 schedule my appointment online Yes go to www gbmc org click on services full list of services alphabetical list of services Radiology click icon request an appointment in the middle of the page and complete online form Someone from our scheduling team will contact you within 24 hours 4 How is patient informed about prep Scheduler will provide patient with prep instructions 5 Should patient arrive early for test Yes Patient should arrive 15 minutes before appointment time unless otherwise directed 6 What does patient need to bring on arrival for appointment Prescription physician order insurance card photo ID 7 How long does the test take This depends on the test and can range from five minutes to three hours The Radiology scheduler should be able to tell you how long your test will take 8 When and how do we get test results The Radiology Department will send your results to your physician within 24 48 hrs after your test has been completed Patients should be instructed to call the physician s office Physicians offices can call Imaging library at 443 849 2325 for results or call x2343 and listen to prompt 9 Ifa patient wants copies of images whom does he she call Patients can request copies of images by calling the Imaging Library at 443 849 2325 Images can be copied to dis
15. Be as specific about the cause of the pneumonia as you can If you are treating the patient for a suspected organism state this If patient is being treated for aspiration pneumonia please document Abnormal finding Document all lab findings which are treated or monitored Coders cannot code from lab reports If you consider the finding to be significant please document 20 Anemia thrombocytopenia and leukopenia Please document etiology if known Diabetes Mellitus Please distinguish between Type I and Type diabetes Coders can no longer use the terms IDDM or juvenile or adult onset diabetes Also state all manifestations of the diabetes and whether or not the diabetes is controlled or uncontrolled Wound Debridements Please set the level of debridement e g skin muscle bone Open Wound There is no code for open wound Please specify the etiology of the wound e g skin ulcer or injury Fracture If the fracture is not the result of trauma please state spontaneous or pathological Chest Pain Please state the known or suspected etiology at the time of discharge Mental Status Changes Please state the known or suspected etiology at the time of discharge Renal Failure Insufficiency Coders frequently find that renal failure and renal insufficiency are used interchangeably in the same patients chart The conditions have different codes which have different impacts on patient severity Please clarify whether patie
16. Govt Relations Marketing C om Business Dev Physician Services Managed Care GBMA Physician Practices GBDIP Partnership Ruxton Insurance Data Quality Clinical Decision Sup Patient Financial Services Legal Risk Management Medical Records Patient Access Eric L Melchior EVP CFO John W Ellis SVP Corp Strategy Bus Development Human Resources Surgical Services David Hynson Genetics Interim VP CIO Jody Porter R N Deloris Tuggle VP SVP CNO John R Saunders Jr M D Org Dev amp HR Keith R Poisson EVP CMO EVP COO Compliance Audit Jenny Coldiron Vice President Development Foundation Chairmen Service Line Directors 1 1 1 Harold Tucker M D _ _ _ _ __ John B M D Chief of Staff President CEO March 2013 Management Organizational Chart HealthCare Departments of Clinical Engineering Emergency Management Safety amp Security Department of Clinical Engineering For Clinical Engineering Support Clinical Equipment Director Dan Tesch 443 849 2966 24x7 Area of Responsibility Critical Care Monitors Anesthesia Gas Systems Imaging Systems Radiological Treatment Systems Interventional Cathlab Endovascular Lab Ventilators Defibs Nursecall Systems Patient Beds Wheelchairs and Stretchers Patient Lifting System Misc other Clinical Devices Department of Emergency Operation 443 849 3036 Director Dan Tesch Emergency an
17. PC 03 03 23 For hospitals that do not use accreditation for deemed status purposes Patients in restraint or seclusion for behavioral health purposes are assessed and assisted in meeting criteria for the discontinuation of restraint or seclusion PC 03 03 25 For hospitals that do not use accreditation for deemed status purposes The hospital monitors patients who are restrained or secluded for behavioral health purposes MEN PC 03 05 01 For hospitals that use Joint Commission accreditation for deemed status purposes The hospital uses restraint or seclusion only when it can be clinically justified or when warranted by patient behavior that threatens the physical safety of the patient staff or others PC 03 05 03 For hospitals that use Joint Commission accreditation for deemed status purposes The hospital initiates restraint or seclusion based on an individual order PC 03 05 07 For hospitals that use Joint Commission accreditation for deemed status purposes The hospital monitors patients who are strained or secluded PC 03 05 11 For hospitals that use Joint Commission accreditation for deemed status purposes The hospital evaluates and reevaluates the patient who is restrained or secluded Please see the following page for the Policies and Procedures Infoweb Screenshot 89 8 Print This 4 EmailtoaFriend Font Size Policies amp Procedures Welcome to the Policy and Procedures Use the search tool below
18. Patient Access facilitates completion of death certificates Between the hours of 9am until 9pm Patient Access will notify the attending physician of any death certificates to be signed Physicians have 24 hours to complete and sign the death certificate Please note the attending or his her designee 1s responsible for completing and signing the death certificate Death certificates may be signed at Main Patient Access located in the hospital main lobby from 5 30a 11p and in the ER Patient Access registration area from 11 5 30a OB Patient Access open 24 7 located on the 2nd floor of the main hospital facilitates completion of death certificates as related to the following Fetal Deaths Live Birth Deaths Any death of a infant admitted to the NBN or NICU Other Death Certificate Reminders Death certificates must be completed in black ink No corrections scratch outs are permitted Cardiac Arrest and Respiratory Arrest are not acceptable diagnoses per Vital Records Stillborn and or pre maturity is not an acceptable cause of death 27 GBMC CLINICAL POLICY AND PROCEDURE ABBREVIATIONS AND SYMBOLS APPROVALS Signature on file Signature on File Chief of Staff Sr VP of Patient Care Services amp CNO PURPOSE To assist in the delivery of health care to the patient that is dependent on written information and to avoid misinterpretation of medical record entries that may result in harm to t
19. Surgical Testing and Primary Care Physician contact information Cases should be posted by the Procedure Name as listed on the Surgeon specific List of Procedures previously provided e Each procedure on the list has a specific Preference Listin our computer system that gives us Surgeon s preferences needs for supplies equipmentand room set up for that particular case The time for the case will be posted according to the average procedure time in our computer system which updates the surgeon s historical case time experience during the past month Scheduled Turnover varies by Location Service Procedure A FAX confirmation will be automatically returned for ALL cases that have been posted in our computer system 48 GBMC ON LINE SURGICAL POSTING www gbmc org surgicalposting Complete the on line form and submit If your block time has released you must call to be sure time is available before sending your on line posting request Please call Surgical Posting at 443 849 6700 for all cases within 24 hours that need to be canceled or rescheduled All fields that have an asterisk are required If required fields are not filled the form will not submit You will be prompted to fill in required fields When the posting form is complete it will submit to the Scheduling Office A confirmation that we have received posting will be e mailed back A confirmation will be sent via fax when the case is posted The turn
20. a new finding of an abnormal EKG ischemic changes abnormal rhythm should be evaluated preoperatively The physician preparing the pre surgical evaluation must specifically comment on each cardiac issue or refer to a cardiologist to do so Any patient with unstable cardiac status must have a consultation by a cardiologist 8 Patients with a past medical history of a CVA within 6 weeks of surgery need pre op medical clearance 9 The pre surgical evaluation of any patient on anti coagulation medicines e g Coumadin must specifically address the issue of whether bridging with other anti coagulation medicines is required and if so what regimen should be utilized GUIDELINES FOR MEDICATION Consult with your Primary Care Doctor as to instructions for taking insulin on the day of surgery Patients taking Aspirin Aspirin products Plavix Coumadin Warfarin should consult their physician or cardiologist in regard to taking medicine day of surgery Patients taking antidepressant antianxiety and psychiatric medications should continue day of surgery Please consult prescribing physician if any concerns Vitamins Iron Premarin discontinue day of surgery Topical medications creams and ointments should be discontinued day of surgery 56 Metformin Glucophage Glucovance Avandamet and Actos Plus MUST be stopped 24 hours prior to surgery Viagra Levitra Cialis or similar drugs should be discontinued 36 hours prior to surgery
21. admission process If ambulatory the patient should be directed to the Admissions Desk in the Main Lobby until 10 p m after that the patient should go to the Registration Desk in the Emergency Department until 6 a m the following morning and inform the registrar that they are to be directly admitted and be escorted to their room From 6 00 8 00 a m the patient should be directed to go directly to the Admission Desk in the main lobby and be escorted to their room In the event the patient is being transported by ambulance the patient should be taken to the Emergency Department and the Clinical Unit Coordinator in the Emergency Department will tell the ambulance team the location of the patient s room The patient will be registered for admission either at the Admission Desk in the main lobby or at the Registration Desk in the Emergency Department If a transporter 1 required Admitting or the Emergency Department Registration desk will page the transporter STAT for transportation of the patient Direct admissions will be assigned to the first bed available When the patient arrives on the unit the Physician orders will be reviewed immediately by the RN to facilitate patient care The admitting RN should contact the physician if in that nurse s judgment the patient s condition warrants immediate further evaluation In the event that the patient needs blood work and the floor nurses are unable to draw the necessary labs th
22. discharge summary the principal diagnosis That diagnoses which is responsible for the admission to the hospital Include all secondary diagnoses which affected care and management of the patient 22 GBMC Meditech MEDITECH Greater Balk Electronic Signature Quick Reference Guide Signing and Rejecting Documents Orders in Meditech 1 Sign into Meditech and click EMR 2 Click EMR View Patients Physician Main Desktop 4 Applications EMR View Patients Emergency Dept TEST 5 64 Physician Desktop Medical Medication Transfer Orders EMR TEST 5 64 Radiology Depts TEST 5 64 Surgical Medication Transfer Orders Other Reports Scheduling OR TEST 5 64 Change Password wo gt 3 Click Sign Documents on the right hand menu Admitted My Group Cover Admitted LTC My Group Cover Emergency Dept Group Other Group New Results Recent Access Persanal List Report Location Record Rounds Report GOU Lover Sign Documents 25 4 Single click in the left hand column next to each order s you wish to sign reject A red will appear next to each one when you chooose it 5 Click Process X the right hand menu bar am Ns i p Dieters Enterprise Medical Record Train1 Dr M D Sign Documents Signing Traini Dr 4 Documents For Traini Dr M D 3
23. improved patient safety by e Avoiding transcription errors e Avoiding omission e Avoid duplication of therapy e Avoiding drug drug or disease disease interactions What medications have to be reconciled Prescription medications Sample medications Herbal remedies Vitamins Over the counter drugs Vaccines Diagnostic and contrast agents Radioactive medications Respiratory treatments Parentral nutrition Blood derivatives IV solutions What will be required of me e Outpatient visits review and update home medication list with patient e admission compare all prescribed medications with those on home list of medications change in level of care review all prescribed medications and compare with home list of medications e On discharge transfer review medication and compare with home list prior to discharge document changes and communicate to the next provider of care service a complete list of medications prescribed 16 GBMC Healthcare Department of Health Information Management The Physician ID number assigned to you is also your Medical Record ID number Physician s Record Office Pro Shop 443 849 2277 The Physician s Record Office PRO Shop 15 located on the 3 floor across the hall from the Executive Offices in Suite 3247 The PRO Shop has five workstations equipped with a PC and telephone for physician use The PRO Shop is daily from 7 00 a m 9 00 p m Accessing Medical Records for Patie
24. in the hospital s training plan which shall be based on the results of quality monitoring activities 2 Physicians who order restraint or seclusion a Shall be educated in the requirements of this policy 95 Clinical Policy and Procedure Restraints and Seclusion Page 5 3 Hospital staff members who assess patients for restraint or who apply restraint shall receive training in the following topics as appropriate to the patient population served a Techniques to identify staff and patient behaviors events and environmental factors that may trigger circumstances that require the use of a restraint or seclusion b The use of nonphysical intervention skills c Choosing the least restrictive intervention based on an individualized assessment of the patient s medical or behavioral status or condition d The safe application and use of all types of restraint or seclusion used by the staff member including training in how to recognize and respond to signs of physical and psychological distress e Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary f Monitoring the physical and psychological well being of the patient who is restrained or secluded including but not limited to respiratory and circulatory status skin integrity vital signs and any special requirements specified by hospital policy associated with the 1 hour face to face evaluation of patie
25. minutes and document this call licensed caregiver is to read back the result to the caller Policy CRITICAL VALUES REPORTING 71 FA FALL REDUCTION AND HAND OFFS S At GBMC we e Assess patients for risk for fall and implement strategies as appropriate Patients at HIGH RISK Red Blanket and nonskid Red Socks and utilizing other nursing interventions Patients at MODERATE RISK Orange Blanket Orange Socks Patients also have color coded wrist bands in addition to socks amp blanket e Educate patients and families about fall risks GD e Reduce fall risk hazards clutter supplies wet floors e Re assess patients for fall risk twice daily S Communicate fall risk to other caregivers at Hand Off e HAND OFF standardized approach to hand off communications including an opportunity to ask and respond to questions Whenever there is a change in caregivers there needs to be hand off Include up to date information regarding the patient s condition care treatment medications services and any recent or anticipated changes Policy FALL RISK ASSESSMENT PREVENTION AND MANAGEMENT ADULT 12 Interpreter Services Effective Communication is an essential component of patient quality care and safety Every patient has the right to receive communication in a manner they understand GBMC now provides interpretation comnect to an interpretes from any phone servic
26. reference lab critical values Amikacin Trough greater than 10 0 ug mL Peak greater than 35 0 ug mL Carbamazepine Tegretol Digoxin gratrthan25pg mL o ooo Gentamicin Trough greater than 2 0 ug mL MEM Peak greater than 10 0 ug mL Lithium eme niSmmd _ Phenobarbital _ graterthan 0Opg mL o ooo Dilantin _ graterthan30ugmL Salicylate greater than 400 mg L Poo Theophyline gratertham2SOpg mL Tobramycin Trough greater than 2 mg L Peak greater than 10 1 mg L MEM VdpocAdi O _ Vancomycin Vancomycin Trough greater than 22 0 ug ml Peak greater than 40 ug mL 42 QM05009 Critical Result Notification Appendix A Page 3 HEMATOLOGY Hematocrit Less than 20 or greater than 60 0 Less than 20 neonate 0 7 days greater than 65 Hemoglobin Less than 7 or greater than 20 0 gm o Less than 7 gm Malarial Parasites 1 or greater Platelets Less than 50 000 or greater than 999 000 Positive APT test WBC Less than 2 000 or greater than 30 000 neonate 0 30 days less than 5 000 neonate 0 30 days greater than 30 000 COAGULATION APTT ereater 119 9 sec Fibrin Split Products Greater than 80 mcg dl Fibrinogen Less than 100 mg dl Less than 100 mg dl 43 GBMC PAT and Posting Departments Guidelines and Information Reference January 2013 GBMC 44 Section Posting 45 About Surgical Posting Department Department Hours
27. regimes have been delivered as expected Interface with specialty consults and ancillary testing Imaging Services at Greater Baltimore Medical Center Services Offered CT Scanning Offers an array of procedures including cardiac scanning and virtual colonoscopy and biopsies Offer 3D rendering of images to aid in diagnosis and treatment Services are provided to outpatients inpatients and emergency room patients Diagnostic Radiology Offers an array of routine x ray services for outpatient inpatient and emergency room patients Offers fluoroscopy arthrograms and plain film procedures DEXA Services Offers services that measure bone density Interventional Radiology Many invasive diagnostic and therapeutic procedures performed that are tailored to meet the needs of the individual patient Procedures include angioplasty fallopian tube recanalization vascular stenting biopsies chemoembolization vascular access procedures vertebroplasties kyphoplasty diagnostic angiography embolization ablation techniques filters venous samplings and more All patients receive a consultation for a detailed explanation and to answer any questions Services are provided on an outpatient and inpatient basis MRI Offers an array of procedures used to evaluate head neck thorax abdomen spine and extremities In addition MRA Magnetic Resonance Angiography and Breast Biopsy Procedures are performed Services are provided to outpatients inp
28. screen Physician Main Desktop will now appear For further instructions on using the Meditech software several resources are available e Contacting 443 849 2200 for assistance and training Meditech Logon Guide e Quick Reference Brochure e The MIS Help Desk Information on accessing these resources is listed in the Quick Start section above Accessing Radiographic Images via PACS Patient radiographic images are now stored and can be viewed electronically via a system called PACS To access and view an image for your patient begin by viewing that patient s data in the Meditech system Then click on the Imaging option on the right hand menu When the list of images appears click on the camera icon on the far right to view the study of interest This will start specialized software called LightView For more detailed instructions on accessing images and using the LightView software the following resources are available e PACS Quick Reference Guide e MIS Help Desk Information on accessing these resources is listed in the Quick Start section above Accessing the System Remotely 1 Obtain a remote access logon see above From any PC with Internet connection go to the remote access web page by typing https weblogin gbmc org in the address box 3 If the Citrix remote access software has never been installed on that PC click on the Download Citrix link and follow the instructions This software only ne
29. 24 7 for any order entry questions or problems Obtaining Access to the System All physician requests for access should be directed to the Medical Staff Office for review 443 849 2370 Quick Reference Guides For experienced computer users quick brochure style reference guides are available for both Meditech and PACS A logon guide and a more comprehensive user s manual are also available for Meditech These materials can be obtained by contacting the Medical Staff Office Physician Relations 443 849 6176 or the MIS Help Desk GBMC On The Web From any PC that has Internet access start Internet Explorer and type www gbmc org in the address box Then click on the Physician Portal tab to access educational and research resources link to Meditech remotely or learn more about physician services and the medical library Obtaining Access to the System There are three types of system access for physicians at GBMC Depending on whether you are employed by the hospital or not and where you wish to view patient information you may need any or all of the following types of access Meditech Logon This is used to access order entry patient data reports and radiographic images in the Meditech software system see below Once you have requested and received access to Meditech your user ID will be the same as your five digit dictation number also assigned to you by the Medical Staff Office Please note that Computer Pro
30. EURO amp PAIN GENERAL SURGEY FAX 443 849 3915 PRESS 7 DEBBIE COX EYES PLASTICS amp PODIATRY FAX 443 849 3913 PRESS 8 TRACIE BROWN VASCULAR PULMONARY amp DAVINCI FAX 443 849 3914 THE SCHEDULERS WILL NO LONGER ANSWER PHONE CALLS ON ANY LINE OTHER THAN THE ABOVE OPTIONS WHEN A SCHEDULER IS OFF OR ON VACATION HER PHONE WILL BE FORWARDED TO AN ASSIGNED ALTERNATE 47 How to Posta Surgical Case Surgeons with Block Time at GBMC may post cases via fax or online http www gbmc org s urgicalpos ting e Surgeons without Block Time may post cases via telephone e The minimum Information required to post a case that must available at time of posting includes Date Time Requested Surgeon Site Procedure Patient Type Inpatient Outpatient AM Admit 23 hour Observation Patients Name Last First and Middle Initial Parent s name if patientis a minor DOB Social Security Address Home Business Cell Phone Numbers Weight BMI Patient s Insurance Carrier Policy Number Group Number Subs criber s Name and DOB e Diagnosis Post operative disposition SICU SIMCA e Request for Assisting Doctor Contract Surgeon RNFA or 2 Scrub Resident Colon Rectal Fellow Specific Equipment Needs Vendors Need for Blood Type of Anesthesia Implants and or Supply Equipment Specialty Requests should be communicated Indicate if Clinical Trial LATEX Allergy Sleep Apnea pacemaker AICDs Place of Pre
31. L Date Name 10 15 10 MOUSE MICKEY TEE P 11 58 00000004810 60 M Unmark All 10 15 10 PRINCESS ARIEL T 11 56 V00000004436 32 As Other Provider 1 44 iot Order LAB CBC PLATELETS For Other Provider Patients Order DR CHEST AND LATERAL 00566 2 Novell MEDITECH Mr 4Mediec Icom The next order you chose will appear again you must click the Sign Icon Then a scre n will appear 2 orders selected for signature choose Sign at the bottom of this screen A screen will display that requires you to enter your Meditech password After CONTINUED NEXT PAGE 24 ee ee Patient FOOT BALL Age Sex 31 M DOB 00000001 245 Room Bed 4803 4 Location 1148 Unit 1000000512 Dr Ross Laurence Reason for Visit LOSER Category LABORATORY Ordered Date Time 10 15 10 1144 Procedure CBC PLATELETS Service Date Time 10 15 10 1600 Priority k Quantity 1 Ordering Dr Dr Status Cancelled Order 1015 0031 Entered By NURSES TRAINING CBCP includes WBC CWBC RBC HGB HCT MCV MCH MCHC PLTS RBCOW Cancelled Auto cancelled after 1 day Signature Comments Order Num 1015 0031 Service Date Time 10 15 10 1600 Ordered by Traint Dr Rejection Comment Not a CPOE Physician 25 GBMC PATIENT ACCESS About Us Patient Access services include admissions registration upfront collections patient information and other r
32. Neri Cohen M D Reginald J Davis M D Michael Scheerer M D James R Buck M D William Crawley M D Victor Tritto D P M Ronald Tutrone Jr M D Peter Mackrell M D Acting Note Phone Fax extensions are preceded by 443 849 if calling from outside unless otherwise specified MANAGEMENT ORGANIZATIONAL CHART GBMC PATIENTS AND COMMUNITY GBMC STAFF Perioperative Services Inpatient Services Cancer Institute Women s Services Volunteer Services Environmental Safety Clinical Engineering Construction Mgmt Budget amp Reimbursement Plant Operations Controller HOB Security Services Accounting Food Services Finance Env Services George Bayless VP Finance Senior Services Care Management Palliative Medicine Gilchrist Hospice Care Catherine Hamel VP Post Acute Services Center for Nsg Exc Staffing Office Accreditation Patient Safety Quality Outcomes Performance Improvement Service Excellence Financial Analysis Carolyn Candiello Imaging Services V P Quality amp Lab Services Material Mgmt Michael Forthman Neospine Patient Safety Graduate Medical Education IGMEC Continuing Medical Education Medical Staff Office Spiritual Support Matern Org Development Pharmacy Employee Health al Newborn Health Med Surg Services Critical Care amp Emergency Services VP Facility amp Support Services Performance Impr MIS Telecom ASAP
33. TABLE OF CONTENTS DEPARTMENT CHAIRMEN AND DIVISION HEADS 1 ORGANIZATIONAL CHAR eR REESE Sats tasers 3 DEPARTMENT OF CLINICAL ENGINEERING EMERGENCY MANAGEMENT SAFETY amp SECURITY ecce eee nennen 4 DEPARTMENT OF INFORMATION SYSTEMS e eere 5 HOSPITALIST GROUP EP 8 INPATIENT MID LEVEL TEAM SERVICES eee eere 9 IMAGING SERVIC 10 MEDICAI LEIBRANY 15 MEDICA TION RECONCILIATION 16 DEPARTMENT OF HEALTH INFORMATION MANAGEMENT 17 Electronic Signature Quick Reference Guide ccc cece cee e eee e eee es 23 PA AOC Tio ciii ti essit E E E bU Ud C 26 GBMC CLINICAL POLICY ABBREVIATIONS AND SYMBOLS 28 PATHOLOGY 30 Pathology 35 Donor Appointment EN I 36 GBMC Laboratory Test Directory suse 37 GBMC Clinical Policy Critical Result 38 Critical Notification Appendix 4 GBMC PAT AND POSTING DEPARTMENT GUIDELINES 44 POSUNE TT 45 46 One Lane dudes daa pu ARRIANUS EAD UA AD tes 49 Pre surbical DeSttlg
34. actitioner who is responsible for the patient or 2 By a registered nurse if necessary to protect the patient staff members or others from harm provided that an order 1 immediately obtained from a licensed independent practitioner who is responsible for the patient C Notification of the Attending Physician If the attending physician is not the person who ordered the restraint he or she shall be notified by the RN caring for the patient that a restraint was applied by the end of the calendar day D PRN Orders PRN orders for restraint or seclusion shall not be used E Duration of Restraint Orders 1 Violent or Self Destructive Behavior Behavioral Restraint Orders for restraint or seclusion applied to manage violent or selfdestructive behavior that jeopardizes the immediate safety of the patient a staff member or others shall remain in effect until the patient s behavior or situation no longer requires the use of restraint or seclusion but no longer than a 4 hours for adults 18 years of age or older b 2 hours for children and adolescents 9 to 17 years of age c 1 hour for children 8 years of age or younger d Renewal orders may be given for the above durations if the indications for restraint or seclusion persist However continuation of restraint or seclusion for longer than 24 hours shall be based on an in person evaluation by a responsible licensed independent practitioner 2 Medical Surgical Restraints Non Violent B
35. al ONLY H amp P HCT EKG H amp P HCT EKG CXR Glucose see exceptions see exceptions BUN Creatinine See exceptions ADULT FEMALES 50 ADULT FEMALES 50 69 ADULT FEMALES 70 and over H amp P HCT amp HCG H amp P HCT amp EKG H amp P HCT EKG CXR see exceptions see exceptions Glucose BUN Creatinine see exceptions 57 EXCEPTIONS PREOPERATIVE CONDITIONS Cardiovascular disease HTN MI HCT Lytes EKG Angina arrhythmia also need G B C Atrial Fib and CHF also needs CRX PT PTT Aortic Stenosis also needs recent Echo Pulmonary disease Severe asthma SOB gt 20 pk yr smoker COPD EMPHYSEMA HCT amp CXR also needs EKG G B C Renal disease peritoneal amp hemodialysis need amp Na within 24 hours of surgery HCT Electrolytes Glucose BUN Creatinine EKG CXR Hepatobiliary disease Exposure to hepatitis drug abuse excessive alcohol use biliary disease Platelets PT PTT Electrolytes Glucose BUN Creatinine Liver group Diabetes HCT Electrolytes Glucose BUN Creatinine EKG Malignancy Radiation or Chemotherapy within 3 months CBC Lytes Glucose BUN Creatinine CXR or CT of the chest Infection HIV CBC also needs CRX G B C Anticoagulant use or bleeding disorder HCT PT PTT Platelets Endocrine disease or morbid obesity BMI greater than 45 or Weight gt 3005 HCT Electrolytes Glucose BUN Creatinine EKG Diuretic use HCT Elec
36. around time for all e mail postings is 48 hours Thank You Roberta Cordara Nurse Manager Posting Pre Surgical Testing 443 849 3442 rcordara gbmc org 49 GBMC Surgical Posting Windows Internet Explorer BEE 1 3c a http fiw gome orgfbody cfm id 13378Fr true __ A rile ravaribes loos E Print This Page Email to Friend O A Adjust Font Size Welcome to GBMC Surgical Posting If the posting is for within 72 hours please call the For all scheduling beyond To reschedule or Schedule Department at 72 hours 443 849 6700 Click Here Click Here Click Here Click Here Vascular Thoracic Click Here Click Here Pulmonary Urology DaVinci Click Here Click Here Click Here Click Here 50 Block Time Policy Overview For maximum efficiency OR time is organized in blocks and is allocated to physicians groups and services on the basis of need as indicated by utilization in the past quarter New Requests for Block Time will be submitted in writing to the Surgical Scheduling Manager who will present to the Peri Operative Executive Committee Requests will be reviewed and allocated by the Peri Operative Executive Committee The surgeon has a probationary period of three months to achieve 70 utilization Physicians requesting ADDITIONAL Block Time must demonstrate a utilization of current blo
37. as RBT in the LIS system comments The Laboratory must also document attempts at contacting physicians such as Dr Smith paged or physician office called line was busy and indicate the date and time of those attempts References l CAP Standards 01 4132 03 0660 2 CLIA Standards 42 CFR 493 1109 f 40 QM05009 Critical Result Notification Appendix A ANALYTE CRITICAL VALUE REQUIRES REDUNDANT CALL TO PHYSICIAN Inpatients Only CHEMISTRY Acetaminophen greater than 300 mg L Alcohol Ethyl blood greater than 250 mg dL BUN greater than 80 0 mg dL Calcium less than 7 or greater than 12 0 mg dL EE neonate 0 3 days less than 6 Chloride less than 75 or greater than 140 meq L CO2 less than 15 or greater than 40 meq L less than 15 meq L Creatinine greater than 5 0 mg dL Glucose less than 50 or greater than 450 mg dL neonate 0 3 days less than 40 0 60 days gt 200 mg dL Magnesium less than 1 0 or greater than 4 3 mg dL Magnesium therapeutic greater than 7 99 mg dL greater than 7 99 mg dL Neonatal Bilirubin Total greater than 15 mg dL Potassium less than 2 5 or greater than 6 0 meq L less than 2 5 or greater than 6 0 meq L Sodium less than 120 or greater than 150 meq L less than 120 meq L infant day 1 year less than 125 meg L_ less than 125 meq L 41 QM05009 Critical Result Notification Appendix A Page 2 DRUG LEVELS tests sent to reference lab reflect
38. atient and expedite the transportation of the patient from designation to designation The patient chart will be identified with a bright sticker in the top left hand corner to alert staff that this is a direct admit The Diagnostic Center and Department of Radiology will expedite the care of the direct admit patients Direct admits will be given priority service in the Diagnostic Center and in the Department of Radiology In the event that the EKG bed in the Diagnostic Center is occupied or the patient s condition prevents the EKG from being performed in the Diagnostic Center this will be noted on the Flow Sheet to alert the RN that the EKG must be performed when the patient arrives on the inpatient unit Direct admissions will be assigned to the first bed available In the event that the patient has Department of Radiology orders and is unable to travel to the Department of Radiology in the Radiology Meditech Comment field the following will be entered STAT the patient 15 on the floor The patient chart will be flagged with the bright sticker designating it as a Direct Admit When the patient arrives on the unit the Physician orders will be reviewed immediately by the RN to facilitate patient care When the patient arrives on the unit the patient will be seen by the Nurse Practitioner who will be paged STAT unless the attending physician writes to the contrary in his her admitting orders Procedure for Medical Private Attendi
39. atients and emergency room patients Nuclear Medicine Offers an array of procedures that include myocardial perfusion bone lung renal and gastric studies Services are provided to outpatients inpatients and emergency room patients PET CT Offers an array of exams useful in the detection of cancer and evaluating degenerative conditions such as Alzheimer s disease and cardiac viability Services are provided to outpatients and inpatients Ultrasound Offers an array of procedures specializing in echocardiography vascular and general diagnostic ultrasound Services are provided to outpatients inpatients and emergency room patients Location of Services Services located on Level III e Diagnostic Radiology e CT Scanning e General Ultrasound e Interventional Radiology Upon entering hospital grounds follow Radiology Services signs to Garage D Follow signs to main lobby Register at the main lobby Patients will be escorted to Radiology Services located on Level I e Echocardiography Ultrasound Nuclear Medicine Vascular Ultrasound MRI PET CT Upon entering hospital bear left and make your 1 right into parking lot C If scheduled for MRI PET CT upon entering parking lot C turn right and follow signs 10 Hours of Operation for Outpatient Services CI SCUBILBE a a 7 30am 5pm Monday Friday Diagnostic 7 30am 4pm Monday Friday Interventi
40. ational or research use under circumstances in which my identity will be protected from disclosure to persons not otherwise involved in my care NOTE THIS IS A TWO SIDED FORM 61 Form 601 C50 Rev 1 09 2 I consent to the study use and disposal by Medical Center authorities of any tissue or parts that may be removed 3 I consent to the administration of blood and blood products if required by any person qualified to do so I understand that blood or blood products may be needed to correct anemia replace blood lost during a procedure or to help my blood clotting Uncommon reactions may include chills fever or a rash Rare but more serious conditions may be heart kidney or other organ failure a reaction due to blood incompatibility or acquiring an infectious disease such as Hepatitis or AIDS These procedures possible alternatives such as autologous donations and their respective risks and benefits have been explained to my satisfaction 4 No warranty or guarantee has been given to me by anyone as to a the results that may be obtained from the procedures covered by Paragraph 1 or b the fitness or quality of any drug anesthetic blood or blood product or other substance to be used in those procedures 5 I understand there are risks involved all procedures These include but are not limited to infection hematoma hemorrhage pneumonia heart attack stroke urinary tract infections nerve damage and even death Oth
41. bdominal aneurysm acute intracranial bleeding imminent brainstem herniation renal trauma pneumoaoperitoneum in newborn pediatric volvulus newborn APRIL 2011 Gl bleeding with hypotension perforated viscus with hypotension systemic sepsis large or small bowel obstruction with hypotension systemic sepsis acute abdomen or peritonitis in unstable patient any service or reason necrotizing soft tissue infection any location enda ophthal mitis globe foreign body laceration acute spinal cord compression with neurologic compromise free flap w potential compromise stable non ruptured ectopic pregnancy adnexal torsion re exploration for postoperative bleeding service limb bowel threatening arterial ischemia symptomatic pseudoaneurysm crescendo compartment syndrome upper or lower postoperative tonsillar bleeding re exploration free tissue transfer for suspected vascular compromise urinary bladder perforation acute dotor urinary retention after urologic surgery priapism ruptured testide pediatric incarcerated hernia pediatric wound dehiscence with evisceration pediatric pneumoperitoneum pediatric bowel obstruction 52 D within 24 hours stable or chronic Gl bleeding SBO uncomplicated small bowel obstruction SEO wy iciti acute incarcerated hernias esophageal foreign body acute
42. ck time of at least 70 with consistent additional hours of surgery outside of block for a consecutive 3 month period A minimum of 70 utilization per month is required to maintain block time eBlock Time Utilization is reported quarterly Block Time is defined as the average utilization for a 3 month period and will be reviewed by the Peri Operative Executive Committee Utilization will be used to maintain allocated block as well as released time of allocated block eln the event thata physician is on vacation or otherwise not us ing their block time they may voluntarily release established blocks or any portion of the bloc if they are unable to use the time Voluntary block time releases should be faxed to Surgical Posting at 443 849 3744 three weeks in advance of the day in question This Overview DOES NOT include all aspects of our Block Time Policy Fora copy of the Policy please contact the S urgical Scheduling Managerat 443 849 3442 51 GBMC URGENT EMERGENT CASE CLASSIFICATION lt 2 hours lt 6 hours Airway compromise acute hematoma postop head amp neck surgery or any other reason thyroid carotid etc foreign body airway or esophagus with espiratory compromise exsanguinating hemorrhage any location or reason head amp neck thorax bdomen extremity expanding hematoma chest abdomen neck ext pericardial tamponade ruptured ectopic pregnancy unstable ruptured thoracoa
43. d Safety Program Specialist Michelle Tauson Emergency and Safety Support Secretary Donnie Dietz Area of Responsibility Hazmat WMD Terrorist Incident Training and Resources GBMC Hazmat Decon Team Coordinator Disaster Critical Incident Committee Note During a Disaster event you are to follow the GBMC Emergency Operation Plan Department of Life Safety Director Safety Officer Dan Tesch Emergency and Safety Program Specialist Michelle Tauson Emergency and Safety Support Secretary Donnie Dietz 443 849 3036 Monday Friday 443 849 2222 Security all other Times Areas of Responsibility Safety EOC Committee Fire Safety MSDS Compliance Environment of Care Issues Department of Security Protection Director Safety Officer Dan Tesch 443 849 2090 Main Security 24x7 443 849 2222 Note For Critical Safety Issues you are to follow your departments Safety Fire Disaster plans Security is to be notified of hazardous situations by calling ext 2222 Security Personnel are available at this extension 24 x 7 GBMC HEALTHCARE DEPARTMENT OF INFORMATION SYSTEMS Computing Resource Guide for New Physicians Quick Start Resources at a Glance More in depth information can be found on subsequent pages MIS Help Desk Call 443 849 3725 anytime for live phone help with questions or problems related to GBMC s computing and telecommunication resources The CPOE Helpline 443 849 2200 is available
44. e charge nurse on the floor will call the Administrative Coordinator beeper 406 If she unable to draw the necessary labs she will call the charge nurse in the Emergency Department 443 849 6861 who will send a technician to draw the blood at the patient s bedside 103 The Joint Commission You have the right to contact The Joint Commission TJC with any concern about the safety quality of care provided at GBMC or at any hospital GBMC cannot take disciplinary action against you for filing a complaint with The Joint Commission We would prefer That you give us the opportunity to address your concerns Contact Your manager Your manager s boss Compliance 443 204 8128 Quality Assurance 443 849 3807 Risk Management 443 849 2514 Division Chief Department Chair or Chief of Staff Contact Information Www jointcommission org E Mail to complaint jcaho orgFax to Office of Quality Monitoring 630 792 5636 Print a Quality Incident Report Form 104 Compliance and Internal Audit Compliance Hotline 1 800 299 7991 available 24 7 anonymous reporting available Compliance GBMC HealthCare s GBMC Board of Directors approved the development of a Corporate Compliance Program in October 1998 to emphasize and enhance GBMC s commitment to business ethics legal and regulatory compliance The Compliance Program was developed based on the seven key elements outlined in the Office of Inspec
45. e g suspected cord compression will be read on a 24 7 basis Procedures for Obtaining MRI Reports on Inpts 9 GBMC 14 John E Savage Medical Library at GBMC Main Hospital Lobby 6701 N Charles Street Baltimore MD 21204 Phone 443 849 2530 Fax 443 849 2664 Website http Ainfoweb body cfm id 124 inside hospital Website http www gbmc org medicallibrary outside hospital call for a password Staff Deborah A Thomas MLS Library Director dathomas gbmc org Dianne Deck Library Coordinator library gbmc org Staffed hours Mon Fri 8 00am 4 30pm for after hours access contact us 443 849 2531 Services available to attending physicians Journal articles free of charge emailed faxed or mailed ACOG article sets Literature searches Book ordering ClinicalKey search engine call 443 849 2530 for a personal password Library purchase recommendations gladly accepted Laptop sign out for hospital use 13 Internet connected PC s for your use Meeting room use 15 Medication Reconciliation JCAHO Patient Safety Goal requires organizations to reconcile medications across the continuum of care accurately and completely by developing a process for obtaining a complete list of each patient s current medications What is meant by completely reconcile Process of comparing what the patient 1s taking at the time of admission or entry into a new setting with what the organization is providing The goal supports
46. ear Medicine amp Vascular Ultrasound 443 849 2922 Russell Gelman MD Medical Director Diagnostic Ultrasound 443 849 2922 Shu Li MD Medical Director Cat Scan 443 849 2922 Charles Yim MD Medical Director Interventional Radiology 443 849 2311 Lee Goodman MD Medical Director Diagnostic Radiology 443 849 2922 Loralie Ma MD Ph D Medical Director Medical Imaging of Baltimore 410 580 2331 Key Radiology Administrative Contacts Philip J Komenda Administrative Director 443 849 2324 Barbara Nagle Bodyk PACS Administrator 443 849 2945 Carole McCreadie Scheduling Supervisor 443 849 2320 Cindi Kendrick Facility Manager Medical Imaging of Baltimore MRI amp PET CT 410 296 5610 12 Frequently Asked Questions 1 What information does the patient s physician s office need to schedule an appointment Patient s full name and date of birth type of test insurance information It is helpful if patient has prescription physician order when calling 2 How long does it generally take to come in for an Imaging Exam depending on whether you need prep prior to your exam The following times apply outpatient Inpatient Modality stat urgent routine stat urgent routine Same Nuc Med day 1day 7 days 1 5 hr 8 hrs 24 hrs same Ultrasound day 1day 7 days 1 5 hr 8 hrs 24 hrs same CT day 1day 7 days 1 5 hr 8 hrs 24 hrs same Diag Rad day 1day 7 days 1 5 hr 8 hrs 24 hrs same Interv Rad day 1day 7 days 1 5 hr
47. ed to patient safety which are particularly important GBMC Policy National Patient Safety Goal Standard Text Standard PATIENT IDENTIFICATION NPSG O1 01 01 Use at least two patient identifiers when providing care treatment and services POLICY BLOOD RECIPIENT NPSG 01 03 01 Eliminate transfusion errors related to patient misidentification IDENTIFICATION SYSTEM BLOOD BRACELET USE OF Report critical results of tests and diagnostic procedures on a timely basis REPORTING LABELING OF Label all medications medication containers and other solutions on and off the sterile field in MEDICATION perioperative and other procedural settings Note Medication containers include syringes medicine cups and basins ANTICOAGULATION NPSG 03 05 01 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy Note This MANAGEMENT requirement applies only to hospitals that provide anticoagulant therapy and or long term anticoagulation prophylaxis for example atrial fibrillation where the clinical expectation is that the patient s laboratory values for coagulation will remain outside normal values This requirement does not apply to routine situations in which short term prophylactic anticoagulation is used for venous thrombo embolism prevention for example related to procedures or hospitalization and the clinical expectation is that the patient s laboratory values for coagulation will remain within or close to normal
48. eded basis for emergent cases or DOS redraws BUT should not be standard protocol for clearing patients All Documents must be COMPLETE and LEGIBLE 55 GBMC HEALTHCARE INC PERIOPERATIVE SURGICAL SERVICES Pre Surgical Testing Phone GOR 443 849 6445 Fax 443 849 3013 History amp Physical within 30 days SSC 443 849 6325 Fax 443 849 8182 EKG within 30days WSC 443 849 3239 Fax 443 849 8000 Labs within 30 days Spine Total Joints Eye 443 849 3196 Fax 443 849 2700 CXR CT within 6 months PRE SURGICAL TESTING GUIDELINES 1 Every anesthesia patient must have a HISTORY AND PHYSICAL no more than 30 days old Update done by surgeon DOS on purple H amp P form 2 All TEST RESULTS MUST be faxed to GBMC within 72 hours of patient s surgery 3 NAMES DATE OF BIRTH AND DATE TEST PERFORMED must be on all tests and pages 4 All LAB WORK must be done within 30 days Pregnancy tests are valid for 7days otherwise a urine test will be performed at the hospital the day of surgery 5 EKG S No more than 30 days old Interpretation and Physician signature is needed EKG 6 CHEST X RAY OR CT S no more than 6 months old CXR S not required for Eye surgery 7 CARDIAC CLEARANCE Any patient with a documented history of cardiac disease CAD with or without h o MI any patient s p CABG or stents h o CHF arrhythmias significant valvular disease etc should have their cardiac issues specifically addressed In addition any patient with
49. eds to be installed once per PC If you are not sure there is no harm in repeated installations Enter your user name and password then click the Log In button 5 Depending on your type of remote access you will either see a Meditech icon or a desktop icon Click the icon Once you see a Meditech icon click on it and the Meditech software will appear Then logon to Meditech as above 6 Detailed instructions on using remote access are available and can be obtained by e Contacting the Medical Staff office e Contacting the MIS Help Desk e Following the link on the Info web Information on accessing these resources is listed in the Quick Start section above Contact Information MIS Help Desk 443 849 3725 anytime CPOE Helpline 443 849 2200 anytime Medical Staff Office 443 849 2370 weekdays 8 30AM to 5 00PM The Hospitalist Group at GBMC Introduction The Hospitalist Group at GBMC is a dedicated practice of internal medicine physicians specializing exclusively in the care of the hospitalized patient The practice at GBMC consists of ABIM board certified board eligible physicians Collectively GBMC hospitalists provide care in the hospital 24 hours a day every day of the year Since its inception in 2007 the Hospitalist Group at GBMC has emerged as one of the longest successfully running hospitalist models in Baltimore The practice is proud to have developed longstanding relationships with all physician groups at this ins
50. ehavior Physician orders for a restraint that is not used for the management of violent or self destructive behavior shall remain in effect until a The patient s behavior or situation no longer requires the use of restraint b The end of the calendar day following the date of the order 93 Clinical Policy and Procedure Restraints and Seclusion Page 3 F Assessment and Monitoring 1 Restraint seclusion monitoring and assessments shall include elements indicated on the current version of relevant approved forms and templates a Violent Self Destructive Behavior Behavioral Restraint Management of violent or self destructive behavior that jeopardizes the immediate safety of the patient a staff member or others i One hour Face to face Assessment A responsible licensed independent practitioner Nurse Practitioner or a Physician s Assistant shall perform a face to face assessment of the patient s physical and psychological status and sign the order within 1 hour of the initiation of restraint or seclusion Independent practitioners Nurse Practitioners or Physician Assistants who perform such assessments shall be educated as specified in Section IV of this policy li Monitoring Restrained or secluded patients shall be subject to monitoring by individuals educated according to Section IV of this policy lil Simultaneous Restraint and Seclusion Patients who are simultaneously restrained and secluded shall be continuo
51. elated services We provide services for various outpatient and inpatient areas throughout the hospital and are staffed with 75 team members Patient Access Registration Areas Antenatal Testing OB Patient Access Anti Coagulation Clinic Special Imaging Diagnostic Center Lab Emergency Department Endoscopy General Operating Room GOR Main Patient Access Patient Information Desk Sherwood Surgical Center Women s Surgical Center Admission amp Direct Admission Requests Please contact the hospital Administrative Coordinator at x2076 or x2077 with admission and or direct admission requests If unavailable he or she may be reached by using the hospital paging system Dial 443 849 3135 and enter beeper 406 and then your extension Please contact the hospital operator if paging assistance 1 needed Patients directly admitted to the hospital are asked to register at Main Patient Access Main Lobby between the hours of 7am and 11pm and after hours in the Emergency Department with the exception of those patients being directly admitted to IMC MICU SICU In those situations Patient Access will be notified of the need to register the patient at the bedside location The Administrative Coordinators have provided additional and specific requirements regarding direct admit requests orders See also Table of Contents Daytime Direct Admissions pg 97 amp Direct Late Admissions pg 99 Information and Services Contact
52. er Verbal Insertion Rewind to the point where the passage is to be inserted Depress and 6 then dictate the insertion To exit the insert mode press 3 Formats for Dictation Discharge Summary dictate at time of discharge work type 1 for routine work type 7 for STAT or Transfer Summary Admission and discharge dates Principal Diagnosis that diagnosis which was determined have study to have caused the admission Brief reason for admission and HPI Significant physical findings Significant test results from this visit BRIEF hospital course treatment rendered Procedures performed Discharge destination 1 e home Discharge instructions Operative Report dictated immediately after procedure work type 2 Date of surgery Primary surgeon Assistant surgeon s and or residents Anesthesiologist Pre operative diagnosis Post operative diagnosis Anesthesia used Blood loss blood replaced Specimens removed Complications and drains Detailed description of technical procedure used Condition at conclusion of procedure 19 History amp Physical completed within 24 hours of admission work type 5 Chief complaint History of present illness Past medical and or surgical history Medications Allergies Review of systems Physical exam HEENT Neck Chest Abdomen GI GU Extremities Neuro Assessment diagnostic impression of care treatment recommendations Admission Note
53. er specific risks include 6 These procedures possible alternative procedures and their respective risks and benefits have been explained to my satisfaction by the physician in charge DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT UNDERSTAND IT AND AGREE WITH WHAT IT SAYS Witness Signature Patient Signature Print Name Print Name Other Authorized or Required to Consent Relationship to Patient NOTE THIS IS A TWO SIDED FORM 62 Form 601 C50 Rev 1 09 section 11 Important Contacts Important Contact Information at GBMC Reason To Call Contact Information Questions regarding patients health status ANESTHESIOLOGIST ON CALL Telephone 443 849 3586 Anesthesia Plan of Care for patients on TODAY S schedule Resolve Issues or Policy Questions related to Roberta Cordara RN Telephone 443 849 3442 Posting and or Pre surgical Testing NURSE MANAGER Rcordara gbmc or Emergent Urgent Case Scheduling Control Desk General Operating Room Telephone 443 849 2240 Surgeon Delayed Clinical Partner General Operating Inquire about status of OR time for Surgeon with Room Telephone 443 849 3588 Scheduled Case Surgeon Delayed in Getting to Scheduled Case Clinical Partner Sherwood Surgical Telephone 443 849 8440 Inquire about status of OR time for Surgeon with Center Scheduled Case Holding Area Pre Op Telephone 443 849 2416 Surgeon Delayed in Getting to Scheduled Case Clinical Partne
54. es through Cyracom If you are in need of an interpreter please use the blue dual handset CryaCom ClearLink telephone available on all patient care units To view the training videos go to the InfoWeb Home gt Department gt Interpreters 73 74 75 76 Why Reporting is so important To continue to learn and improve To prevent it from happening again To recognize good catches Most importantly it s the right thing to do 77 I E gt Who should complete an incident report If you were involved in an incident If you were informed of incident If you discovered the incident NOTE It is OKAY if more than one person submits an incident report on the same issue 78 hen should I report e As soon as it is reasonably possible after you have taken care of any patient issues ALWAYS before your shift is over 79 What Happens After I report Quality and Safety Department receives each incident The incident 1s reviewed by the department the incident occurred Opportunities to improve are identified and shared 80 iere to report Infoweb IIS ER V w Pinatas Tode What s New View All News Search All News The Employee Center View Full List In Action to Improve Our Care Analytics Productivity Medical Librar
55. f the Sheppard Pratt Health System Our address is 6545 North Charles Street Suite 201 Baltimore Maryland 21204 Contact Us otacey McGreevy CPA Chief Audit Executive and 443 849 4325 Compliance Officer amp HIPAA Privacy Officer Heather Hill CPC CPC H Director of Revenue Integrity 443 849 4317 CCS Lisa Sharp RN Clinical RAC Coordinator 443 849 6783 Teresa Schorr Compliance Manager 443 849 2358 105 Barbara Olsen CPC Compliance Auditor 443 849 4316 Donna Stetka RN BSN Medical Auditor 443 849 4322 Dan Shelly CPA Senior Internal Auditor 443 849 4327 Voicemail is available for after hours concerns You may also email the Compliance Department by sending an email to compliance gbmc org If you would like to place an anonymous call or have an issue that you need to report and are unable to reach anyone in the Compliance Department please call the Compliance Hotline 1 800 299 7991 This line is available 24 hours a day seven days a week 106
56. he patient POLICY The indiscriminate use of abbreviations is extremely dangerous It is recommended that abbreviations should be used as little as possible PROCEDURE A Medical Abbreviations most recent addition by Neil M Davis is the approved reference for all abbreviations This reference can be accessed via the GBMC Infoweb B Attachment A is a listing of Dangerous Abbreviations which if used can be misinterpreted leading to potential errors The use of these abbreviations in all forms of clinical documentation at GBMC is prohibited C If uncertainty exists the person who wrote the abbreviation or symbol shall be contacted for clarification Clinical Policy and Procedure Abbreviations and Symbols Page 2 Date Posted on Web 01 2011 Responsible for Review VP of Nursing Date Reviewed Revised 08 23 00 09 03 02 01 22 03 05 23 03 08 15 05 11 03 06 09 03 08 01 2011 Attachment A Dangerous Abbreviations Do Not Use Listing GREATER BALTIMORE MEDICAL CENTER DANGEROUS ABBREVIATIONS PROHIBITED Intended Meaning Common Misinterpretation Alternative Mistaken as a zero resultin U or u Unit 5 Unit in Ten fold overdose International unit Misread as IV intravenous Units Q D QD q d qd and Q O D QOD q o d Once daily and every Daily piherday Mistaken for each other oer das Never write a zero by itself after a decimal Decimal point is missed point and always use
57. herapeutic blood donation services are available at the Diagnostic Center 30 Location on GBMC Campus The Diagnostic Center is located on the 3 Floor just down the hall from the Main Lobby in Suite 3100 Phone 443 849 2213 Hours of Operation e The Diagnostic Center is open 6 days a week Monday Friday 6 00am 7 00pm o Saturday 6 00am noon o Closed on Sundays and Holidays Please Note e EKGs are performed Monday Friday from 8 00am 5 00pm e Appointments are required for Autologous Therapeutic blood donors Call 443 849 2817 to schedule an appointment at the Diagnostic Center e Patients are seen in the order of their arrival however some patients are called ahead of others due to prior scheduling or extended procedures Frequently Asked Questions 1 What does a patient need to bring to the Outpatient Service Center to be serviced The patient must bring a prescription or a completed requisition indicating e Lab tests to be performed CD 9 codes completed by physician s office e Insurance information Note Some patients insurance plans do not allow them to use certain laboratories 2 My patient needs to have blood drawn every week for the next 3 months Is an order necessary each time the patient comes to the Outpatient Service Center No This is a standing order The original order prescription will be kept on file in the Outpatient Service Center A copy of the order will be made to accompa
58. ill indicate that the result was printed to their printer for example We have a critical high glucose result on Mr Sam Jones and it was verified and sent to print to your printer Staff will request and document read back of result by indicating in the LIS documentation section If results have not printed they can be faxed or given verbally to the caregiver Any time a verbal report is given to a licensed caregiver read back of the test result to the technologist or customer service representative to confirm the report must be documented in LIS The technologist will document in the Laboratory Information System LIS the following information for each critical result the name of the analyte with the critical value the name of the person notified and whether the result was confirmed as well as the time The caregiver will read back the result and laboratory staff will document the readback 39 GBMC Department of Pathology and Laboratory Medicine Title OM05009 Critical Result Notification Ver Page 3 7 Outpatient l Calling Critical Values for outpatient results obtained during regular business hours will be the responsibility of the Customer Service Representative who will generate a call list from LIS If after hours the technologist performing the test will call or page the patient caregiver within 30 minutes of verification of test results The technologist should utilize after hours emergency phone numbe
59. information and references are available on our Info Web page http infoweb body cfm id 183 Other available information e Patient Financial Assistance contacts and information e Patient Information and Registration Area Phone extensions e Nursing Unit Phone Extensions and more 26 Lab amp Radiology Information Please utilize your GBMC LabCorp or Quest lab requisition forms Please also utilize the Lab amp Radiology Insurance Reference Grids tables available on the Patient Access InfoWeb page to determine participating lab and radiology facilities and or referral requirement for your patients See Patient Access InfoWeb page for References L Lab Grid http infoweb body cfm 1id 197 or References Radiology Grid http infoweb body cfm 1d 202 Writing orders legibly will assist with identifying the correct order requests A signature is required on all orders and requisitions To avoid follow up calls to your office delays to the patient and billing issues please include the diagnosis and all diagnosis code s associated with the patient s order In the event that an ABN Advanced Beneficiary Notice 15 generated we will be calling your office to verify all codes and or obtain additional codes The e Clinical Works eCW application is currently being used at Greater Baltimore Medical Associates GBMA office locations to enter Lab Radiology orders and receive results electronically Death Certificates
60. k and made available to the patient or referring physician 10 Who should we call to schedule a biopsy All Radiology biopsy procedures are scheduled by calling 443 849 2311 13 Procedures for Obtaining MRI Reports on Inpatients at GBMC From GBMC MRI and PET CT Center From 7 30 a m to 4 p m Monday through Friday MRI s are read by a radiologist and reports are typed until approximately 4 p m Preliminary reports are faxed to the Unit Check with the Unit Clerk The final signed report will be scanned into the EMR Remember a radiologist is at the center until 4 p m to discuss the results of any test From 4 p m to 10p m Monday through Friday If the report is not on the floor or in EMR call 410 580 233 report After 10pm call 1 866 941 5695 for report Saturday 7am 2pm Call 410 580 233 report Between 2pm if the report is not on the floor or in the EMR call 410 377 1590 After 6pm call 1 866 941 5695 Saturday 7am 2pm Call 410 580 2331for report Between 2pm if the report is not on the floor or in the EMR call 410 377 1590 After 6pm call 1 866 941 5695 Sunday The center is available for emergencies only Between 7am 6pm if the report is not available on the floor or in the EMR call 410 377 1590 for report After call 1 866 941 5695 REMEMBER The verbal or faxed reports obtained on nights and weekends are preliminary Finally a report on a MRI obtained on a STAT basis
61. l conduct a face to face evaluation of the patient to determine whether continuous restraint is appropriate Care Plan The restrained or secluded patient s written plan of care shall be modified to address appropriate interventions implemented to assure the patient s safety and encourage the prompt discontinuation of restraint J Monitoring Restraint related Deaths Hospital personnel shall promptly contact the quality and patient safety department or the administrative coordinator whenever a patient dies while restrained or within twenty four hours after being released from restraint or a patient dies as the result of a restraint related condition within seven days after restraint removal Hospital personnel shall maintain a log of all such deaths The log must be made available to CMS immediately upon request K Emergency Department Patients If a patient arrives in restraints they will remain in restraints until evaluated by the ED physician Document patient arrived in restraints After evaluation by ED physician an order must be obtained if the use of restraints is to continue Appropriate documentation must follow L Training 1 Hospital and Medical Staff Members Shall receive training in the following subjects as appropriate to assigned duties performed under this policy Such training shall take place before the new staff member is asked to implement the provisions of this policy and shall be repeated periodically as indicated
62. lete delinquent medical records within 90 days post discharge will result in automatic revocation of medical staff membership and clinical privileges 17 Dictation Transcription Health Information Management provides transcription services for the reports of GBMC patients who were treated for an inpatient admission same day surgery or emergency department visit You will receive copies of each of your dictated reports via fax When dictating always state the following Your name The attending physician physician you re dictating for when applicable The patient s name The eight digit medical record number The date of admission discharge spelling of physician name to whom copies of reports are to be sent include the complete address for physicians not on staff at GBMC Transfer Summaries must be dictated as a work type 7 to ensure these reports are given priority and are available at the time of the patient s transfer Dictation Instructions To access the dictation system dial extension 2883 outside the hospital call 443 849 2883 After the announcement enter your personal five digit ID number if your is less than five digits enter zeroes before your number to create a five digit ID the two digit work type number and the eight digit patient medical record number The work types are as follows WORK TYPE NUMBERS 1 Discharge Summary 6 Admission Note 2 Operative Report 7 Stat Transfer Summary
63. logy Rehabilitation Medicine Harold M Goll M D H Alexander Munitz M D Lee Goodman M D Charles Yim M D Henry Wang M D Barton M Cockey M D Jeffrey Sternlicht M D Robin Motter D O Francis Grumbine M D Francis C Grumbine M D Eugene Katz M D Joan Blomquist M D Neal Friedlander M D Reed Riley M D James H Mersey M D Niraj Jani M D John A Nesbitt M D Charles A Haile M D Alan Kimmel M D Paul Celano M D Jeffrey Posner M D A Allan Genut M D George Bedon M D Howard W Hauptman M D Department Chairmen and Division Heads Page 2 OPHTHALMOLOGY Ext 2196 Fax 2646 OTOLARYNGOLOGY H amp NS 410 821 5151 Fax 410 561 5275 Oral Surgery Dentistry PATHOLOGY Ext 2257 Fax 3016 PEDIATRICS Ext 2780 Fax 8083 Neonatology Ambulatory Pediatrics Peds ED Inpatient PSYCHIATRY 443 849 2368 Fax 2248 RADIATION ONCOLOGY Ext 2540 Fax 2595 SURGERY 410 821 6260 410 821 7058 Colon Rectal General Surgery Thoracic Surgery Section Neurosurgery Orthopedic Surgery Pediatric Surgery Plastic Surgery Podiatry Urology Vascular Surgery Pat Wilkinson M D Brian Kaplan M D Julius Hyatt D D S Charles Walowitz D D S Robert A Palermo M D Timothy F Doran M D Howard Birenbaum M D John A Boscia M D Melissa Sparrow M D Darin Lerner M D Robert K Brookland M D Jack Flowers M D George Apostolides M D Francis Rotolo M D
64. medical conditions are discovered less than 48 hours prior to DOS in order to ensure the safety of patient e ALL PAPERS MUST HAVE D O B amp NAME ON IT FOR IDENTIFIERS amp PATIENT SAFETY e Upon posting of case or not later than 48 hours in advance of DOS in accordance with Medical Staff bylaws 96 Hours Prior to DOS PAT will contact Surgeon s office for H amp P or health status of patient If not received PRIOR to DOS by PAT staff Surgeon should plan to arrive 30 minutes prior to scheduled case start time to complete H amp P Informed Consent e Receive by noon day before DOS e Surgeon is requested to arrive 20 minutes prior to scheduled start time if an Informed Consent needs to be executed Cardiac Clearance and e Cardiac Clearance or other consults should be submitted at least 48 hours in advance of DOS as additional Other Consults tests work up may be required prior to surgery e If patient is scheduled as First Case surgery MAY have to be delayed and or cancelled at discretion of Anesthesia Manager as informed by Pre Op and OR Charge RN in order to ensure the safety of your patient e To follow cases may also be postponed to the end of the schedule if it is anticipated that required clearances will not be obtained within four hours prior to scheduled time Results Labs EKG e Test Results should be submitted upon receipt at the Surgeons office but at least 48 hours in advance CXR e Stat labs can be accommodated on an as ne
65. ng Direct Admissions G 101 Procedures for Medical Attending Direct Late Admissions Purpose Direct Late Admissions of patients by Medical Attendings will be facilitated to provide a safe comfortable and efficient admission for the patient their family and the physician This procedure is to be used Monday Friday 6 30 p m 8 00 a m and Saturday and Sunday until 8 a m Monday l The physician will call the Administrative Coordinator at 443 849 2000 Beeper 406 to request admission The following information will be needed Patient name Admitting Physician Name Date of Birth Diagnosis Type of bed requested Present location of patient office home nursing home etc Estimated time of arrival Condition of patient ambulatory wheelchair or ambulance Whether Hospitalist involvement will be necessary Whether medical Nurse Practitioner involvement is requested The medical Nurse Practitioners are available until 9 00 pm Monday through Friday with the exception of holidays Administrative Coordinator will secure bed and provide the physician with bed assignment The Administrative Coordinator will also notify the Admitting Office if before 10 pm or from 6 am 8 am the following morning or the Registration Desk in the Emergency Department from 10 pm 6 am about the patient and the unit to which the patient will be admitted including the estimated arrival time Physician will write Admission orders and fax the o
66. not have access to a GBMC network PC call Customer Service 443 849 2314 and the patient s laboratory results can be relayed to you verbally or via fax Outpatient Reports are auto faxed to most physician offices o If utilizing eClinical Works results will go into the medical record if matched to an order e Please Note Laboratory results will only be provided to persons licensed under the provisions of the law Laboratory results will not knowingly be released to patients Patients are asked to request all laboratory results from their physician so the data can be interpreted properly 6 How do the physician offices receive the laboratory results on their patients All results will be auto faxed or manually faxed Electronic transmission to eCW is now possible if there is a corresponding order in eCW that is transmitted to Meditech 7 What does the lab do if one of my patients has a critical value reported as a result Or if I need to be notified of a STAT result The Department of Pathology has a published list of critical values that will generate a call by the Customer Service Specialist to the physician s office or nursing unit for the inpatients All designated STAT test orders upon verification of the laboratory result will be faxed e For Inpatient Units CRITICAL results will automatically print to the designated printer in that Unit 32 8 10 10 11 What does the lab do if the test result i
67. nt Care Medical records for patients seen from August 1 1996 to present are available in the EMR Electronic Medical Record 1n Meditech Please contact the PRO Shop ext 2277 for access to records prior to August 1 1996 Accessing Medical Records for Studies or Research Research studies must be accompanied by written approval from the IRB Please contact the Medical Staff Office at ext 2370 Completion of Records Medical records of each discharged patient must be completed within 30 days following discharge Records are evaluated for signatures on dictated reports and for the presence of a Discharge Summary on stays longer than 48 hours a Discharge Note on stays less than 48 hours and for a dictated operative report on surgical patients Health Information Management Department will fax a letter listing deficient medical records 21 days post discharge You will receive a notification via fax containing the information on the medical records you need to complete Failure to complete medical records within 30 days post discharge will result in Administrative Action The names of physicians on Administrative Action will be sent to the Executive Management that include the Executive Vice President and Chief Medical Officer Chief of Staff Director of Performance Improvement and Clinical Chairmen Failure to complete delinquent medical records within 60 days post discharge will result in suspension of clinical privileges Failure to comp
68. nt has renal failure or renal insufficiency Arrhythmia s Please be as specific as possible If the patient has Paroxysmal SVT please state rather than SVT Frequently missed diagnoses The following are diagnoses which frequently exist and meet criteria for coding but are not documented Acute Renal Failure Dehydration CHF Chronic Renal Failure COPD Hypotension Hydronephrosis Hypoxia Morbid obesity Respiratory failure Valve disorders Electrolyte disturbances Present on admission It has become mandatory that hospitals report whether or not patients are admitted with certain diagnoses or these diagnoses occur during the hospital stay This 1s part of a 21 national and state quality of care initiative and the correct reporting of these conditions will have a major effect on hospital report cards and also reimbursement Conditions that are reported not present on admission can be considered HAC Hospital Acquired Conditions and reduce the reimbursement to the hospital for care It is therefore very necessary to clearly document whether patients come in with certain conditions or the condition is acquired after the patient 15 admitted Catheter infections and decubitus ulcers are examples of diagnoses which may be involved A final note Please be as specific as you can be This will help the hospital achieve an accurate profile of its case mix and help you avoid retrospective queries from coders Document clearly in your
69. nts restrained or secluded for the management of violent or self destructive behavior g The use of basic life support and certification in the use of cardiopulmonary resuscitation including required periodic re certification 4 Hospital staff members who monitor restrained patients shall be trained in the recognition of signs of physical and psychological distress including the signs of asphyxia Date Posted on Web 01 2013 Responsible for Review CNO Date Reviewed 1 2003 4 2003 12 2003 4 2003 11 2006 11 2007 8 201 1 11 2011 12 2012 96 Medical Surgical Restraints Non Violent In Patient Units ICU and Med Surg A Medical Surgical Restraint is used to promote medical healing and to prevent the patient from interfering with care treatment and services to achieve healing Medical Surgical Criteria Necessitating Restraint Dislodging drains IV access dressings Pulling at endotracheal tube e Pulling at central vascular access line Interfering with necessary care or treatment 1 RN must obtain an order as soon as possible after initiation of restraint 2 Restraint order must be renewed every calendar day 3 Physician must physically see and evaluate the patient on a daily basis to assure restraint is still required 4 Assessment Re assessment in Meditech is required Q2 hour REQUIRING A PHYSICIANS ORDER 2 pt only 4Bed Rails Soft Upper Roll Mittens Lap Belt Limb 977 Violent o
70. ny the specimen to the testing laboratory Standing orders are kept for only 6 months Offices utilizing eCW do not have the ability to enter standing orders 3 My patient s lab work must be performed by Quest or LabCorp Laboratories because of insurance reasons Can the patient be serviced at GBMC Yes the patient may be drawn at the Diagnostic Center however the Diagnostic Center provides specimen procurement services only All Quest or LabCorp specimens will be transported to Quest or LabCorp Laboratories for testing The ordering physician will receive test results directly from Quest or LabCorp Patients with STAT requests for Quest or LabCorp Laboratories must be serviced at a Quest or LabCorp Laboratories Service Center All patients that must have their lab work performed at Quest or LabCorp must present with a completed Quest or LabCorp requisition 3 4 How long is the expected wait at the Patient Service Centers Patients are seen in the order of their arrival however some patients may be called ahead of others due to prior scheduling or extended procedures During peak periods patients may experience a longer wait The average wait 1 approximately 20 minutes 5 How do get laboratory results on my patients e Inpatients Access to the EMR is available from PCs on each of the nursing units Lab results can be viewed e Outpatients If you have access to a PC on the GBMC network then you can access the EMR If you do
71. o 3 00 p m Monday through Friday How to Make an Appointment for your Patient All Pre Surgical appointments are scheduled during the Posting of a case and may be cancelled or changed by calling the Posting Department 443 894 6700 If your Patient is having Pre Surgical Testing done by his her Primary Care Physician please provide that information upon posting the case Staff Contacts Roberta Cordara RN RNFA Pre Surgical Testing Manager telephone 443 849 3442 Names of staff members Sharon Short RN Nancy Rizer RN EE Beverly Bye NP Chametra Chase Renee Tankersley Bernadine Wilson Telephone 443 849 3196 general inquiries and 443 849 3420 to contact Registered Nurse Fax 443 449 8000 Any information about cases scheduled in Women s Surgical Center Fax 443 849 2700 Any information about either Joint Spine Cases OR Ophthalmology cases Fax 443 849 3013 Any information about cases in General Operating Room e Fax 443 849 8182 Any information about cases in Sherwood Surgical Center 54 What is Required to Clear Patients BEFORE Day Of Surgery wear Wy Anesthesia Pre e Upon posting of case or not later than 48 hours in advance of DOS to establish requirements for clearance Surgical Testing PAT RNs complete chart clearance by noon day before DOS Guidelines Form e Case may have to be cancelled or delayed if all requirements for clearance have not been obtained and or unknown
72. o discuss the provisions and procedures associated with special protocols Special accounts can also be established with the Laboratory for diagnostic testing Please call 443 849 2091 to initiate the process 33 SPECIMEN LABELLING PROCEDURE The Department of Pathology and Clinical Laboratories receives many patients specimens for testing Many patients have the same last name and first name and even the same middle initial When specimens are registered and processed within the Laboratory they are separated from the laboratory requisitions that accompanied them Therefore it is imperative that all specimens submitted to the laboratory for testing are labeled with e patient s full name e and the patient s social security number or date of birth e date of collection collection time and initials of person collecting specimens To ensure that patient specimens are labeled appropriately all specimens should be labeled in the patient s presence either in the examining room or other drawing location Any deviation from this procedure will put the integrity of the specimen and the safety of the patient at risk Please be aware this policy will be strictly enforced Specimens will be rejected if the requested information is not present on each individual patient specimen The physician s office will be notified per phone call of any specimen collected by the office that 1s not labeled properly and therefore deemed unacceptable
73. olent or self destructive behavior that jeopardizes the immediate physical safety of the patient a staff member or others C Chemical Restraint is the use of a medication used to restrict the patient s freedom of movement that is not a standard treatment for the patient s new or continuing medical or behavioral condition It is this hospital s policy to only use medications that are a standard treatment for the patient s ongoing or newly emerging condition Therefore chemical restraint is not used in this institution D Licensed Independent Practitioner LIP any individual permitted by law and by GBMC to provide patient care services without direction or supervision within the scope of his or her license and in accordance with individually granted clinical privileges IIl POLICY A Indications Restraint or seclusion may be used when less restrictive means would not be effective to protect the physical safety of patients a staff member or others Seclusion may only be used for the management of violent or self destructive behavior that jeopardizes the immediate safety of the patient a staff member or others 1 The standards for restraint use do not apply when a staff member s physically redirects or holds a child without the child s permission for 30 minutes or less 92 Clinical Policy and Procedure Restraints and Seclusion Page 2 B Restraints may be initiated 1 Upon the order of a licensed independent pr
74. ology and Laboratory Medicine Title OM05009 Critical Result Notification Ver 7 Page 2 Redundant notification of selected critical values requires a call to the caregiver on inpatient units and a follow up call to the patient s physician with those same results This redundant notification to the physician may be placed by someone other than the technologist and will also be documented All readback requirements will apply The algorithm for contacting the physician is documented in Appendix B This algorithm is the basis for the logic contained in the Meditech Inpatient Physician Notification report REDUNDANT NOTIFICATION LIST ANALYTE CRITICAL VALUE CO2 less than 15 meq L Magnesium therapeutic greater than 7 99 mg dL Potassium less than 2 5 or greater than 6 0 meq L Sodium less than 120 meq L Hematocrit less than 2096 Hemoglobin Less than 7 gm Fibrinogen Less than 100 mg dl INR Greater than 4 99 Positive blood cultures Positive CSF bacterial antigens Positive CSF gram stains or other positive smear or culture Emergency Department ED l All Emergency Department Critical Results will automatically print upon verification of results The technologist performing the test s will call the ED and notify the physician taking care of the patient that there is a critical result on the patient If an ED physician is not assigned to a patient or is not available results may be given to the charge nurse The technologist w
75. onal 8am 4pm Monday Friday Ultrasound Echo General 7 30am 5pm Monday Friday 7 30am 8pm Monday Friday 9 00am 12 30pm Saturday Tr 8am 3 30pm Monday Friday Scheduling an Outpatient Exam Patient services assistants are available to schedule appointments from 8am 5pm Monday Friday To schedule an appointment call Diagnostic nnne mene 443 849 2320 CT Ultrasound or Nuclear Medicine eene enne 443 849 2343 Interventional Radiology cccsssssesssseeeeceeeeeeeceeeaeaeeeeseseeeeeeeeeeeeeeseaaas 443 849 2311 410 580 2330 Oncology Imaging and Interventional 443 849 2020 Radiology Final Reports Diagnostic Radiology CT Scanning Nuclear Medicine Ultrasound Echo General Vascular Diagnostic CT Nuclear Medicine and General Ultrasound final reports will be faxed to your office within 24 hours Echo and Vascular reports will be faxed within 48 hours If you wish to speak with a radiologist regarding a radiology stat report during normal business hours call 443 849 2922 If you need to obtain a copy of a report call Imaging Library 443 849 2325 or call 443 849 2343 listen to prompt for Radiology reports Interventional Radiology Final rep
76. ortal and choose the option Laboratory Test Directory 2 On the GBMC Infoweb intranet site On the top of the screen click on Clinicians The Menu Clinicians Physicians Quick links opens and then click on the Laboratory Test Directory The Laboratory Test Directory provides information related to tests available for order through the GBMC Laboratory Information in the directory includes specimen requirements frequency performed turnaround time and clinical utility If you have difficulty locating a test or do not see a test you would like to order please call the Client Service Department at 443 849 2314 If they cannot answer your question you will be referred to the appropriate technical or medical personnel if indicated If you have any difficulty accessing the sites indicated above please call the GBMC Help Desk at 443 849 3725 37 GBMC Department of Pathology and Laboratory Medicine Critical Result Notification Title OM05009 Critical Result Notification Ver II 7 PURPOSE To develop the most effective method of notifying the licensed caregiver of critical laboratory results Notification of critical results of laboratory tests is medically necessary to assure appropriate care of critically ill patients These test values represent a pathophysiological state which may be life threatening and require immediate medical intervention Timely communication of the results is mandatory The lis
77. orts will be faxed to your office If the findings require immediate intervention an Interventional Radiologist will call the referring physician If you wish to speak with an Interventional Radiologist call 443 849 2311 during normal business hours MRI amp PET CT Final reports will be faxed to your office within 24 hours If you wish to speak with a radiologist call 410 580 2331 Access to Images PACS If you have privileges at GBMC you can gain access to your patients medical images from most any personal computer Images can be accessed through the Meditech EMR If you require access to Meditech contact the help desk at 443 849 3725 PACS Quick Reference Guide is available at the Imaging library in our Radiology Department Radiologist Coverage Availability Radiologists are available in the hospital from 8am to 7pm Monday through Friday and 8am to 6pm on weekends and holidays A Radiologist reads GBMC Stat studies from a remote location after the radiologist has left the hospital Preliminary reports are faxed to the ordering physician A radiologist is on call each night To contact a radiologist on call call 443 849 3950 If you have any questions or concerns please contact Radiology Administrative Assistant Patricia Miller at 443 849 2935 or e mail plmiller gbmc org 11 Key Radiologist Contacts H Alexander Munitz MD Chairman Department of Radiology 443 849 2935 Barton Cockey MD Medical Director Nucl
78. r Women s Surgical Telephone 443 849 6807 Inquire about status of OR time for Surgeon with Center Scheduled Case Holding Area Pre Op Telephone 443 849 804 Provide information inquire about any pre surgical Sharon Short RN Pre Surgical Testing Telephone 443 849 3420 testing requirements patient specific pre surgical Nancy Rizer RN Pre Surgical Testing Sshort gbmc or test results and or clearances status of patient Nrizer gbmc org clearance for surgical procedure Post Change or Cancel Case Posting Department Telephone 443 849 6700 64 Additional Brochures For Additional Copies of Brochures please contact Brochure Type Department Contact Pers on Phone Number Patient Rights Roberta Cordara 443 849 2015 Notice of Privacy Practices Roberta Cordara 443 849 3442 65 66 Accreditation and Regulatory Committee ARC Includes Vice President of Quality and Safety Sr Vice President Patient Care Services amp Chief Nursing Officer and Chapter Leaders Review of mock tracers TJC Perspectives and OnLine PPR MOS Data Presentation Regulatory Updates Joint Commission Outpatient Sub Committee Report 67 Accreditation and Regulatory Committee ARC Outpatient Setting Focus Group Statement of Purpose To provide safe and effective care of the highest quality in GBMC Outpatient Settings in compliance with Joint Commission Standards Topics Compliance and protocols for the Ambulatory
79. r Self Destructive Behavior Restraint Emergency Dept and Unit 36 All other units need to notify their Nurse Manager or AC A Restraint for violent or self destructive behavior is to protect the patient from causing imminent harm to self or others Criteria Necessitating Restraint for Violent amp Self Destructive Behavior Include e When behavior is NOT driven by an underlying clinical condition e When other non physical interventions are not effective in deescalating the patient s behavior Hostile outbursts threatening safety of self or others Physical bodily threat to self or others Inability to control actions with progressively violent behavior Severe aggression 1 RN must obtain an order as soon as possible after initiation of restraint 2 Restraint order must be renewed based on age time limits 3 Physician must physically see and evaluate the patient within 1 hour of initiation 4 Re assessment is required Q15 minutes on paper documentation form Requiring a Physician s Order Neoprene Cuffs Neoprene Hobble Neoprene Ambulatory belt Seclusion 98 SURGICAL ORIENTATION GBMC has 38 operating rooms on site located in the three locations the General Operating Suites GOR Virginia Sherwood Surgical Center and Women s Surgical Center GBMC staff is eager to make your transition to our surgical world an easy one You are welcome to join us for a separate orientation To Schedule An Orientation Contac
80. rders to the Administrative Coordinator at 443 849 3425 The orders need to be received prior to the patient arriving The physician may give the admitting orders to the patient to bring to the hospital and will notify the Administrative Coordinator that the patient will be bringing his her orders Labs and X ray orders should be written STAT e Aphysician telephone number or pager should be provided on the orders for any questions 102 Procedures for Medical Attending Direct Late Admissions Page 2 4 10 If the physician does not have a fax machine or other methods by which to get the admitting orders to the hospital the physician must call the Hospitalist 443 849 3135 Pager 398 and request the Hospitalist s involvement the case which will include an admitting note and admitting orders result of the discussion between the physician and the Hospitalist the Hospitalist will be responsible for the patient until the attending physician assumes care of his her patient at 8 am The Hospitalist may direct the patient to the Emergency Department for an initial evaluation if needed If the patient does proceed directly to the Unit the Unit will notify the Hospitalist once the patient arrives The Hospitalist group will be available to assist in Direct Late admissions from 6 pm to 8 am Monday through Sunday During the day 8 am to 6 pm on Saturday Sunday and holidays the physician will be responsible for the entire direct
81. rocedure Current medications Known Allergies Vital signs and Physical Exam appropriate to patient s condition Legible Signature of Practioner performing H amp P exam AND SURGEON 186 WHEN Complete H amp P exam must be WRITTEN no more than 30 days before surgical procedure for ALL patients that will receive Anesthesia during surgery Update note MUST be done regardless of any change in patient s status for All H amp Ps WHO Surgeon may delegate responsibility for H amp P exam to other practitioner BUT surgeon MUST SIGN for and ASSUME full responsibility for these activities REVIEW OF SYSTEMS eyes Blurred vision double vision cataracts glaucoma ENT Sinusitis tinnitus hearing loss epistaxis woats hoarseness CNS ENDOCRINE Thyroid disease recent weight change DM BREASTS Lumps pain discharge CARDIOVASCULAR Chest pain palpitations edema claudication phlebitis PULMONARY SOB hemoptysis productive cough wheezing asthma pneumonia cent change in bowel habits ulcer HH GD disease colitis hemorrhoid Frequent UTI s renal stones dysurin hematuria frequenay nocturia PHYSICAL EXAM CoO PnhESSun integument Skin heir nalis Heed Neok Skull thyroid carotide Pupils conj sclera m ENT Canals TM s mucosa Lymph Nodes Cervical supractavicular axillary ing Breasts Symmetry palpation nipples Lungs
82. rs provided by the office voice message In the rare event that a licensed caregiver can not be contacted or does not return a page after three attempts to contact him a pathologist on call will be notified by the technologist The technologist must provide the pathologist with the following information Patient name patient number birth date physician name and number and patient contact information as well as the critical result and any other test result information for that patient The pathologist on call will make the determination regarding direct patient notification The pathologist will read back the result and the technologist will document RBT in the LIS Calls will be made using the phone number provided to call the Physician s office or Health Care Provider Critical or life threatening results may only be communicated to the licensed caregiver at that facility The laboratory staff member will document in the Laboratory Information System LIS the following information for each critical result the name of the analyte with the critical value the name of the person notified the result was confirmed by read back as well as the time If the results are called and faxed include that comment in the call field ex Critical platelet count called and faxed to Dr Smith All verbal printed and faxed reports of critical values must be read back by the health care provider to verify accuracy and completeness This must be documented
83. rvey Training Reference Materials NOTE gt External Links of any incident that has resulted in gt Newsletter Archive Instructions e You may log on using your Novell password for most people the user name is your first initial last name e You may also complete an incident report anonymously e Required fields are identified with an asterisk Patient Safety Resources Click here for Norief tutorial on how to submit an incident x 3412 Cate O Connor Devlin Nursing Manager coconnor gbmc org x 3412 Pain Nurses Monday Friday evenings x 6350 men 4 gt Localintranet 100 4 start op Novell GroupWise Mai Just Culture TRAINING ts 1 27 11draft 2 GBMC Infoweb wind Patient and Safety 0 dj amp 11 37 83 nz Fb moles Hp Log in Using Novell MINIM IR Password and User ID 7 Reed Ms QARO or Log in er Anonymously GBMC b Tos db ep saf Login Password Help N Ld Lagin ID Report an Event Occurence Anonymous We value your contribution in rraating safer environment Event Reporting Tutorial ge Complete My Event 5 Ewent ID Patient gt Cli to report a safaty event that affectod a Patiant
84. s not a STAT or critical value but I still want to be notified of the result Requests for special handling for test results on a specific patient such as Call results to Dr Smith at 828 9999 must be CLEARLY written on the laboratory requisition A Customer Service Specialist will call the result s when the test 1 verified The telephone number must be listed on the laboratory requisition form an answering service or a pager number is acceptable This same request can also be honored for the faxing of results How do I obtain laboratory requisition forms The GBMC Department of Pathology provides pre printed laboratory requisitions to all physicians who direct their outpatients to the GBMC Patient Service Centers To order your pre printed requisitions please call Customer Service Monday through Friday 7 30am 6 00pm or Saturdays 8 00am 12 noon holidays excluded How do I obtain a urine container for my patient for a 24 hour urine test Send the patient to the Outpatient Service Center to pick up a urine container For Quest and LabCorp Patients Patients must go to one of the Quest or LabCorp Patient Service Centers Who do I call to get formalin containers Call the Surgical Pathology Department at 443 849 2812 to obtain formalin containers Who do I contact to discuss laboratory testing or specimen collection and processing for a research study or a clinical trial Contact the Customer Service Department t
85. t of tests with critical values is determined by the Department of Pathology and Laboratory Medicine in conjunction with representatives of the Medical Staff and approved by the Medical Board see Appendix A for list of tests POLICY All critical laboratory results must be reported to the patient s licensed caregiver immediately following confirmation of the result Standard Laboratory procedure requires that all first time critical results are confirmed by repeating the test and that a physician nurse or other licensed caregiver must be notified by the technologist technician performing the test or by a laboratory customer service specialist The first attempt at notification must occur immediately following but no later than 30 minutes following test verification A licensed caregiver includes but is not limited to the registered nurse licensed practical nurse advanced practitioner or physician In the event that the patient s caregiver is not immediately available the information may be given to the charge nurse of a unit CALL PROCEDURE Inpatient 1 All Inpatient Critical Results will automatically print to the unit clinic ward that the patient is registered upon verification of results 2 The technologist performing test s will call the unit confirm that the patient is on that unit and notify the licensed caregiver of that patient that there is a critical result on the patient The technologist will indicate that the resul
86. t was printed to their printer for example We have a critical high glucose result on Mr Sam Jones and it was verified and sent to print to your printer Staff will request and document read back of result by indicating RBT in the LIS documentation section If results have not printed they can be faxed or given verbally to the caregiver 3 Any time a verbal report is given to a licensed caregiver read back of the test result to technologist or customer service representative to confirm the report must be documented in LIS If the patient has been discharged the technologist must notify the attending physician of the critical value If the licensed caregiver is not immediately available the laboratorian must ask for the charge nurse and convey and document the read back in the same manner 4 The technologist will document in the Laboratory Information System LIS the following information for each critical result the name of the analyte with the critical value the name of the person notified and whether the result was confirmed as well as the time The caregiver will read back the result and laboratory staff will document for read back test If the patient has been discharged and the attending physician was notified that information must be documented 5 If results do not print to the unit the MIS Help Desk should be called x3725 by the unit to help resolve the printer problem 38 GBMC Department of Path
87. t your Physician Relations Representative Bonnie Longerbeam or Ann Veltre to facilitate Physician Relations main number 15 443 849 6176 Key Contacts Treve Kosco RN GOR 443 849 2138 Mary Knapp RN Nurse Manager Sherwood 443 849 8440 Calvin Fletcher RN Women s Surgical Center 443 849 8920 Charlene Mahoney RN GOR PACU 443 849 2250 Roberta Cordara RN Scheduling amp Pre Surgical Testing 443 849 3442 MEDITECH Training Call GBMC Help Desk 443 849 3725 Orientation Includes 1 Tour 2 Introduction to key staff 3 Locker information 4 Scrub access 5 Access to the area badge access 6 Address special equipment needs 7 Posting cases 8 Preference cards 9 Overview of OR Rules and Regulations 10 Address any questions re anesthesiology 99 Procedures for Medical Attending Daytime Direct Admissions Purpose Direct admissions of patients by Medical Attendings or the Hospitalists will be facilitated to provide a safe comfortable and efficient admission for the patient and the physician This procedure 1 to be used Monday Friday 8 a m 6 30 p m l The physician s office will call Administrative Coordinator at 443 849 2076 to request admission The following information will be needed Patient name Admitting Physician Name When was the patient last seen must be seen by a physician within last 24 hrs Last set of VS temp heart rate Bp and pulse ox Date of Birth Diagnosis SSN or Medical Records
88. titution GBMC hospitalists take care of a large percentage of medical patients admitted in all areas of acuity general medicine med psych oncology telemetry and intermediate care unit Hospitalists are further involved in emergent urgent care as part of GBMC s Rapid Response Team Beyond this the hospitalists provide consultation services to any admitting physician on request at GBMC and frequently co manage the care of surgical gynecologic and orthopedic inpatients The group 1 available to physicians using the Sherwood Surgical Center as well in case of acute medical consultation As hospitalists these physicians are also well trained in the discharge needs of inpatients Ultimately the hospitalist group at GBMC offers comprehensive medical care to any patient at the request of the referring physician Contact Numbers Hospitalist pager numbers can easily be accessed in Meditech by clicking on the picture of the World with an R in front of it Reference Links Icon in the lower right and then choosing Patient List Hospitalist To reach a specific member of the group each hospitalist has a personal pager These numbers are easily available through the hospital operator or Meditech and are clearly listed on each hospital unit The Hospitalist Group Office Manager is Mrs Penny Tognocchi available at 443 849 8046 Hospitalist Fax 443 849 8057 Location e
89. to find a specific policy If you would like to update or submit a new policy please click here Search by Policy You may search either by the exact policy number or perform a keyword search within the policy content search by Facility Department hanual if you would like to retrieve the policies based on which facilities departments and or manuals the policy 15 In usa Most Recent Policies within the Last 30 days This area displays recent policies within the last 30 days based on your preferred facility Search by Policy Next review date falls in Results sorted by Policy Title Policy Number Relevancy Legend shi system manual indicator 91 GBMC CLINICAL POLICY AND PROCEDURE RESTRAINTS AND SECLUSION APPROVAL Signature on file Sr VP Patient Care Services amp CNO PURPOSE To provide a consistent standardized hospital wide procedure for the assessment application and evaluation of the use of restraints To make certain that GBMC uses all alternative measures prior to the use of restraints Il DEFINITIONS A Restraint any manual method physical or mechanical device materials or equipment that immobilizes or reduces the ability of a patient to move his or her arms legs body or head freely B Seclusion the involuntary confinement of a patient alone in a room or area where the patient is physically prevented from leaving Seclusion may only be used for the management of vi
90. tor General s Compliance Program Guidance for Hospitals The fundamental mission of the Compliance Program is to ensure that GBMC conducts its business operations with the highest of ethical standards and complies with state and federal regulations The Compliance Department is often called upon to facilitate the interpretation of compliance related rules provide guidance in setting standards recommend corrective action where necessary and ensure that appropriate lines of communication training and feedback exist President and CEO John B Chessare M D fully supports all Compliance efforts HIPAA GBMC HealthCare has a HIPAA Privacy and Security plan in place We take very seriously the protection of our patients protected health information and follow all state and federal guidelines Internal Audit The purpose authority scope and responsibilities of Internal Audit are outlined in the GBMC HealthCare Board approved Internal Audit Charter The Internal Audit Department is often utilized as an independent objective assurance and consulting mechanism designed to add value and improve an organization s operations In addition to the GBMC Code of Business Ethics and Standards of Conduct our department adheres to The Institute of Internal Auditors Code of Ethics regarding the principles and standards we use in carrying out our professional responsibilities to GBMC Location We are located in the South Chapman building on the Campus o
91. tory Managers LIS Analyst Quality and Education Coordinator ADMINISTRATIVE DEPARTMENT DIRECTOR CHAIRMAN Medical Director Janis Smith Robert Palermo M D 35 Donor Appointment Guidelines Please give patient the Donor Room Message Line 443 849 2817 as we cannot always answer the phone if we are attending other patients Patients should leave their name phone number and best times to call back We will return their call to set up donation appointment The patient has to bring a written request from their doctor with the surgery date and the number of donations ordered If they cannot bring it in then the doctor s office can phone in the order and fax to our Donor Room at 443 849 3100 If the patient does not have a request then we are not allowed to perform the procedure until one is obtained For therapeutic donations Multiple donor appointments must not be any less than seventy two 72 hours apart and the donor s surgery must not be less than seventy two 72 hours from the last scheduled donation Patients should call the Donor Room as soon as their surgery 15 scheduled as appointments fill quickly e Incase of immediate attention such as surgical add on or urgent surgery please call 443 849 3568 36 THE LABORATORY TEST DIRECTORY The Laboratory Test Directory available to you by the following two mechanisms 1 At the internet site of www gbmc org On top of the screen click on Physician p
92. trolytes PROCEDURE Laparoscopic procedures of the abdomen chest and pelvic region HCT T amp S IF Hct lt 28 Major Neurosurgical Thoracic Splenic Major abdominal Major Vascular Urologic EKG CXR CBC Platelets PT PTT Lytes G B C LFTs T amp S Also UA for Urology cases Myomectomies TAH CBC Lytes T amp S GYN Resectoscope Urologic Resectoscopes TURB TURP HCT Lytes HCT Lytes T amp S Total Joint Replacement EKG CXR CBC PT PTT Electrolytes Glucose BUN Creatinine T amp S Clean caught UA if Abnormal do 5 Spine Cases with Instrumentation fusion CBC PT PTT Lytes G B C EKG T amp S D amp C for incomplete missed or therapeutic abortion HCT and Rh screen required Revised 6 01 2009 Reviewed 1 2012 58 GBMC 6701 North Charles Street Baltimore MD 21204 OUTPATIENT HOME MEDICATION RECONCILIATION FORM Patient home medication recorded on admission Documented by RN check Date Time MEDICATION HERBAL VITAMINS CONTRAST OVER THE COUNTER NAME DOSE FREQUENCY REASON DATE TIME LAST TAKEN Allergy or Adverse Reactions SEVERITY Changes New Orders 59 What is Required in a Complete History amp Physical GREATER BALTIMORE MEDICAL CENTER 6701 North Charlos Street Baltimore Maryland 21204 HISTORY AND PHYSICAL MIDEN ON MEDICAL HISTORY e722 Minimal Requirements Documentation of recent and past medical history Indication for surgery p
93. usly monitored through face toface observation by staff members iv Restraint or Seclusion Alone Patients shall be monitored on an ongoing basis by staff members who are stationed nearby the patient The observations made and data collected during such monitoring shall be documented at least every 15 minutes b Assessment Assessments by a Registered Nurse or Physician Assistant or evaluations by a responsible Licensed Independent Practitioner shall occur as often as indicated by the plan of care based on the patient s condition behavior and environmental considerations but at least once every 60 minutes 94 Clinical Policy and Procedure Restraints and Seclusion Page 4 G Medical Surgical Restraints Non Violent Behavior 1 Restraint not used for the management of violent or self destructive behavior a Monitoring and assessments shall occur at least every 2 hours by the RN or unlicensed assistive personnel as designated Reassessment observed behavior and alternative measures for restraint need is documented at least once per shift H Discontinuation 1 Restraint or seclusion shall be discontinued by the Registered Nurse once the behaviors or situation that served as the basis for the restraint are no longer present and the safety of the patient staff members or others may be assured through less restrictive means 2 If a patient in restraints requires continuous restraint for over a 24 hour period a physician shal
94. values MEDICATION NPSG 03 06 01 Maintain and communicate accurate patient medication information RECONCILIATION INFECTION CONTROL NPSG 07 01 01 Comply with either the current Centers for Disease Control and Prevention CDC hand hygiene PLAN guidelines or the current World Health Organization WHO hand hygiene guidelines BBP EXPOSURE CONTROL PLAN 87 GBMC Policy National Patient Safety Goal Standard Text Standard INFECTION CONTROL PLAN NPSG 07 03 01 Implement evidence based practices to prevent health care associated infections due to Mandatory MRSA Active multidrug resistant organisms in acute care hospitals Note This requirement Surveillance Testing applies to but 1s not limited to epidemiologically important organism such as AST in Critical Care methicillin resistant staphylococcus aureus MRSA clostridium difficile CDI Units continued vancomycin resistant enterococci VRE and multidrug resistant gram negative bacteria INFECTION CONTROL NPSG 07 05 01 Implement evidence based practices for preventing surgical site infections SURGICAL SERVICES INDWELLING URINARY NPSG 07 06 01 Implement evidence based practices to prevent indwelling catheter associated urinary tract CATHETER infections CAUTI This NPSG is not applicable to pediatric populations REMOVAL Research resulting in evidence based practices was conducted with adults and there STANDING ORDER is no consensus that these practices appl
95. vider Order Entry CPOE access will only be granted after the provider attends a CPOE training class e Novell Logon This is used to access system applications such as email on GBMC computers Your username will be your first initial followed by all or part of your last name For example Dr William Smith would be wsmith gbmc org while Dr Sandra Clementine might be sclement gbmc org the last name being truncated in this case 5 e Remote Access This is required as part of CPOE Any Internet connection will do however a higher speed connection such as DSL or cable modem provides better performance and 1 necessary for adequate viewing of radiographic images Requests for remote access are processed through the Medical Staff Office Accessing Patient Data via Meditech 1 2 A de M Obtain a Meditech logon see above Start the Meditech software by double clicking the Meditech icon The icon looks like this MEDITECH Greater Baltimore Medical Center rk e On the desktop of GBMC computers throughout the hospital On the remote access desktop if you are using remote access Enter your five digit dictation number in the USER field Press Enter Enter your password in the PASSWORD field Press Enter The first time you logon to Meditech and periodically thereafter you will be required to change your password Follow the on screen instructions to enter and confirm a new password The Meditech home
96. y What s similar between hotel room towels and hospital hand hygiene Read Dr Chessares latest blog post In Action to Improve Our Care to find out Broadcast nfoweb Form 2 Medical Staff Employee Opinion Survey Grand Prize Winner Portfolio Report mm i pem The 2011 Employee Opimon Survey concluded on August 19 Thank you to all employees who participated The survey s final grand prize winning code is in Incident Tool gt Net Leaming Please check your Kronos E OnBase Retrieval Legacy Chase at Shawan Downs Car Raffle Tickets Lawson Self Serace WingSpan Login Tickets are now on sale for the Legacy Chase at Shawan Downs Car Raffle You can win a 2 year lease on a new 2012 Volkswagen Passat 2 5 15 Or win the cash prize of 10 000 in lieu of the lease Read the August 18 Edition of the Pulse eNewsletter beck out the latest adition of D newsletter that provides employees padcast emails are a Jl 100 81 82 Quantros User Friendly 7 Patient and Safety Event Manager Windows Internet Explorer Ky ey gt http finfoweb body cfm id 1796 MN File Edit Favorites Tools Help we Patient and Safety Event Manager 7 Ej ah gt Tools gt National Patient Safety Goals REPORT AN EVENT gt gt NPSGs gt Quality and Safety Concerns gt VSurvey Access gt VSu
97. y result n disuplinarr action up to and nduding termination 3002 2010 Quanirca Inc All Rights Amearaed Prrvecy Policy 84 Quantros SEM 5 5 Windows Internet Explorer a https iqxpert quantros com srm controller A4nonymousSRMController ServName QEventAdd amp _qc 432d386aaaal67682dd22F4cSfOarcf9 YOS GBMC Greater Baltimore Medical Center 00 05 6701 Charles Street Baltimore 21204 Patient Safety Event ID GJQ5876408 Anonymous Reported on 01 27 2012 11 45 Reported by Anonymous Reporter Occurred on 01 27 2012 What i s Actual or near miss event Actual Event Near Miss Close Call What happened Type to activate search Advanced Search Describe what happened include who was notified and outcome if known Check Spelling Was any device equipment involved Cyes Clear Selection When Where Date Time of event 01 27 2012 Date unknown hh mm s Time unknown Department where event occurred Select Other department involved Select External facility involved Cyes Clear Selection 85 86 In applying for appointment reappointment applicants consent to abide by the Bylaws Rules and Regulations of the Medical Staff and other hospital and administrative policies and guidelines as they presently exist or as amended from time to time The following are key policies relat
98. y to children Footnote Evidence based guidelines for CAUTI are located at Compendium of Strategies to Prevent Healthcare Associated Infections in Acute Care Hospitals at http www shea online org about compendium cfm and Guideline for Prevention of Catheter associated Urinary Tract Infections 2009 at http www cdc gov hicpac cauti 001 cauti html SUICIDAL PRECAUTIONS NPSG 15 01 01 Identify patients at risk for suicide Note This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals UNIVERSAL PROTOCOL Conduct a preprocedure verification process MN 88 UNIVERSAL PROTOCOL UP 01 03 01 A time out is performed before the procedure GBMC Policy National Patient Safety Goal Standard Text Standard PC 03 03 07 For hospitals that do not use accreditation for deemed status purposes Staff are competent RESTRAINTS AND SECLUSION in minimizing the use of restraint and seclusion for behavioral health purposes and maximizing patient safety when they are used PC 03 03 15 For hospitals that do not use accreditation for deemed status purposes A licensed independent practitioner sees and evaluates in person the patient who is in restraint or seclusion for behavioral health purposes PC 03 03 19 For hospitals that do not use accreditation for deemed status purposes Patients who are in restraint or seclusion for behavioral health purposes are reevaluated

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