News and Views for Healthcare Accreditation Professionals

Archive for March, 2013

CDC Rules on Multi-Dose Vials

CDC Rules on Multi-dose Vials

cdc on multidose vials


Only Physician can record discharge summary: CMS

Interpretive Guidelines §482.24(c)(2)(vii)
All patient medical records must contain a discharge summary. A discharge summary discusses the outcome of the hospitalization, the disposition of the patient, and provisions for follow-up care. Follow-up care provisions include any post hospital appointments, how post hospital patient care needs are to be met, and any plans for post-hospital care by providers such as home health, hospice, nursing homes, or assisted living.

The MD/DO or other qualified practitioner with admitting privileges in accordance with State law and hospital policy, who admitted the patient is responsible for the patient during the patient’s stay in the hospital. This responsibility would include developing and entering the discharge summary.
Note:  While others may perform this function, it is clear that they should have participated in the care of the patient AND be recognized to perform this function under the state licensing act.  What if the state is silent?  Then it probably cannot be done by them.

Who Qualifies For Privileges: NEW CMS PERMISSION

There is an age old dilemma about who qualifies to be privileged by the medical staff.  Traditionally it had been those to provide a “medical level of care”.  In the most recent release of the Condition of Participation the following is noted:

§482.12(a)(1) Determine, in accordance with State law, which categories of practitioners are eligible candidates for appointment to the medical staff;

Physician assistant;
Nurse practitioner;
Clinical nurse specialist (Section 1861(aa)(5) of the Act) (master level);
Certified registered nurse anesthetist (Section 1861(bb)(2) of the Act);
Certified nurse midwife (Section 1861(gg)(2) of the Act);
Clinical social worker (Section 1861(hh)(1) of the Act;
Clinical psychologist (42 CFR 410.71for purposes of Section 1861(ii) of theAct)
Registered dietician or nutrition professional
So the rest are a “NO GO” and organizations must apply the Human Resources standards to others such as: rounding RNs, all other RNs, surgical technicians, surgical assistants, perfusionists.