Hospital References and General Information Library
This section includes general information for reference on department and services. This is not an all inclusive list of procedures and policies. Please contact the individual departments for additional and more detailed information and guidance on policies and procedures.
DEPARTMENTAL REFERENCES
01. SURGICAL SUITE, TREATMENTS, AND INFORMATION
02. HEALTH INFORMATION MANAGEMENT (HIM) AND RECORD PROCEDURES
03. DIAGNOSTIC IMAGING REQUESTS
04. INFECTION PREVENTION AND CONTROL
05. SAFETY GUIDELINES
GENERAL REFERENCES
06. CAFETERIA
07. CME REQUIRMENTS AND EDUCATION
08. DISASTERS AND EMERGENCY RESPONSES AND CODES
09. IMPAIRMENT RECOGNITION
10. MAIL
11. MODERATE SEDATION REQUIREMENTS
12. MEETINGS
13. PARKING
14. RISK MANAGEMENT
15. SAFETY
16. SMOKING
17. UNAPPROVED ABBREVIATIONS
SURGICAL SUITE, TREATMENTS, AND INFORMATION
To Schedule: 910-457-3819
Monday - Thursday 7:30 am to 4:00 pm.
Friday - 7:30 am - 2:00 pm
They will need:
Patient First and Last Name
Date of Birth
Patient Phone
Patient Address
Social Security if NOT a previous patient at Dosher.
Procedure Specifics (i.e;Procedure/Left/Right)
Orthopaedic cases should inform of orders made directly with rep's providing equipment.
Scheduling will confirm the treatment rooms for patients requiring ongoing services and inform your office.
Dosher follows strict guidelines and adherence to SCIP (Surgical Care and Improvement Performance). SCIP Guidelines are monitored by regulating organizations and are also addressed during performance reviews.
If you intend to perform a new procedure at Dosher, it must be on your privilege list. If the new procedure does not appear on your granted privileges, you must apply and be monitored. A request for a New Procedure can be obtained by filling out the New Procedure Request Form available in the Bylaws and Forms section of this site. Go to Documents Now
If you have the Privilege of Conscious Sedation, you must have the applicable ACLS/PALS certification.
FOR ANY ADDITIONAL QUESTIONS REGARDING THE OR - CALL 910-457-1195.
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HEALTH INFORMATION MANAGEMENT (HIM) AND RECORD PROCEDURES
Contact for Medical Records: 910-457-3865
For dictation instructions please call 1-866-409-6375.
HIM is open from 8 am - 4:30 pm Monday - Friday. HIM is located on the 1st floor main corridor.
Policies and Procedures can be found in the Bylaws and Documents section of the Medical Staff portal. Go to Documents Now
However, the following information is provided for quick reference:
History and Physical (H&P) Requirements
Dictation Instructions for Medical Records
Authorization for the Release of Protected Health Information
HIPAA and CONFIDENTIALITY
For privacy Issues call Marcia Jennings at 910-457-3802.
To report any compliance issue - Call(586) 212-9904
HIPAA PRIVACY and SECURITY, and CONFIDENTIALITY
Athena Compliance: (586) 212-9904
For I.T. HIPAA ISSUES: Susan Shomaker - 910-457-3827
Patient information is always confidential, private, and maintained within a secure environment. Only designated, authorized persons including healthcare workers caring for a patient may access, use or disclose patient information "as needed" to fulfill their duties within the scope of their defined responsibilities. Examples of ways to protect patient information include using passwords properly and ensuring that no medical record leaves the campus at any time.
Understanding and practicing Dosher's privacy and I.S. security policies are crucial to ensuring the community's trust in Dosher's services. In order to be in full compliance with federal and state laws relating to privacy and security, it is required that any suspected or known breach or activity that possibly would result in a breach of privacy or security must be reported to the Privacy or Security Officer. For more detailed information on policies, contact the above office.
Call the Privacy or Security Office if you have any questions on HIPPA policies. The federal Office of Civil Rights enforces HIPAA and the HITECH Act of 2009. Go to Links Now
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DIAGNOSTIC IMAGING REQUESTS
To Schedule Diagnostic Imaging: 910-457-3948
Detailed information of Diagnostic Services are available in the public services section of this website.
Contact regarding special requests, PACS, or general questions: 910-457-3923. The PACS authorization form is located in the forms section of this website. Go to Documents Now
Full imaging services are located at the hospital as well as the Dosher Medical Plaza.
However, MRI and DEXA are only available at the Dosher Medical Plaza at 4222 Long Beach Rd. (From Southport to Oak Island on the left)
Laboratory services are available in both locations.
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INFECTION PREVENTION AND CONTROL
Contact: 910-457-3937
Infection Control is everyone's responsibility and extremely important to our patients and others visiting the hospital Please refer to this Infection Prevention and Control Education link.
Infection control is everyone's responsibility and extremely important to our patients and others visiting the hospital.
Routine hand hygiene is the single most effective preventative measure in reducing the occurrence of healthcare associated infections. A healthcare associated infection is defined as a hospital acquired infection that was neither present nor incubating at the time of admission.
The Infection Control policies are available to provide you with specific references that you might need pertaining to:
*Infection control measures
*Hand hygiene measures
*Isolation precautions
*Post exposure prophylaxis
Remember to perform hand hygiene:
*Before any patient contact
*After any patient contact
*After removing gloves
*After touching blood/body fluids, non-intact skin, mucous membranes and wounds
*After touching objects near patients (i.e. side rails, IV poles, etc.)
Waterless, alcohol hand foam is available in all patient care and hospital areas, but remember that it is not effective against spore forming organisms (i.e. c. Diff.)
Hospitalists will need to get fit for a respirator to utilize during emergency or infectious periods. Call 910-457-3937
ISOLATION PRECAUTIONS
Precautions will be directed for the following:
AIRBORNE: Known or suspected to have serious illnesses transmitted by droplet nuclei. Examples; Measles, tuberculosis, varicella. Staff must use respiratory protection for entry into an airborne infection isolation room.
DROPLET: Known or suspected to have serious illnesses transmitted by airborne droplets. Examples: Meningitis, pneumonia, mumps, influenza. Staff must wear a surgical mask upon room/cubicle entry.
CONTACT: Known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patients environment. Examples: MRSA, VRE, Clostridium difficile, etc. Staff must put on gown and gloves upon room/cubicle entry.
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DNV-GL GUIDELINES
Dosher Memorial Hospital is accredited by DNV-GL. The below information highlights some of the important guidelines we adhere to at Dosher.
NATIONAL PATIENT SAFETY GOALS
IMPROVE THE ACCURACY OF PATIENT IDENTIFICATION
PATIENT INDENTIFICATION:
Use at least two patient identifiers (NAME & BIRTHDATE) whenever administering
medications or blood products; taking blood samples; and other specimens
for clinical testing; or providing any other treatments/procedures.
Process:
a) Ask the patient their name and birth date
b) Check the identification bracelet as to what the patient said
c) Check the MAR, Lab slip, paperwork to make certain the info matches the
identification bracelet and what the patient stated
IMPROVE THE EFFECTIVENESS OF COMMUNICATION
TELEPHONE/VERBAL ORDERS:
Must be given to the nurse so that he/she can enter
into the computer and READ BACK to the MD and
electronically sign TOR (telephone order).
CRITICAL TEST VALUES:
These must be reported verbally reported to MD, recorded in the nursing notes,
and noted when the critical value reported.
DO NOT USE ABBREVIATIONS:
If used, physician will be contacted to clarify.
THE LIST OF "DO NOT USE ABBREVIATIONS" IS ON THE
WEBSITE.
REDUCE HEALTHCARE INFECTIONS
HAND HYGIENE:
Comply with Center for Disease Control hand hygiene guidelines and no artificial nails.
Wash your hands before going into the patient's room, between changing gloves and after
leaving the patient's room. Please use the foam or wash and water for 15 seconds.
ACCURATELY AND COMPLETELY RECONCILE MEDICATIONS ACROSS THE CONTINUUM OF CARE
Document all medications the patient is taking at home in the H & P.
Nursing also documents the Home Med History from which a Medication Reconciliation Report is generated.
The physician must sign/confirm the medications to be taken as an inpatient on the Medication Reconciliation Report Form. (This includes Endoscopy and Outpatient Surgery)
Admission Medication Reconciliation Form.
Medication orders are re-written and signed by the MD when the patient's status changes during hospital stay.(changes in level of care or surgery)
A complete list of medications is generated on the Medication Reconciliation Report and then this form is signed by the physician when the patient is discharged or transferred to another facility.
REDUCE THE RISK OF HARM FROM PATIENT FALLS
Implement a fall reduction program and evaluate the effectiveness of the program.
Fall risk assessment completed on admission and daily.
A star sign on chart and door denotes patient is HIGH RISK for falls.
Each dept/nursing unit tracks the frequency and outcome of falls to prevent
future occurrences.
Arm Band Color bands are placed on patients as:
Red=Allergy
Yellow=Fall Risk
Purple=DNR
UNIVERSAL PROTOCOL
Complete pre-procedure checklist for all invasive
procedures/surgeries. Conduct a "TIME OUT" prior to
start of surgery/procedure.
The time out is all nurses and physicians in the room pausing
& re-stating the patient's name, birthdates, physician,
procedure, antibiotic administration, beta blocker,
Life Code status, and site, to be certain all information
is correct. This includes all patients receiving Moderate Sedation
and bedside/local cases on the nursing unit, (like
chest tube placement, I&D etc) This must be documented
on the procedure form.
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GENERAL REFERENCES
CAFETERIA
The cafeteria is open from 11:30 am - 1:30 pm. Vending machines are also available.
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CME REQUIREMENTS/EDUCATION
Contact Medical Staff Office: 910-454-4739
CME requirements are indicated in the Medical Staff Bylaws. You are required to provide proof of CME at reappointment. Go To LINKS Now For ACLS and PALS classes, contact Joanne Turzer-Commesso at 910-457-3818.
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DISASTERS AND EMERGENCY RESPONSES AND CODES
When Dosher Memorial Hospital activates Emergency Plan, temporary disaster privileges may be granted to any licensed medical provider in order to accommodate immediate patient care needs.
A practitioner "Call Tree" may be initiated and you would be expected to respond. Information may be available, however, you would be expected to report to the Main Entrance Lobby of the hospital for direction. This "Call Tree" may change as needed, so please refer to the updated "Call Tree" provided in the Bylaws and Documents section of this website. Go to Documents Now
All staff practitioners must have an identification badge. It must be worn at all times in the hospital and will be needed during a disaster for access to the hospital. You may not be granted access through a police roadblock in times of disaster without a namebadge. Badges may be obtained in the Human Resources Department on the 2nd Floor Administration Wing.
While in the hospital you may hear a list of commonly known pages. If you are in the area of an emergency, pick up the nearest phone and dial "O". State the nature of the emergency/code and specific location.
CODE LIST:
Announce FACILITY ALERT for
(Name the incident)
Evacuation/Relocation
Wound Care Chambers
Hazardous Materials Spill
Mass Casualty
Medical Contamination
Surge Capacity
Utility/Technology Interruption
Weather
Announce CODE RED for:
Fire/Smoke Alarm
Fire/Smoke Alarm Wound Care
Announce CODE BLUE for:
Medical Emergency or Incident
Announce SECURITY ALERT for:
Event
Missing Infant/Child
Missing Persons >18 Yr Old
Armed Intruder/Shooter/Hostage Situation
Bomb Threat/Suspicious Package
Civil Disturbance
Controlled Access
You should announce the SECURITY ALERT + TYPE + DESCRIPTOPR + LOCATION
You are responsible for the ability to handle a fire extinguisher in an emergency situation. Contact Plant Operations 457-3894 for operational instructions.
"PASS":
Pull the pin out
Aim at the base of the fire
Squeeze the trigger
Sweep at the base of the fire
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IMPAIRMENT RECOGNITION
The hospital and its medical staff are committed to providing patients with quality care. The delivery of quality care can be compromised if a member of the medical staff is suffering from an impairment. The American Medical Association defines the impaired physician as "one who is unable to practice medicine with reasonable skill and safety to patients because of a physical or mental illness, including deterioration through the aging process or loss of motor skill, or excessive use or abuse of drugs, including alcohol." Impairment may result from a physical or mental condition.
The Physician Health Policy can be viewed from the Bylaws and Policies section of this website.
If you have need to identify a situation or self report, please refer to this Impairment Recognition and Assistance document. Go to Documents Now
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Active practitioners are provided a "snail mail" receptacle located in Health Information Management. You are responsible for collecting and attending to mail provided in this manner. This is a primary source of disseminating information and hospital correspondence to Active Medical Staff. This includes operative reports, H&P's, and some laboratory and radiology reports. Please be timely manner. Non-collection and non-attentiveness to mail will not be acceptable if errors occur effecting standards of patient care.
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MODERATE SEDATION REQUIREMENTS
Only physicians that hold a current ACLS certificate and are credentialed and privileged may perform moderate sedation at Dosher Memorial Hospital.
Each practitioner granted privileges is expected to have knowledge of the medications in the moderate sedation policy, the appropriate dosages, side effects, reversal agents etc. Each practitioner granted privileges is also expected to have knowledge of the ASA classification scale.
All physicians that are privileged for Moderate Sedation will maintain a current ACLS certificate (and PALS if applicable) and supply copy to the Medical Staff Office. If you have not supplied the Medical Staff Office the current certificate, your Moderate Sedation privilege will be considered terminated.
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MEETINGS
Active Staff are required to attend 4 out of 6 meetings as outlined in the Medical Staff Bylaws. All calendars and committee contacts are in the MEETINGS and COMMITTEES section of this portal. Go to Meetings Now
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PARKING
Physician parking is available in front of the main entrance or near the Howe Street loading dock for surgeons. Please do not block the entrance to the loading area. Hospitalists and other practitioners will find more parking available in the rear lot or across from Fodale Ave.
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RISK MANAGEMENT
Risk Management means making the hospital as safe as possible, preventing problems, arid taking action to solve problems if they do occur. Each patient's medical record is legal proof of the quality of care that we provide. Be certain that all documentation reflects the care provided and adheres to hospital policy and procedure.
Legibility is an important part of documentation and is monitored at Dosher Memorial Hospital on a regular, ongoing basis.
Should any unexpected event occur, notify a department manager immediately, so that an incident report can be completed. Incident reports must be completed within 24 hours of the occurrence.
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SAFETY
Be safety conscious at all times. Unsafe conditions should be reported immediately to a hospital employee.
Report any incident involving threats, harassment, or other inappropriate behavior that occurs in the workplace.
Security staff is available to assist you if walking to your vehicle at night or for other emergencies.
The hospital reserves the right to inspect any parcel carried on or off the hospital property.
Persons carrying packages or equipment from the hospital may be asked to prove ownership.
You are required to wear your namebadge at all times while you are on hospital property.
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SMOKING
Dosher is a tobacco free campus. Smoking is not allowed in the hospital or on the campus. This includes parking lots and access roads. This applies to all employees, staff, patients, and visitors.
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UNAPPROVED ABBREVIATIONS
The Joint Commission National Patient Safety Goals require adherence to written abbreviations when writing orders. The document outlining the "DO NOT USE ABBREVIATIONS" is located in the Bylaws and Documents section of this website. Go to Documents Now
The nurses and pharmacists will be required to call you to clarify all orders, so please use the top our order sheets or progress note as a reminder of the prohibited abbreviations. This will save you the inconvenience of a phone call. All usage of approved abbreviations are monitored by the Medical Staff as well, and could lead to negative action toward your privileges. Fines are issued for incorrect usage and unpaid balances are posted at the Medical Staff Meetings.
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