Medical Staff Education 2022

2022 Edition

CONTENTS

Mission, Vision & Values .......................................................................................................................2
Joint Commission Notification ................................................................................................................2
Antimicrobial Stewardship . ....................................................................................................................3
Strategies to Prevent Infection...............................................................................................................4
Annual Flu Shot ....................................................................................................................................6
Diarrhea Decision Tree: C-DIFF Screening Protocol ................................................................................8
Pain Management Assessment & Managing Pain......................................................................................9
Pain Management and Opioids – 2022 .................................................................................................. 10
Restraint Utilization ............................................................................................................................. 12
Case Management............................................................................................................................... 13
Clinical Documentation Improvement and Queries ................................................................................. 15
EMTALA Requirements for Physicians ................................................................................................... 18
Use of Interpretative Services .............................................................................................................. 19
Physician HCAHPS ............................................................................................................................... 19
Handoff Communication ...................................................................................................................... 20
Surgical Consent ................................................................................................................................. 20
Inpatient Wound Care ......................................................................................................................... 20
Abuse and Neglect .............................................................................................................................. 21
Corporate Compliance ......................................................................................................................... 21
Centers of Excellence .......................................................................................................................... 22
High Reliability Organization................................................................................................................. 22
Cultural Diversity................................................................................................................................. 23
Implicit Bias ........................................................................................................................................ 24
Workplace Violence ............................................................................................................................. 25
De-Escalation in Healthcare.................................................................................................................. 25
Disruptive Behavior ............................................................................................................................. 27
Physician Impairment .......................................................................................................................... 27
HIPAA Compliance for Physicians ......................................................................................................... 28
Physician’s Medical Record Documentation Guidelines ........................................................................... 32
Standardized Medical Record Abbreviations........................................................................................... 35
Emergency Management and Safety..................................................................................................... 37
Fire Prevention “Mr. Red” ................................................................................................................... 37
Evacuation.......................................................................................................................................... 38
Hazardous Materials ............................................................................................................................ 38
Safety Management............................................................................................................................. 39
Paragon Clinician Hub (PCH)................................................................................................................ 40

Page 1 of 45

MISSION, VISION AND VALUES

Our Mission

Jackson Hospital is a not-for-profit organization committed to improving the health of all members of
our community by providing superior, patient-centered and cost-effective care in a safe, compassionate
environment.

Our Vision

The vision of Jackson Hospital is to be Central Alabama's first choice for healthcare.

Our Values

Compassion: We care for our patients with empathy and kindness regardless of their ability to pay.
Diversity: We embrace the differences in our patients, staff and community.
Education: We improve the health of our region through the continuing education of our patients, staff
and community.
Innovation: We continually improve the care we provide through evidence-based medicine and
technological advancements.
Integrity: We are forthright, honest, ethical and respectful.
Quality: We strive to achieve excellence in everything we do while providing outstanding customer
service.
Safety: We maintain a safe environment for our patients, visitors and staff.
Teamwork: We work together to achieve common goals.

JOINT COMMISSION NOTIFICATION

When a member of the medical staff has any concerns about patient care and safety in
the organization, he or she is encouraged to contact the hospital’s administrative team.
If the concerns in question cannot be resolved at that level, the individual may contact
The Joint Commission by calling the Office of Quality Monitoring at 800-994-6610.

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ANTIMICROBIAL STEWARDSHIP

Antimicrobial Stewardship refers to coordinated interventions designed to improve and measure the
appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen,
dose, duration of therapy and route of administration.

Importance of Antimicrobial Stewardship:

 Global threat of antibiotic resistance continues to increase
 Clostridioides difficile infections are a significant healthcare burden
 Shortage of novel antibiotics being developed and approved
 Complications/adverse reactions of antimicrobial therapy can be significant
 Requirement (survey element) by CMS and The Joint Commission effective January 1, 2017

Antimicrobial Use and Resistance:

 Each year in the U.S. at least 2.8 million people become infected with resistant bacteria and at
least 35,000 people die as a direct result of these infections

 At least 220,000 C. diff infections and 12,800 deaths which are directly related to antibiotic use and
resistance occurs each year in the U.S

 Recent literature found that approximately 75% to 80% of antibiotics prescribed inpatient for UTI
and CAP were inappropriate

 Antimicrobial resistance is more prevalent in healthcare-associated bacterial infections, compared
with those from community-acquired infections

 Patients with healthcare-associated infections caused by resistant strains are more likely than control
patients to have received prior antimicrobials

 Areas within hospitals that have the highest rates of antimicrobial resistance also have the highest
rate of antimicrobial use

 Increasing duration of patient exposure to antimicrobials increases the likelihood of colonization with
resistant organisms

Goals of Antimicrobial Stewardship:

 Optimize clinical outcomes
 Reduce morbidity/mortality
 Decrease length of stay
 Minimize unintended consequences/adverse drug reactions
 Mitigate toxicity
 Avoid the selection of pathogenic organisms
 Prevent emergence of resistance
 Reduce healthcare costs

Strategies of an Antimicrobial Stewardship Program:

 Staff education
 Prospective audit and feedback
 Guidelines and clinical pathways for common infections
 Streamlining or de-escalation of therapy based on culture results
 Dose optimization and pharmacokinetic monitoring
 Formulary restriction and preauthorization
 Reducing length of therapy to the shortest effective duration
 Parenteral to oral conversion
 Antibiogram development
 Incorporation of rapid diagnostics within the microbiology laboratory

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Current Actions at Jackson Hospital:

 Multidisciplinary Antimicrobial stewardship team
 ID physician consult service
 ID pharmacist and decentralized clinical pharmacy specialists
 Reporting antimicrobial use data to medical staff
 Education
 Order set development and review
 Medication use evaluations
 Annual Antibiogram
 Enhancing technologies within the microbiology laboratory
 Drug shortages with recommendations
 Pharmacokinetics dosing service
 Automatic renal and indication-based dosing program
 Automatic IV to Oral program

What can providers do to improve patient care and promote antimicrobial stewardship?

 Utilize facility order sets and antibiograms to guide empiric therapy
 Employ diagnostic strategies early to rule out infection or resistant organisms (e.g. procalcitonin,

MRSA nasal screen, appropriate cultures)
 Document recent antibiotic exposure
 Assess allergies (especially ẞ-lactam allergy)
 Review appropriateness of empiric antimicrobials after initial 48 hours of therapy
 De-escalate therapy based on culture results
 Include an indication and stop date when ordering antimicrobials
 IV to PO conversion
 Ensure correct duration of therapy for discharge antibiotics
 Use evidence based/guideline recommended treatments and duration of therapy
 Decrease C. diff risk factors (decrease use of antibiotics that increase risk such as clindamycin and

fluoroquinolones, decrease PPI use)

STRATEGIES TO PREVENT INFECTION

What can you do to protect your patients and yourself from healthcare associated infections?

 Hand washing is the single most important thing you can do to
prevent the transmission of organisms that cause infections.
Hands should always be washed before and after contact with each patient
using liquid soap and friction for at least 20 seconds before rinsing.
Hands should be washed before and after wearing gloves.

Waterless hand sanitizer can be very effective in situations where you
cannot readily access sinks for hand washing (except for C. difficile).
Always perform hand hygiene with soap & water after caring for a
patient with C. diff.

 Always follow Standard Precautions by using appropriate personal protective equipment (PPE)
to avoid skin and mucous membrane exposure when contact with blood or body fluid is anticipated.
Remember that all patients are potentially infectious. In addition to Standard precautions, use
transmission-based precautions when needed to protect against possible exposures. See chart
below.

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Condition or Disease Type of Isolation Precautions Minimum PPE
Required
(Examples) CONTACT:
MRSA, VRE, C. diff, ESBL, CRE, Designed to prevent transmission by Gloves and gown are required to
Rotavirus, RSV, Lice or Scabies, direct contact with patient or by be worn before entering the
Shingles (localized) and Draining contact with items in the patient’s patient’s room.
wounds environment.
Remove PPE and dispose before
exiting the patient’s room and
perform hand hygiene.

Flu, Meningitis, Mumps, R ubella, DROPLET: Mask and/or face attire if splatter to
Pertussis, Mycoplasma Pneumonia Designed to prevent transmission by face is likely to occur.
and Strep
air (large droplets) over short Gown, gloves, surgical mask
distances. and/or face attire is indicated prior
to entering the room. Remove
PPE before exiting room.

TB, Measles, Severe Acute Respiratory AIRBORNE: Gown, gloves, N-95 mask prior to
Syndrome (SARS), Chickenpox, Designed to prevent transmission by entering room. Ensure the mask
Shingles (disseminated), Smallpox, air (small particles) seals properly and covers the nose,
Hemorrhagic Fevers (Ebola, Lassa, mouth and chin.
Marburg).

Follow the “bundles.” These are sets of best practices which help to prevent Central line Associated
Bloodstream Infections (CLABSI), Catheter Associated Urinary Tract Infections (CAUTI), Ventilator
Associated Pneumonias (VAP) and Surgical Site Infections (SSI) when all elements are done.

1. Central Line Bundle
• Hand hygiene immediately before insertion
• Maximum barrier precautions on insertion
• Skin prep with Chlorhexidine (CHG)
• Optimal catheter site selection, with the subclavian vein as the preferred site for non-
tunneled catheters
• Daily review of line necessity, with prompt removal of unnecessary lines

2. Bladder Bundle
• Avoid unnecessary urinary catheters
• Insert catheters using aseptic technique
• Hand Hygiene before and after any catheter manipulation
• Secure catheter with a securement device
• Daily review for catheter necessity

3. Ventilator Bundle
• Elevation of the head of the bed to between 30 and 45 degrees.
• Daily “sedative interruption” and assessment of readiness to extubate
• Peptic ulcer disease prophylaxis
• Deep vein thrombosis prophylaxis

4. SSI Bundle
• Appropriate use of antibiotics
- Administer within 1 hour prior to incision
- D/C within 24 hours post op (48 hours for cardiac surgery)
• Appropriate hair removal using clippers, not razors
• Control OR traffic during surgery

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• Control blood glucose level during the post op period
• Colorectal surgery patients with immediate postoperative normothermia

 To identify MRSA colonization or infection early in the admission process, order MRSA surveillance
screens on patients in certain high-risk groups. These include patients who are:

 Admitted to JH intensive care unit (SICU, CCC or CVICU) as a new patient or transferred
from within JH

 Receiving pre-screening for CABG or open-heart surgery
 Receiving pre-screening for total joint surgery
 Admitted with draining wounds

 Remember to get your vaccinations: Flu and COVID-19! This is the
best way to reduce the chances of being infected with seasonal flu and
COVID-19. Jackson Hospital offers flu & COVID-19 vaccines free of charge
to staff and licensed independent practitioners. Please help us achieve our
annual flu vaccination goal of 90% and COVID-19 protection.

 A respiratory illness might be the flu or COVID-19 if the symptoms are fever, cough, sore
throat, runny or stuffy nose, body aches, headache, chills, and fatigue. Although symptoms are
similar, flu does not typically affect a person’s sense of smell or taste. Some people may have
vomiting and diarrhea. People may be infected with the flu or COVID-19 virus and have respiratory
symptoms without a fever.

 Because some of the symptoms of flu and COVID-19 are similar, it may be hard to tell the
difference between them based on symptoms alone, and testing may be needed to help confirm the
diagnosis.

 People with flu or COVID-19 can spread it to others up to about 6 feet away. B o t h viruses are
spread mainly by droplets made when people with cough, sneeze or talk. These droplets can land
in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. Less often,
a person may become infected by touching a surface or object that has the virus on it and then
touching their own mouth or nose.

 To avoid this, people should stay away from sick people and stay home if sick. It also is important
to wash hands often with soap and water for at least 20 seconds. If soap and water are not
available, use an alcohol-based hand rub.

GUIDE FOR INITIATING AND DISCONTINUING
ISOLATION ON PATIENTS

This document is not meant to be an all-inclusive listing of every situation that would require
transmission- based precautions but it is meant to provide simple guidance on some of the more common
organisms encountered in our facility. For a complete listing, see Infection Control Policy IC 400.6
“Transmission Based Isolation Precautions” with CDC’s Appendix A, “Type and Duration of Precautions for
Selected Infections and Conditions” and Infection Control policy IC 400.8 “Infection Control Precautions
for Syndromes”.

Microorganism When to Initiate Isolation Duration of Isolation Type of Precaution
• With positive test result Duration of illness Droplet
Adenovirus
(Pneumonia) • As a Precautionary- waiting on Entire hospital stay if Contact+ Enteric
C-diff testing results positive or re-admission
C-Difficile
• With positive testing result
• Re-admissions within last 6

months with history of C-Diff

Page 6 of 45

Microorganism When to Initiate Isolation Duration of Isolation Type of Precaution
Chicken Pox/ Airborne + Contact
Disseminated • As a Precautionary- waiting on Until lesions are dry and
Shingles (Varicella) testing results crusted Contact

CRE • With positive culture result Entire hospital stay Contact
(Carbapenem-Resistant
Enterobacteriaceae) • Re-admission with history of CRE

ESBL (Extended regardless of time frame
Spectrum Beta-
Lactamase) • With positive culture result Entire hospital stay
• Re-admission with history of

ESBL regardless of time frame

Seasonal Flu • As a precautionary- waiting on Duration of illness Droplet
(Influenza) testing results
Until 24 hours after Droplet
Haemophilus • With positive test result initiation of effective
Influenza (Meningitis & • therapy Contact
Pneumonia)
• With positive test result Contact

Lice • As a precautionary Until eradication Contact
• With a definitive diagnosis
Droplet
MDROs • With positive test result Entire hospital stay if
(Multi-Drug Resistant • Re-admissions with history positive or readmission Contact
Organisms) Droplet
MRSA • With positive culture result Entire hospital stay
(Methicillin-Resistant • With positive MRSA Nares Airborne
Staphylococcus Aureus) Until 24 hours after
Screening result initiation of effective Contact
Neisseria Meningitidis • Re-admissions within last 6 therapy
(Meningococcal) Entire hospital stay Airborne preferred. If
months with history of MRSA airborne isolation room is
Norovirus • As a Precautionary- waiting on unavailable, droplet
precautions with COVID-
testing results 19 required PPE
• With a positive test result Airborne only if aerosol
• With positive culture result generating procedures
are performed
RSV • With positive test result Entire Hospital Stay
(Respiratory Syncytial
Virus) in infants, young • As a Precautionary- waiting on Until Isolation is D/C’d by
children and testing results Infectious Disease or
immunocompromised Pulmonary
adults) • With a positive test result

TB (Tuberculosis)

VRE • With positive culture result Entire hospital stay
(Vancomycin Resistant • Re-admission with history of VRE
Enterococci) Until Isolation is D/C’d by
regardless of time frame Infectious Disease or
COVID-19 Pulmonary
• As a precautionary- waiting on
testing results

• With a positive test result

Page 7 of 45

Diarrhea Decision Tree: C-DIFF Screening Protocol

This document does not substitute for clinical assessment and judgment.

C. DI FFI CI LE ADULT TREATMENT ALGORITHM (FROM IDSA)

Consider empiric therapy for strong pre-test suspicion of CDI with Contact isolation
Reconsider/discontinue inciting antimicrobial agent(s) if clinically appropriate
Avoid anti-peristaltic agents (loperamide, diphenoxylate)

Non-severe Cases Initial Episode
(WBC ≤ 15,000 AND SCr < 1.5)
Vancomycin 125mg PO Q6H X 10 days
OR

Fidaxomicin 200mg PO Q12H x10 days (Restricted to ID and GI)

May use Metronidazole 500mg PO Q8H x10 days
if the above are unavailable

Severe Cases Vancomycin 125mg PO Q6H x10 days
(WBC ≥ 15,000 OR SCr > 1.5) OR

Fulminant Cases Fidaxomicin 200mg PO Q12H x10 days (Restricted to ID and GI)
(Hypotension or shock; ileus;
Vancomycin 500mg PO/NG Q6H
megacolon) PLUS

Duration may be extended to 14 days in Metronidazole 500mg IV Q8H
cases of delayed response to treatment. If ileus/megacolon:

consider giving Vancomycin 500mg/100mL NS Per Rectum Q6H
plus Metronidazole 500mg IV Q8H ± Vancomycin 500mg PO Q6H x10 days (ID,

Surgeon, GI consult recommended)

Recurrent Episodes

Metronidazole used for initial Vancomycin 125mg PO Q6H x10 days

1st Recurrence: Vanc standard regimen used for Vancomycin PO:
initial 125mg Q6H x10-14 days,
≥ 2nd Recurrence: then 125mg Q12H x7 days,
then 125mg Q24H x7 days,
C. diff Algorithm 2018 then 125mg Q48-72H x14-56 days

Vanc used for initial episode Fidaxomicin 200mg PO Q12H x10 days
(Restricted to ID and GI)
Vancomycin PO: 125mg Q6H x10-14
days, then 125mg Q12H x7 days,
then 125mg Q24H x7 days,then 125mg
Q48-72H x14-56 days

OR Fidaxomicin 200mg PO Q12H x10 days

OR Vancomycin 125mg PO Q6H x10 days, Restricted to ID and GI
then Rifaximin (restricted to GI & ID) 400mg
Consider after at least 2 recurrences (ID/GI
OR PO Q8H x20 days consult

OR Fecal microbiota transplantation
* available at JacksoPnag*e 8 of 45

Reference:
McDonald LC, Gerding D, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the
Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018:1-48.

PAIN MANAGEMENT ASSESSMENT & MANAGING PAIN

Pain assessment
A comprehensive pain assessment is conducted on admission and with each episode of newly reported
pain as appropriate for the patient’s condition and the scope of the care, treatment and services
provided. Pain will be reassessed following intervention and include at a minimum pain level and location
of pain.

Pain Scales
• mild pain (1-3): nagging, annoying, but doesn’t really interfere with activities of daily living
• moderate pain (4-7): Interferes significantly with daily living activities
• severe pain (8-10): disabling, unable to perform daily living activities

Please use the pain management order sets within the electronic medical record. Pain
management order sets should cover each range of pain as determined by the pain scale.

The prescriber responsible for the pain management plan it to be notified when:
1. Pain is inadequately controlled or inadequately relieved
2. Medication dosage seems inappropriate for patient’s condition
3. If patient is exhibiting signs and symptoms of over-sedation
4. If patient is exhibiting signs and symptoms of respiratory depression
5. When the location or nature of pain changes

Geriatric Patients
Assessment and treatment is complicated by the following:

• Under-reporting of symptoms
• Existence of multiple comorbidities that complicate the geriatric patient’s response to pain
• Alterations in pharmacokinetics and pharmacodynamics in geriatric patients that increase the risk of

adverse effects from pain medications
• Increased prevalence of cognitive impairment

In addition to using the specific term “pain” when interviewing older adults, the use of other descriptors
such as “discomfort”, “aching”, “soreness”, etc can improve pain assessment.

Patient Education
The Pain Management plan needs to be reviewed with the patient and/or family:

• Patient’s role as a member of the pain management team
• Pain medicine ordered
• Side effects/complications of pain medicine
• ALL pain management interventions
• PCA – Patient-Controlled analgesia, when appropriate

Requirements:
1. Initiate shared decision making conversations about:

• Risks and benefits of opioid therapy
• Proper use, storage and disposal of opioids
• Consider prescribing the rescue medication naloxone for all patients at risk for opioid-

induced respiratory depression (OIRD), if discharged on opioids.

2. If opioids are used to manage pain, the diagnosis for which opioids are used must appear on the
problem list.

9

3. Involve the patient in the pain management treatment process through the following:

• Develop realistic expectations and measurable goals that are understood by the patient
for the degree, duration, and reduction of pain (documentation required on the chart).

• Discuss the objectives used to evaluate treatment progress (i.e., relief of pain and
improved physician and psychosocial function)

4. Providing education on pain management, treatment option, and safe use of opioid and non-opioid
medications when prescribed.

Pain Management and Opioids – 2022

Opioids for Pain

Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for treatment of pain.
Clinicians should consider opioid therapy only if expected benefits for both pain and function are
anticipated to outweigh risks to outweigh risks to the patient. If opioids are used, they should be
combined with non-pharmacologic therapy as appropriate.

Before starting opioid therapy for management of pain, clinicians should establish and document
treatment goals with all patients, including realistic goals for pain and function, and should consider how
therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy
only if there is clinically meaningful improvement in pain and function that outweighs risks to patient
safety.

Before starting and opioid therapy, clinicians should discuss with patients known risks and realistic
benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

For the purpose of preventing controlled substance diversion, abuse, misuse, addiction and doctor-
shopping the use of Alabama’s Prescription Drug Monitoring Program (PDMP) is recommended:

• For controlled substance proscriptions totaling 30 MME (morphine milligram equivalents) or less
per day, physicians are expected to use the PDMP in a manner consistent with good clinical
practice.

• When prescribing a patient controlled substance of more than 30 MME per day, physicians shall
review that patient’s prescribing history through the PDMP at least (2) times per year, and each
physician is responsible for documenting the use of risk and abuse mitigation strategies in the
patient’s medical record.

• Physicians should query the PDMP to review to patient’s prescribing history every time a
prescription for more than 90 MME per day on the same day the prescription is written.

Referrals out to pain management

• Patients who have been on treatments for more than three (3) months should be considered for
a referral for the treatment of their pain.

• If a provider assesses the patient’s condition and identifies a risk for withdrawal, appropriate
medications should be prescribed to bridge the patient’s care until a Pain Management
appointment has been scheduled.

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Below is a list of treatment programs that treat opioid addiction and the program’s contact
information.

Opioid Treatment Program Directory

Program Name DBA Street City State Zip Phone
BHG Bessemer
TCC, LLC Treatment Center 4204 Edmonton Dr. Bessemer AL 35022 (205) 425-1200
Birmingham Metro
Metro Treatment of Alabama L.P. Treatment Center 151 Industrial Drive Birmingham AL 35211 (205) 941-1799
Tri County Treatment Center P.C. 5605 Clifford Circle Birmingham AL 35210 (205) 836-3345
Chilton County Clanton
Chilton County Treatment Center Treatment Center 2100 Holiday Inn Drive AL 35046 (205) 755-4300
BHG Cullman 1912 Commerce Ave. Cullman
TTC, LLC Treatment Center NW, P.O. Box 2085 AL 35056 (256) 739-5595
BHG Gadsden
Gadsden Treatment Center Treatment Center 1121 Gardner Street Gadsden AL 35901 (256) 549-0807
Opioid Treatment
Gulf Coast Treatment Center, Inc. Center 12271 Interchange Rd. Grand Bay AL 36541 (251) 865-0123
Marion County
Marion County Treatment Center Treatment Center 1879 Military Street Hamilton AL 35570 (205) 921-3799
Huntsville Metro Treatment Center South Huntsville AL 35805 (256) 881-1311
P.C. Walker Recovery 2227 Drake Ave., Suite Huntsville AL 35816 (256) 721-1940
Center 19 Jasper AL 35504 (205) 221-1799
Huntsville Recovery, Inc. 4040 Independence
Drive
Walker Recovery Center
Bradford Health Services - Madison 2195 North Airport Rd.
Medically Monitored Residential
Detoxification Adult NTP 600 Browns Ferry Road Madison AL 35758 (256) 461-7272
Mobile AL 36605 (251) 476-5733
Mobile Metro Treatment Center P.C. 1924 - C Dauphin Island
Parkway
AltaPointe Medication Assisted
Treatment Program 4211 Government Blvd. Mobile AL 36693 (251) 666-2569
Mobile AL 36609 (251) 341-9505
ECD Program, Inc. 808 Downtowner Loop
Metro Treatment Center of Alabama W.

Montgomery Metro 6001 East Shirley Lane Montgomery AL 36117 (334) 244-1618
Treatment Center

MedMark Treatment Centers of MedMark Treatment 9283 W. U.S. 84 Newton AL 36352 (334) 692-4455
Alabama, Inc. Centers Dothan
AL 36203 (256) 831-4601
MedMark Treatment Centers of MedMark Treatment 118 East Choccolocco Oxford AL 35007 (205) 216-0202
Alabama, Inc. Centers -- Oxford St. Saginaw- AL 35660 (256) 383-6646
Alabaster AL 35772 (256) 437-2728
Shelby County Treatment Center Shoals Treatment 750 Highway 31 South AL 35405 (205) 752-5857
(SCTC) Center 3430 North Jackson Sheffield
Northeast Alabama Hwy. AL 35180 (205) 244-2960
The Treatment Centers, Inc. Treatment Center Stevenson
Comprehensive Management BHG Tuscaloosa 196 County Road 85
Group, LLC Treatment Center
1001 Mimosa Park Road Tuscaloosa
TTC, L.L.C.
Bradford Health Services -Warrior 1189 Allbritton Road Warrior
Medically Monitored Residential
Detoxification Adult NTP

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RESTRAINT UTILIZATION

The restraint policy has been modified to ensure compliance with regulatory agencies. Two procedures
for restraint use have been identified: Non Violent Restraint and Violent/Self-Destructive (VSD) Restraint.

Non Violent Restraint: Is all other restraint other than Violent/Self-Destructive Restraint as defined
below.

Indications: Assessment of the patient for possible restraint application is made by a registered nurse or
physician to ensure that the patient meets one of the following criteria for non-violent restraint:

 It is necessary to use restraint in order to maintain or deliver treatment associated with a medical
condition that if left untreated would medically compromise the patient.

 The patient is unable to follow directions to avoid unintentionally harming himself or herself without
the use of restraint.

Physician Order: If the treating physician is not available, a registered nurse may initiate restraint by
entering an electronic order for “JH Initiation of Restraint Protocol” The treating physician must be
notified and a restraint order obtained immediately (as soon as clinically possible).

The treating physician must perform a face-to-face assessment of the patient within 24 hours of the
initiation of restraint, at which time the physician will either discontinue the restraint or enter an order
for the continuation of the restraint.

The treating physician must perform an in-person assessment of the restrained patient at least once
every calendar day, at which time the restraint shall either be re-ordered by entering an order for
restraints, or the restraint will be discontinued.

The physician’s order cannot be written as a PRN or “May Restrain” order. If restraints are
discontinued prior to the expiration of the original order, a new order must be obtained for reapplying
the restraints.

Violent/Self-Destructive (VSD) Restraint: Assessment of the patient for possible restraint
application is made by a registered nurse or physician to ensure that the patient meets the following
criteria for VSD Violent/Self-Destructive restraint use:

 The restriction of patient movement by restraint for the management of violent or self-destructive
behavior that jeopardizes the immediate physical safety of the patient, a staff member or others.

Initiation of restraint: A registered nurse may initiate restraint in advance of the physician’s order by
entering an electronic order for “JH Initiation of Restraint Protocol”

As soon as clinically possible after the initiation of the restraint protocol, the nurse will consult with the
physician about the patient’s physical and psychological status and obtain an order The initial and all
subsequent restraint orders will expire in:

 18 years or older……….. 4 Hours
 9-17 years…………………. 2 Hours
 Under 9 years……………. 1 Hour

Orders may be renewed according to the above time limits for a maximum of 24 consecutive hours.

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One hour face-to-face assessment for violent/self-destructive restraints: A physician/CRNP will
perform a face-to-face assessment of the patient’s physical and psychological status within 1 hour of
the initiation of restraint. If the restraint is discontinued before the face-to-face assessment is conducted,
the one-hour face-to-face evaluation is still required to be completed.

Ongoing face-to-face assessments: A physician/CRNP will perform the in-person evaluation as
described above every twenty-four hours. The evaluation includes the patient’s condition, situation,
response to restraint and need to continue the restraint.

CASE MANAGEMENT

Definition of Case Management
Case Management is a collaborative process of assessment, planning, facilitation, care coordination,
evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive
health needs through communication and available resources to promote patient safety, quality of care,
and cost effective outcomes. Case Management is a dynamic process that assesses, plans, implements,
coordinates, monitors, and evaluates to improve outcomes, experiences, and value (ACMA, 2021).

Philosophy of Case Management
The underlying premise of case management is based in the fact that when an individual reaches the
optimum level of wellness and functional capability, everyone benefits: the individuals being served, their
support systems, the health care delivery systems and the various reimbursement sources.

Case management serves as a means for achieving client wellness and autonomy through advocacy,
communication, education, identification of service resources and service facilitation. The case manager
helps identify appropriate providers and facilities throughout the continuum of services, while ensuring
that available resources are being used in a timely and cost-effective manner in order to obtain optimum
value for both the client and the reimbursement source. Case management services are best offered in a
climate that allows direct communication between the case manager, the client, and appropriate service
personnel, in order to optimize the outcome for all concerned.

Case Managers at Jackson provide discharge planning for our patients. The discharge planning process is
initiated following a Discharge Planning Assessment that occurs within 24 hours of admission. The
Discharge Planning Assessment focuses on the patient’s goals, preferences and needs to facilitate timely
discharge plan and transition of care to the next appropriate level of care. It identifies patients with
complex discharge planning needs arising from diagnosis, therapies, and psychosocial or other relevant
circumstances as well as the patients at risk for readmission. A complex case manager is assigned to
coordinate a care plan. The discharge planning process facilitates transfers to the appropriate level of
care facilities throughout the continuum of care. Documentation of all discharge planning is completed in
the Allscripts and placed in the medical record. Current accurate information regarding community
resources is maintained on the intranet. In addition, the Utilization Review Nurses perform (based on
Payor) a utilization review function at the time of admission and throughout the patient stay (so as to
determine the medical necessity of the admission and continued stay).

Case Managers screen patients at the time of admission, using JVION, to determine the patient’s risk for
readmission. Recommendations are identified and initiated so as to reduce the risk of readmission/return
visit to the Emergency Room.

The case managers attend weekly Length of Stay Meeting > 10 Days meetings. Case Managers identify
barriers to discharge and make appropriate referrals to post-acute facilities/ departments as needed.
Case Managers facilitate these post-acute referrals to home health, DME, outpatient infusion, home
infusion, acute rehabilitation, LTAC, and skilled nursing placement. Case management also provides
community resource information.

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In order to encourage the most efficient and appropriate use of available health resources and services,
Interdisciplinary (IDR) Rounds are conducted to identify in real time any barriers to discharge and
progression of care delays. The discharge plan is reviewed on an ongoing basis. If post-acute services
are required, Case Managers/ Social Workers will provide options for the patients from which to choose.

What is Utilization Management?
Utilization Management is the evaluation of the appropriateness, medical necessity, and efficiency of
health care services, procedures and facilities according to established criteria or guidelines and under
the provisions of an applicable health benefits plan. The Institute of Medicine defines utilization
management as a “set of techniques used by or on behalf of purchasers of health care benefits to
manage health care costs by influencing patient care decision making through a case by case assessment
of appropriateness of care prior to its provision.”

Standard utilization management services include prospective review, concurrent review, retrospective
review and pre-certification of hospital stays.

Utilization Management at Jackson Hospital
The objective of the Utilization Management Plan (UM Plan) is to maintain high-quality, medically
necessary and efficient treatment for all patients regardless of payment source, by ensuring that patients
receive the appropriate care at the appropriate time in the appropriate setting.

• Monitoring patient care and assuring our services meet approved criteria established by
evidenced based and or regulatory guidelines

• Assuring inpatient treatment is the appropriate level of care with the length of stay based on the
needs of the patient.

• Utilizing screening criteria approved by the Utilization Management Committee and the Medical
Executive Committee.

• Promote cost-efficient utilization of hospital resources and services in accordance with the
patient’s acute medical needs and preferences.

• Use objective data to assess physician practice trends and patterns regarding length of stay and
resource utilization for the purpose of improving quality of care and service delivery.

• Recommend and/or take corrective actions to improve resource utilization and the quality of care.
• Review appropriateness, medical necessity, and timeliness of support services provided by the

hospital or through referrals.

Essential requirements for the effective Utilization Management

• Delineates the responsibilities and authority of personnel for conducting internal utilization review
• Outlines processes to review medical necessity of admissions, extended stay, and

appropriateness of setting
• Outlines processes to review outlier cases based on extended length of stay and/or extraordinary

high costs
• Defines processes to review potential overutilization, underutilization, and inefficient use of

resources
• Defines processes for coverage determinations, denials, appeals and peer review within the

organization and;
• Identifies framework for reporting, corrective action, and documentation requirements for the

utilization management process.

Utilization Review and Peer Process

• Monitors to ensure only medically necessary care is provided

• Notifies hospital administration, the practitioner or practitioners responsible for the care of the
patient and the patient, in writing of the determination that an inpatient admission or continued
stay in the hospital is not medically necessary.

• Conducts special interdisciplinary studies or arranges peer review cases referred to the PA.

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• Reviews all continued stay and cost outlier cases within specified timeframes.
• Tracks, trends and analyzes outlier cases to identify patterns of performance improvement.

Results are included on respective physician scorecards.
• Reviews professional services to determine medical necessity and to promote the most efficient

use of healthcare services
• Documents the outcome of cases reviewed for medical necessity, including approvals, denials

and reasons, and actions taken to resolve identified problems. The UR Nurses may request the
provider to participate in P2Ps (Peer to Peer Reviews).

CLINICAL DOCUMENTATION IMPROVEMENT AND QUERIES

Successful documentation improvement (CDI)
programs facilitate the accurate representation of a
patient’s clinical status that translates into coded data
and quality reporting, physician report cards,
reimbursement and public health data.

GOALS OF THE DOCUMENTATION IMPROVEMENT PROGRAM

Some of the goals of are:

• Accurate, timely, concise physician documentation
• Clarification of ambiguous, conflicting or confusing documentation
• Provide an accurate reflection of the severity of illness (SOI), risk of mortality (ROM), and

Hierarchical Condition Categories (HCC)
• Providing supportive documentation for medical necessity of the appropriate level of care (e.g.,

observation or inpatient) and specific treatments
• Improved coding and billing accuracy due to the improved quality of documentation

Please consider the following components for a complete diagnosis:

1. Present on Admission (POA): If you suspect a diagnosis on the day of admission, please
document it or include in differential diagnoses. If a condition was not mentioned on day 1, you
can clarify present on admission (POA) status later as well.

2. SPECIFICITY: If it can be described with more accuracy or its location pinpointed, please do so.
3. ETIOLOGY: If you suspect the underlying cause, please document them as possible/probable

etiologies. Possible/probable diagnoses are appropriate in the discharge summary.
4. ACUITY LEVEL: If it can be described as acute, chronic, or acute on chronic, please do so.
5. Discharge Summary: Discharge summary should include every diagnoses relevant to the in-

patient stay, including improved and resolved conditions.

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HOW CAN YOU HELP IMPROVE DOCUMENTATION ON A DAILY BASIS?

• Provide the reason for admission, including possible or suspected diagnosis, at point of care, and
carry themthrough tothe discharge. Authenticate, date,and time all medical record entries.

• Dictate H&P’s w ithin 24 hours of each patient’s admission. Document accurate, complete, and
timely progress notes, orders, and consultations daily or as needed.

• Respond to the queries as soon as possible and document your response in the progress
notes, discharge summary, consultation, H&P, etc. of the medical record. Sign, date, and time the
queries as they are a part of the medical record. If you do not understand a query, please page
the Clinical Documentation Improvement staff. Extensions will be on the queries or contact the Lead
CDI at 6807.

• Dictate discharge summ ary and complete the medical record as soon as possible after
discharge but no later than 7 days of the discharge date.

When reporting Present on Admission (POA) information to CMS we have only a few options:

Y = YES: present at the time of inpatient admission;
N = NO: not present at the time of inpatient admission;
W = CLINICALLY UNDETERMINED: provider is unable to clinically determine whether condition was
present on admission or not (If chosen, this answ er defaults to “Yes, P OA”)

How Documentation affects you:
 Assist with clinical performance improvement (RVU’s) The better the documentation= the better
the RVU
 Measure the quality, safety, severity of illness, and efficacy of care
 Manage care and disease processes
 Track public health and risks
 Provide data to consumers regarding costs, quality, and treatment option outcomes
 Design payment systems and process claims for reimbursement, including pay-for-performance
measures
 Perform research, epidemiological studies, and clinical trials
 Serve as “clinical” data set for some personal health records
 Design healthcare delivery systems and monitor resource utilization
 Identify fraudulent practices
 Set health policy

What’s Your Diagnosis?
 Criteria we MUST follow in order to accurately code a diagnosis/procedure
 Developed to standardize reported inpatient data elements
 PRINCIPLE DX- the Chief Diagnosis after Study Determined to be the MAIN REASON for the
admission. Determining the ACCURATE PDX is VITAL:
 The PDX Establishes your DRG-
 Determines if the Admission and ALL services provided MEET MEDICAL Necessity
 Is the Basis of Cohort selection for MANY Quality Measures
 Secondary DX: Additional Conditions that affect patient care in terms of requiring: Clinical
evaluation, therapeutic treatment, diagnostic procedures, extended length of stay in the hospital,
increased nursing care and or monitoring and the expenditure of all other hospital resources.

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When Do We Query?
 Conflicting information
 Ambiguous information
 Incomplete information
 Clinically relevant information not addressed
 Significant reportable condition or procedure
 Lack of clarity for present on admission indicator assignment
 Treatment provided without a clear diagnosis listed
 Dropped documentation – was it ruled out? Resolved?

Not Specific Specific, Able to Code
Arrhythmia Persistent atrial fibrillation, atrial flutter, ventricular fibrillation/flutter, ventricular
tachycardia, complete heart block
AMS, confusion “Metabolic encephalopathy d/t UTI”; “toxic encephalopathy d/t meds, drugs, etc.”
Abnormal Labs Acidosis; alkalosis; hypo/hyper-natremia, hypomagnesemia
Arrest “Cardiac/cardio-pulmonary arrest due to AMI/ventricular fibrillation”
CHF, HF, ↓EF, systolic/ Specify HF as acute and/or chronic AND systolic or diastolic: “Acute diastolic CHF”;
diastolic dysfunction treated and now compensated”; “chronic HFpEF”. Note: rEF, pEF are acceptable terms.

Cardiomyopathy Cardiomyopathy (dilated, hypertrophic [obstructive vs. non obstructive], restrictive)
↑ Creatinine Acute kidney injury, acute renal failure (increase of Cr by 0.3 or 1.5 x baseline); ATN;
CKD 3 (GFR 30-59), CKD 4 (GFR 15-29), ESRD; “acute kidney injury, POA: Cr improved
COPD from 1.5 to 1.1 w/ IVF, continue monitoring”; “AKI on CKD 3”.
Type 2 MI “Acute exacerbation of COPD”; “compensated COPD”
Demand ischemia Type 2 MI results from demand ischemia or oxygen supply-demand imbalance,
unrelated to acute coronary thrombosis or plaque rupture.
Diagnosis of type 2 MI requires troponin elevation and one of the following:
- Symptoms of acute MI or ischemia
- New ischemic EKG, pathological Q waves
- Imaging evidence of new loss of viable myocardium or regional wall motion
abnormality
Treatment of type 2 MI does not include antithrombotic therapy or urgent coronary
angiography. Instead, focus is on managing the underlying cause(s) of supply-demand
mismatch. Should be documented as a secondary diagnosis, e.g. “type 2 MI d/t
anemia”

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Not Specific Specific, Able to Code
Fever, ↑ WBC, bacteremia
“Sepsis d/t C. diff enterocolitis”; severe sepsis w AKI/coagulopathy/DIC/acidosis; septic
Hypertension shock; SIRS non-infectious; if BC is positive, link the organism with sepsis: “sepsis due
Hypotension, shock to E. coli”, document if present on admission;

Imaging results Hypertensive crisis; hypertensive emergency. Malignant/accelerated HTN not codeable
Specify shock: “cardiogenic shock”, “distributive shock”, “multifactorial shock: septic
LOC, unresponsive and hypovolemic”; hypotension (in absence of shock)

Document clinically significant findings such as pleural effusion, atelectasis,
pneumothorax, pulmonary edema (acute/chronic), ileus

Coma, comatose; TBI with LOC in hours <1 hr, >1 hr, >24 hrs;

Malnutrition, Request Nutrition Consult; cosign RD’s assessment, if agree; copy the Dx into PN and
↑BMI, ↓BMI DS, specify: moderate, severe malnutrition. Document: obesity; overweight; cachexia
Pulmonary edema Specify if non-cardiogenic and if acute or chronic: “non-cardiogenic acute pulmonary
edema due to ESRD and fluid overload”
Pulmonary embolism
Specify type (eg, saddle, septic), acute/chronic, document if acute cor pulmonale

Pneumonia, HCAP, coverage “Aspiration pneumonia/pneumonitis”, “suspect gram negative pneumonia”; link PNA
for gram-neg, CXR infiltrates, with culture results: “Pneumonia d/t Klebsiella”; “Pneumonia d/t Staph. Aureus”;
“Treating gram negative pneumonia”. Avoid term s: “covering for” “concern for”
cough

Respiratory distress, >4L O2 Acute respiratory failure with hypoxia/hypercapnea; respiratory acidosis/alkalosis;

NC, FIO2 40%, BiPAP, “intubated for respiratory failure (or for airway protection only)”; “chronic respiratory
failure on home O2”. Note: postsurgical O2 support for up to 48 may not be respiratory
intubated, home oxygen

failure, but it may be standard post-surgical treatment.

Other severity drivers DOE (dyspnea on exertion), hypothermia, oliguria (in absence of AKI)

Principal Diagnosis Pulmonary hypertension (secondary/primary); atrial flutter/fibrillation, sick sinus

Alternatives syndrome; supraventricular tachycardia (SVT); ventricular tachycardia (V-Tach, VT

Storm); ventricular flutter/fibrillation; hypertensive HF. Consistently document above

diagnoses and their treatment, as they may be good alternatives for principal Dx.

Rule of thumb: Problem-focused charting is preferred: “Diagnosis XYZ, as substantiated by signs and symptoms of ABC,
will monitor and/or treat by DEF, will delay discharge until improved”. Diagnoses frequently challenged by payers
include: cerebral edema, encephalopathy, ATN, AKI, sepsis, severe malnutrition, respiratory failure, ileus

Questions/Comments: Contact CDI Director, Zviad Ksovreli at 334-293-6807

EMTALA REQUIREMENTS FOR PHYSICIANS

Jackson Hospital is a participating hospital of Medicare and offers emergency services;
therefore Jackson Hospital is required to comply with the Emergency Medical
Treatment and Active Labor Act (EMTALA). EMTALA is designed to ensure
public access to emergency services regardless of financial status, diagnosis,
race, national origin, or handicap. The provisions of EMTALA apply to all
individuals, not just Medicare beneficiaries, who attempt to gain access
to Jackson Hospital for emergency care.

EMTALA requires Jackson Hospital to provide a medical screening
examination (MSE) to any individual who comes to the emergency
department requesting emergency care and (ii) prohibits hospitals with
emergency departments from refusing to examine or treat individuals
with an emergency medical condition (EMC), including active labor.

Jackson Hospital is then required to provide stabilizing treatment for patients with EMCs. If the hospital is
unable to stabilize a patient within its capability or if the patient makes a request, an appropriate transfer
may be implemented.

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Here are some general reminders to guide you in compliance with EMTALA:

 If an outlying ED needs to transfer a patient to our facility to receive treatment not available at
the transferring hospital (but available here), we are obligated to accept this transfer. There are
case-by-case exceptions to this rule (lack of specialist available, diversion status etc.) but
acceptance of the transfer is generally required.

 As the on-call specialist, when contacted by the ED physician to come in and treat a patient, you
must present in a timely manner. Medical Staff Bylaws give a 30-minute response time.
Requesting tests or studies results prior to coming in is not acceptable but rather a delay in
patient care under the EMTALA law.

 When the on call specialist is requested to come to the ED to see a patient, EMTALA requires an
in person, bedside visit. Attempting to treat over the phone is in violation of EMTALA.

 Transferring a patient to another facility for the convenience of the physician is in violation of
EMTALA. If a medical necessity exists for a transfer or if the patient requests the transfer then
this is acceptable. Appropriate documentation is needed to show compliance with EMTALA.

These are just some general points to remember to help keep you compliant with EMTALA.

USE OF INTERPRETATIVE SERVICES

Jackson Hospital is providing language interpreter service through Stratus Video. As per Joint
Commission regulations, language interpreting services may not be provided by friends or family.

Because of this, the hospital contracts with Stratus Video Interpreting for language
interpretation. Stratus provides standalone video remote interpretation (VRI)
services. This system will allow your patient to see and hear a qualified medical
interpreter in their language. Patients will also be able to have sign language
interpretation using the VRI system. VRI is instant, mobile and available around
the clock.

Should you need to access this system for your patient(s), a video translation service is available on
designated workstations on wheels or via an iPad for our patients. The iPads are stored in the House
Supervisor’s office, the Emergency Department, and Women’s Services. Look for the Stratus Icon to identify
the workstations which have the Stratus app.

PHYSICIAN HCAHPS

Aim for “Always”

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a survey
sent to patients who have been provided inpatient care at a Hospital as required by
Medicare. The intent is to measure the patient experience with regards to particular
aspects of hospital care. The MD Domain is the part where patients are specifically
asked about care provided by the physician. The following questions are asked to
determine their experience:

 During your Hospital stay, how often did doctors treat you with courtesy and respect?
 During your Hospital stay, how often did doctors listen carefully to you?
 During your Hospital stay, how often did doctors explain things in a way you could understand?

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In order for physicians and the hospital to do well, here are some simple suggestions for improving the
patients’ perception of physician courtesy, listening and explanation:

 Be aware of facial expression, body language and other nonverbal language
 Knock on the door before entering
 Introduce yourself and make eye contact with the patient and visitors
 Make a social comment or ask a non-medical question to put the patient at ease
 Sit down if possible when speaking with the patient
 Offer a physical gesture such as a handshake, touch on the shoulder or pat on the knee
 Minimize interruptions from cell phone calls and texts
 Ask patients if they have any questions or need further explanation of treatment or diagnosis
 Close the visit in a positive way such “It was nice seeing you.”

HANDOFF COMMUNICATION

One aspect of physician documentation that The Joint Commission looks at is handoff communication. A
good practice, and one that protects you from liability, is to document when your care of a patient has
ended. Whether as a consulting physician and your services are complete or if you are simply handing
over care to another physician, this should be documented. Having a clear and distinct line documented
where your care ends and another physicians begins can protect you and your practice from unnecessary
litigation.

SURGICAL CONSENT

Written, signed consent shall be obtained prior to an operative procedure according to hospital policy
except in those situations wherein the patient's life or limb is in jeopardy and suitable signatures cannot
be obtained due to the condition of the patient. Discussion with the patient of the risk, benefits,
alternative treatments and what will happen if no treatment should be documented in preop physician
notes. In emergencies involving a minor or unconscious patient in which consent for operation cannot
be immediately obtained from parents, guardians or next of kin, these circumstances should be fully
explained in the patient's medical record and the hospital form for emergency treatment of a minor or
adult shall be signed by two medical staff members.

INPATIENT WOUND CARE

The inpatient wound care nurses at Jackson Hospital are available to consult for wound care
recommendations for patients during the course of their hospital stay. They will write orders for wound
care under the consulting physician which the staff nurse will carry out.

For surgical wounds, they will defer to the surgeon's orders unless the surgeon request the inpatient
wound care nurses to follow the patient. If you would like the wound care nurse to make
recommendations on a surgical wound, please collaborate with the surgeon prior to consulting wound
care.

If you are writing wound care orders, please know that the staff nurses should initiate these and it is not
advised to write for the wound care nurse to initiate, as doing so could result in a delay in treatment.

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ABUSE & NEGLECT

If a physician or other healthcare practitioner has reasonable cause to believe that a condition typifying
suspected physical, sexual, emotional abuse, neglect, or exploitation is present, a report must be filed
with the appropriate authorities.

Acts 1965, No. 725; Acts 1975, No. 1124 (Child Abuse Reporting
Act):
This act provides for the establishment of protective services for the
child and reporting of any abuse of and/or children in need of
protective services.
The Adult Protective Services Act of 1976, Amended 1989 and 1994,
Code of Alabama 1975, Section 38-9-1 through 38-9-11. This act
provides for the establishment of protective services for the adult
and the reporting of any abuse, neglect, and/or exploitation of
adults in need of protective services.

CORPORATE COMPLIANCE

Jackson Hospital & Clinic, Inc. is committed to maintaining an environment that promotes integrity and
trust in order that our management, employees, medical and clinical staffs, and other personnel may

fulfill their duties and responsibilities in accordance with all applicable laws and regulations, and all
applicable rules and standards of ethical and professional conduct. To that end, Jackson has developed
and implemented a Corporate Compliance Program.
The central objective of the Corporate Compliance Program is to develop a culture that values and
emphasizes compliance. If you or a colleague have any concerns of potential violations of fraud and abuse
laws, EMTALA or any fraudulent billing practices (to just name a few) please contact the Corporate
Compliance Officer, Ben Wells, at 293-8819. You can also make an anonymous report by going
to the Pinestreet.com intranet webpage and accessing the online reporting system there. Or, you can call
855- 645-1382 and leave a recorded message.

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CENTERS OF EXCELLENCE

Jackson Hospital is a center of excellence through certification that requires compliance
with national standards, use of evidence-based clinical guidelines, and
meeting/maintaining top performance measure scores. Jackson Hospital goes
through a rigorous on-site review every two years for each program. The Centers
of Excellence at Jackson Hospital include AMI, AAA, Bariatric, Spine and Stroke.

Requirements
 Each Center of Excellence requires annual education specific to the disease type. This is to ensure up to

date caregiver knowledge and skills required for the care of patients in this population.
 Disease-specific departmental competencies
 Coordinators are here to assist. Please don’t hesitate to contact them!
Coordinators
 Erica Sears (Stroke) [email protected] ext. 4065
 Kaitlin Johnson (AMI and AAA) [email protected] ext. 8061
 Brittany Morgan (Spine and Bariatric) [email protected] ext. 8878

HIGH RELIABILITY ORGANIZATION

What is a High Reliability Organization (HRO)?
HRO describes an organizational culture that strives to achieve error-free performance and safety in every
procedure, every time all while operating in complex environments.
High Reliability University Skills
 Skills used to foster better communication that furthers respect among colleagues.
 It also means adopting practices to cross-check work, validate and verify processes, and identify

potential red flags.
 These skills are called ‘universal skills’ because they can be used universally, meaning they can be

practiced and applied by anyone in any role across the organization.

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CULTURAL DIVERSITY

What is Cultural Diversity?
Cultural Diversity is the existence of a variety of cultural groups within a society.
Cultural groups can share many different characteristics. Including:
 Religion, ethnicity, language, nationality, sexual orientation, class, gender, age,

disability, health differences, geographic location and lots of other things.
Cultural Competence: Providing Culturally Sensitive Care
 Engaging in effective communication with the patient provides insight into the patient’s cultural

perspective and understanding of his/her disease.
 Care must be provided in a way that considers each patient’s values, beliefs, and practices. This

promotes health and healing.
 If there is a language barrier, remember to use an interpreter.

 A video translation service is available on designated workstations on wheels or via an iPad for our
patients. The iPads are stored in the House Supervisor’s office, the Emergency Department, and
Women’s Services.

 Look for the Stratus Icon to identify the workstations which have the Stratus app.
Steps to Develop Cultural Competency
 Practice openness by demonstrating acceptance of difference.
 Be flexible by demonstrating acceptance of ambiguity.
 Demonstrate humility through suspension of judgment and the ability to learn.
 Be sensitive to others by appreciating cultural differences.
 Show a spirit of adventure by showing curiosity and seeing opportunities in different situations.
 Use a sense of humor through the ability to laugh at ourselves.
 Practice positive change or action by demonstrating a successful interaction with the identified culture.

Have questions on how to meet cultural needs?
The Joint Commission has a resource that can be downloaded to your mobile
device: Cultural and Religious Sensitivity A Pocket Guide for Health Care
Professionals.
Available through iTunes or Google Play Apps.

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IMPLICIT BIAS

What is “Implicit Bias”?
We have a bias when, rather than being neutral, we prefer (or have an aversion to) a person or group of
people; thus, we use the term “implicit bias” to describe when we have attitudes towards people or
associate stereotypes with them without our conscious knowledge.

Types of Bias
 Race & Ethnicity: Occurs when people assume certain characteristics about someone based on their

race or ethnicity.
 Age Bias: Occurs when people make assumptions about others based on their age.
 Gender Bias: Occurs when people assume one gender is better suited for a particular job.
 LGBTQ Community: Heterosexual physicians, nurses, and other health care providers implicitly favored

heterosexual people over gay and lesbian people. Even people who identify as a sexual minority can
internalize bias against their own group.
 Ability Bias: Assumption that able‐bodied people are the norm in society, and that people who have
disabilities must either strive to become that norm or should keep their distance from abled people.
 Affinity Bias: The tendency for individuals to gravitate toward people similar to themselves
 Beauty Bias: The tendency for individuals to treat attractive people more favorably
 Name Bias: The tendency for individuals to judge someone based on their name
 Weight Bias: The tendency for individuals to judge someone negatively, or assume negative things
about them, if they’re overweight or underweight

Why It Matters?
Scientists have found that most of our actions occur without our conscious thoughts, allowing us to function
in our extraordinarily complex world. This means, however, that our implicit biases often predict how we’ll
behave more accurately than our conscious values.

What can be done about it?
Individuals can identify risk areas where our implicit biases may affect our behaviors and judgments.
Instituting specific procedures of decision making and encouraging people to be mindful of the risks of
implicit bias can help us avoid acting according to biases that are contrary to our conscious values.

Overcoming Implicit Bias
I Introspection: Set aside time to understand your biases by taking a personal inventory of them.
This can be done by taking tests to identify the biases you may have
M Mindfulness: Once you understand the biases you hold, be mindful that you’re more likely to give
in to them when you’re under pressure or need to make quick decisions. If you’re feeling stressed,
pause for a minute, collect yourself, and take a few deep breaths
P Perspective-Taking: If you think you may be stereotyping people or groups, imagine what it
would feel like for others to stereotype you
L Learn to Slow Down: Before jumping to conclusions about others, remind yourself of positive
examples of people from their age group, class, ethnicity, or sexual orientation. This can include
friends; colleagues; or public figures, such as athletes, members of the clergy, or local leaders.
I Individualization: Remind yourself that all people have individual characteristics that are separate
from others within their group. Focus on the things you have in common.
C Check Your Messaging: Instead of telling yourself that you don’t see people based on their color,
class, or sexual orientation, learn to use statements that embrace inclusivity
I Institutionalize Fairness: In the workplace, learn to embrace and support diversity. Individuals
can use the Equity and Empowerment Lens, which is designed to help organizations improve
planning and resource allocation to foster more equitable policies.
T Take Two:
Overcoming unconscious biases takes time. Understand that this is a lifelong process and that
deprogramming your biases requires constant mindfulness and work.

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WORKPLACE VIOLENCE

What is Workplace Violence?
Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including
commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.

Types of Workplace Violence

 Criminal Intent: The perpetrator has no legitimate relationship to the business or
employees and is usually committing a crime in conjunction with the violence
(robbery, shoplifting, trespassing).

 Customer/Client: Customer/client violence is the most common in healthcare
settings. Research shows that this type of violence occurs most frequently in
emergency and psychiatric treatment settings, waiting rooms, and geriatric
settings, but is by no means limited to these.

 Worker-on-Worker: Violence between coworkers is commonly referred to as lateral
or horizontal violence. It includes bullying and frequently manifests as verbal and
emotional abuse that is unfair, offensive, vindictive, and/or humiliating though it
can range all the way to homicide.

 Personal Relationship: The perpetrator has a relationship to the employee outside
of work that spills over to the work environment. For example, the husband of a
nurse follows her to work, orders her home and threatens her, with implications
for not only this nurse but also for her coworkers and patients.

Reporting an Event
In the event of a known, identified, or suspected act of violence, physicians should notify the security
department or hospital administration of any observed suspicious workplace activity situations or any
potentially problematic incidents. This includes threats or acts of violence, aggressive behavior, offensive
acts, threatening or offensive comments or remarks.

DE-ESCALATION IN HEALTHCARE

The problem of violence toward healthcare workers, and facilities in general, has heightened in recent years
with an increased incidence of active shooters in hospitals and gang violence. The Joint Commission says
de-escalation techniques can include communication, self-regulation, assessment, and safety maintenance
to lower the chance of harm to patients, caregivers, and healthcare staff.

The following provides a list of non-physical de-escalation techniques
recommended by the Crisis Prevention Institute:

1. Be Empathic and Nonjudgmental
Do not judge or be dismissive of the feelings of the person in

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distress. Remember that the person’s feelings are real; whether or not you think those feelings are
justified. Respect those feelings, keeping in mind that whatever the person is going through could
be the most important event in their life at the moment.

2. Respect Personal Space
Be aware of your position, posture, and proximity when interacting with a person in distress.
Allowing personal space shows respect, keeps you safer, and tends to decrease a person’s anxiety.
If you must enter someone’s personal space to provide care, explain what you’re doing so the
person feels less confused and frightened.

3. Use Nonthreatening Nonverbals
The more a person is in distress, the less they hear your words—and the more they react to your
nonverbal communication. Be mindful of your gestures, facial expressions, movements, and tone of
voice. Keeping your tone and body language neutral will go a long way toward defusing a situation.

4. Keep Your Emotional Brain in Check
Remain calm, rational, and professional. While you can’t control the person’s behavior, how you
respond to their behavior will have a direct effect on whether the situation escalates or defuses.
Positive thoughts like “I can handle this” and “I know what to do” will help you maintain your own
rationality and calm the person down.

5. Focus on Feelings
Facts are important, but how a person feels is the heart of the matter. Yet some people have
trouble identifying how they feel about what’s happening to them. Watch and listen carefully for the
person’s real message. Try saying something like “That must be scary.” Supportive words like these
will let the person know that you understand what’s happening—and you may get a positive
response.

6. Ignore Challenging Questions
Engaging with people who ask challenging questions is rarely productive. When a person challenges
your authority, redirect their attention to the issue at hand. Ignore the challenge, but not the
person. Bring their focus back to how you can work together to solve the problem.

7. Set Limits
As a person progresses through a crisis, give them respectful, simple, and reasonable limits. Offer
concise and respectful choices and consequences. A person who’s upset may not be able to focus
on everything you say. Be clear, speak simply, and offer the positive choice first.

8. Choose Wisely What You Insist Upon
It’s important to be thoughtful in deciding which rules are negotiable and which are not. For
example, if a person doesn’t want to shower in the morning, can you allow them to choose the time
of day that feels best for them? If you can offer a person options and flexibility, you may be able to
avoid unnecessary altercations.

9. Allow Silence for Reflection
We’ve all experienced awkward silences. While it may seem counterintuitive to let moments of
silence occur, sometimes it’s the best choice. It can give a person a chance to reflect on what’s
happening, and how they need to proceed. Silence can be a powerful communication tool.

10. Allow Time for Decisions
When a person is upset, they may not be able to think clearly. Give them a few moments to think
through what you’ve said. A person’s stress rises when they feel rushed. Allowing time brings calm.

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DISRUPTIVE BEHAVIOR

The Medical Staff Rules and Regulations define a process for managing issues related to disruptive
behavior. Disruptive conduct by a member of the medical staff is behavior which adversely impacts on the
quality of patient care and includes verbal or physical abuse, sexual harassment and/or threatening or
intimidating behavior toward colleagues, team members or patients/visitors. Any Medical/AHP staff
member, team member, or agent of the hospital, volunteer, patient/visitor may file a complaint about a
practitioner for disruptive behavior. No retaliation will be taken for reporting a concern in good faith. Any
practitioner who observes such behavior by another practitioner shall notify any member of the Medical
Executive Committee or CEO directly. Reports from employees, patients, patient’s families or visitors
should be reported to the nursing supervisor. Complaints should be in writing and will be retained
permanently in the practitioner’s quality peer review file.

PHYSICIAN IMPAIRMENT REPORTING

The Medical Staff Rules and Regulations define a process for managing issues related to
physician health. Part of that process may include working with the Alabama
Professionals Health Program (APHP). The APHP mission is to protect the health, safety
and welfare of the public, while also supporting the health and integrity of Alabama’s
physicians, physician assistants, residents and students.

SYMPTOMS OF IMPAIRMENT IN THE MEDICAL PROFESSION

H OS P I TA L FAMILY

- Making rounds late, or inappropriate, abnormal - Withdrawal from family activities
behavior during rounds - Children neglected, abused or in trouble
- Decreasing quality of performance - Mood swings, arguments or violent outbursts
- Inappropriate orders - Sexual problems; impotence, extramarital affairs
- Medicinal use of alcohol or drugs
- Reports of behavioral changes - Family isolation
- Involvement in malpractice suits - Financial problems
- Unavailability or inappropriate responses to - Spouse in therapy or taking psychoactive
telephone calls medication
- Heavy drinking at staff functions - Geographical separation or divorce by spouse
- Often late, absent or ill
PHYSICAL
- Alcohol on the breath when on duty
- Intoxicated when on call, even at home - Deterioration in personal hygiene
- Deterioration in clothing and dressing habits
OFFICE - Inappropriate dress
- Numerous prescriptions and OTC drug use
- Disruption in appointment schedule - Frequent ER visits or hospitalizations
- Frequent visits to physicians
- Hostile or unreasonable behavior to staff or - Accidents
patients - Multiple somatic complaints
- Withdrawn, “locked door syndrome” - Excessive tiredness or insomnia
- Excessive ordering of drug supplies - Memory problems, difficulty concentrating
- Excessive drug use, prescription - Emotional crises
- Complaints from patients and staff
- Unexplained absences form the office
- Spasmodic work pace, or decreasing work load
and tolerance
- Taking sexual advantage of patients or co-
workers

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EM P LOYM EN T COM M UN I TY

- Frequent job changes or relocations - Neglected social commitments

- Unusual medical history - Embarrassing behavior at social functions
- Arrests for driving while intoxicated or legal
- Indefinite, vague or inappropriate references problems
- Working in positions inappropriate for - Unreliability or unpredictability in community
qualifications activities
- Resistance to pre-employment physical or - Public intoxication or impairment
family interview

Any possible impairment concerns should be reported immediately to Medical Staff Leadership, the
Department Chair, Medical Staff Services or Administration.

Physicians concerned about their personal health and well-being or that of a colleague, friend or family

member, may contact the APHP program for a free and confidential consultation. Additionally, any hospital,

hospital committee, partner group, practice manager, or others who may have oversight responsibilities

for physicians is encouraged to contact the APHP to arrange an initial screening. The APHP accepts
referrals from any source. (Sources of referral are strictly confidential and protected by law.) You can
contact the APHP by calling their confidential, toll-free number at 334-954-2596. Or email at
[email protected].

HIPAA COMPLIANCE FOR PHYSICIANS

Protected Health Information or PHI is information protected under HIPAA.
• PHI is individually identifiable health information held or transmitted by hospitals and physicians’
offices.
• PHI can be paper, spoken word, or in electronic format.
• PHI includes any information that can be linked to a specific
patient, even indirectly.
• PHI includes a patient’s demographic information, financial, and physical and mental health
information if it can be linked to a specific patient.
• PHI includes billing/payment information; insurance eligibility or coverage, the reason a person is
sick in the hospital, clinic, or for an office visit; the patient’s treatments, test results, allergies, and
medications; observations about the patient’s condition; information about past health conditions
and treatments; and discharge planning information.

PHI is considered identifiable if it contains any one of 18 specific identifiers of individuals and
their family members, employers, or household members. The Department of Health and
Human Services (HHS) lists the 18 identifiers as follows:

18 PHI IDENTIFIERS PROTECTED UNDER HIPAA
1. Names

2. All geographic subdivisions smaller than a state including address, city, county, precinct, ZIP
code, and their equivalent geocodes

3. All elements of dates (except year) for dates directly related to an individual, including birth
date, admission date, discharge date, death date, all ages over 89 and all elements of dates
(including year), indicative of the age

4. Telephone numbers

5. Fax numbers

6. Email addresses

7. Social security numbers
8. Medical record numbers

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9. Health plan beneficiary numbers
10. Account numbers

11. Certificate/license numbers

12. Vehicle identifiers and serial numbers, including license plate numbers

13. Implanted Device identifiers and serial numbers
14. Web Universal Resource Locators (URLs)
15. Internet Protocol (IP) addresses

16. Biometric identifiers, including fingerprints and voice prints

17. Full-face photographs or any comparable images
18. Any other unique identifying number, characteristic, or code

PHI—Other examples include: a patient’s diagnoses & procedures, progress or clinic notes;
laboratory & x-ray findings; admission & discharge dates; implanted device identifiers and serial
numbers; patient information on labels on patients’ wrist bands, IV bags, and pill bottles (Discard in
locked shred bins.)

PHI examples also include: conversations about patients’ health care and treatment between
doctors, nurses, clinical staff, and others; and the doctor’s recorded voice used to dictate the patient’s
visit.

UNDER HIPAA, DO PHYSICIANS HAVE A RIGHT TO ACCESS EVERYTHING? ALL PHI? NO! NO! NO!
Working as a physician in the healthcare organization does not authorize you
to access, use, or disclose any and all patients’ records/PHI.
HIPAA’S MINIMUM NECESSARY RULE (Need to Know)

Physicians,
Please be mindful that PHI is confidential and protected under federal and state
regulations. As a physician, you have access to many patients’ paper and electronic
records, but under HIPAA you can only access the records of patients you are treating
or consulting. Your authorized “NEED TO KNOW” only permits you to access the
information that you need to perform your role as the primary or consulting physician.
If you are treating or consulting, it needs to be documented in the patient’s medical
record.
o However, HIPAA does not require practitioners to meet the minimum necessary
standard for treatment purposes. It permits you to exchange all necessary
information to appropriately treat patients without the concern of providing too
much information. You must use your professional judgment to decide which
information can be shared.

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You are not permitted to review or access the medical record or PHI of a former patient,
family member, friend, spouse, employee, colleague, etc., unless you are currently
treating the individual and performing your duties as his/her physician.
SNOOPING is not permitted. It is when a physician or other workforce member
accesses the medical records/PHI of a patient (or former patient) for a reason that is
not job-related, beyond the scope of your job, and without authorization (whether
paper or electronic records).
You are not permitted to access and view or print your own medical record or PHI. If
you would like to request or review a copy of your record, contact the Health
Information Management Department (HIM)/Release of Information Section in person
or by telephone at 334-293-8306 or contact the HIM Director/HIPAA Privacy at 334-
293-8907.
HIPAA allows covered entities (including physicians and hospitals) to use, share, or disclose PHI, without
proper authorization or the patient’s permission, to perform their job for the following reasons: T-P-O
Treatment--to provide treatment for a patient

Payment--to obtain payment—with billers and coders

Healthcare Operations--to perform operations such as quality audits, Joint Commission surveys

Curiosity is not a legitimate reason to access and view patients’ PHI or medical records!

RESP ECT & P R OTECT OUR P ATIENTS’ P RIVACY !!
Violating HIPAA’s Rules may result in civil or criminal penalties. They are enforced by the
Department of Justice. Under HIPAA, employees, physicians, supervisors, directors, and can
be criminally liable and may be subject to civil and criminal penalties (monetary fines and jail
time) if PHI is wrongfully or inappropriately accessed, viewed, and disclosed.

HIPAA Civil Monetary Penalties

Criteria for Determining Penalty for Minimum Penalty Maximum Penalty

HIPAA Violation (per violation/cap) (per violation/cap)

Individual did not know that he/she $100 per violation with $50,000 per violation, with an
violated HIPAA and could not have an annual of $25,000 annual maximum of $1,500,000
been expected to know. for multiple violations
HIPAA violation was due to a $1,000 per violation, $50,000 per violation, with an
“reasonable cause” and not due to with a maximum of annual maximum of $1,500,000
“willful neglect”. $100,000

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HIPAA violation was due to willful $10,000 per violation, $50,000 per violation with an
neglect but the violation was with a maximum of annual maximum of $1,500,000
corrected. $250,000

HIPAA violation was due to willful $50,000 per violation, No specific maximum
neglect and the violation was not with a maximum of
corrected. $1,500,000

There are three (3) separate levels of criminal prosecution for HIPAA violations.

1. If you knowingly obtain or disclose PHI – you may face a $50,000 fine AND

imprisonment up to one (1) year.

2. If you knowingly obtain or disclose PHI under false pretenses –you may face a $100,000

fine AND imprisonment up to five (5) years.

3. If you obtain or disclose PHI with the intent to sell, transfer, or use the information for

commercial advantage, personal gain, or malicious harm-- you may face a maximum

fine of $250,000 AND up to ten (10) years imprisonment.

PROTECT & SAFEGUARD PHI!

1. Avoid discussions about and with patients, family members, healthcare providers, and
others in public places where others can hear, such as hallways, elevators, waiting
rooms, nurses’ stations, and cafeteria. (Lower your voice in public areas or move to a
private area.)

2. Close the door or curtains to a patient’s room or treatment area when discussing
diagnoses, treatments, and administering procedures.

3. Discard patient notes, medication labels, and other information with PHI in a locked
shred bin for destruction—not in a trash can.

4. Do not leave cha rts or ot her PHI (copies of progress notes, operative reports, and
patients’ schedules) on counter tops at the nurse’s station or in areas that are unattended
and not secure. This includes physicians’ lounges, open areas, unlocked offices, or other
areas in the hospital. Whenever possible, lock copies of PHI in file cabinets or drawers
and/or store in a locked office.

5. Do not share your password(s) or leave it where others can read or use it.

6. Do not leave PHI unattended on computer screens. log off your computer or “lock” it
before you leave your workstation or the area to prevent others from using your password

to access. To lock the computer, press L and the windows sign at the same time.

7. Do not send or save PHI on portable/mobile devices, cell phones, etc. unless
protected by a password and encryption. Do not use cell phones or other mobile devices
to share or text patient names or any PHI to physicians and others, unless encrypted.

8. Maintain physical control of your mobile devices and lap top computers by using
encryption, passwords, installing firewall, and by deleting PHI before discarding a device.

9. Contact the Information Technology (IT) Department if you have concerns about email
encryption; security of the electronic health record; and the loss, theft or discarding of
your mobile devices, or computers.

10. Contact the HIPAA Privacy Officer at 334-293-8907 to report a suspected HIPAA violation.

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PHYSICIANS’ MEDICAL RECORD DOCUMENTATION GUIDELINES

HISTORY & PHYSICAL (H&P)-An H&P must be performed and documented no more than 30
days before or 24 hours after a patient’s admission.

 The H&P must be documented in the medical record prior to any operative or other invasive
procedures requiring anesthesia or moderate sedation, except in emergencies. In emergency
situations, when the H&P is dictated, but not in the patient’s record, the practitioner must write
a statement to that effect in the record and an admission note.

 When a practitioner uses an H&P performed and documented (no more than 30 days) prior
to admission, he/she must document an update at the time of admission. The update must be
attached to the H&P (by writing the update directly on the previous H&P, attaching the update
to it, or by using an approved H&P update stamp).

 An H&P must be performed by a member of the medical staff, a certified physician’s assistant,
a certified nurse practitioner, or a resident and filed in the patient’s record within 24
hours of admission. The responsible physician must authenticate the H&P when it is
performed and documented by non-physicians or residents.

OPERATIVE REPORT— Operative reports or notes should be written and/or dictated
immediately after an operative or other high-risk procedure and it must be immediately
available in the patient’s record.

 A full operative report must be completed (written or dictated) and available in the medical record
within 72 hours of surgery, but when a full complete operative/procedure report cannot be entered
immediately into the record, a procedure note must be handwritten or generated electronically.

 Immediately means it is available in the record before the patient is transferred to the next level of
care (i.e. before a patient is transferred out of PACU or the recovery room to the unit or before
he/she is discharged home).

PHYSICIANS’ ORDERS, VERBAL ORDERS/ PHONE ORDERS

 All verbal orders must be authenticated within 14 days from the dictation of the order.
 All orders for patient treatment should be written clearly, legibly, and completely in the medical

record. All orders, including verbal orders, should be dated, timed, and authenticated by the
ordering practitioner or another practitioner who is responsible for the patient’s care.

DAILY PROGRESS NOTES

 Progress notes should be written legibly, authenticated, dated, and timed daily by the attending
physician or his designee at the time of patient observation to document the progression of a
patient’s clinical course. Each of the patient’s clinical problems should be clearly identified in the
progress notes and correlated with specific orders, tests, and treatments.

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CONSULTATION REPORTS
 A consultation report should be written or dictated within 48 hours of the consult. A satisfactory

consultation includes examination of the patient and the medical record. When operative procedures
are involved, the consultation note, except in emergency, should be recorded prior to the operation.
ALL CLINICAL DOCUMENTATION
 All entries in the medical record must be legible, complete, accurate, dated, timed, and authenticated
by the ordering physician.

DISCHARGE SUMMARY/DEATH SUMMARY
A discharge summary must be dictated on all patients within 7 days of a patient’s discharge. A death
summary must be dictated on all death cases within 7 days of the patient’s death. The exceptions for full
dictated summaries are short stays and same day surgeries, and when a patient arrives DOA (dead on
arrival) to the Emergency Department.
 The discharge summary should be a concise and accurate account of a patient’s illness, response to

the treatment, and condition at discharge.
 The discharge summary should address the entire episode of care, from the date of admission to

discharge. If a physician dictates a discharge summary prior to a patient’s discharge, and the patient
remains in the hospital (for any reason), the physician should dictate or write an update or
“addendum” to the summary if the patient stays until the next day or for 24 hours or more,
whichever is shorter.
 Document and “carry over” all diagnoses to the discharge summary, death, and short stay
summaries. Indicate if the diagnosis was present at the time of admission.

FINAL/DISCHARGE PROGRESS NOTE
A final progress note may be substituted for the discharge summary in the case of physicians with minor
problems or interventions who require less a 48-hour period of hospitalization.
 Cases with minor problems or interventions are defined as cases without complicating factors and

that do not require explanation of complicating factors. These are cases such as: a short admission
to evaluate a patient admitted for chest pain or in the case of normal newborn infants and
uncomplicated obstetrical deliveries. (If other significant problems are identified and/or treated
during the hospitalization, a full discharge summary is needed rather than a discharge note.)

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PHYSICIAN’S DOCUMENTATION GUIDE OP NOTE MUST BE DICTATED AND IN
H&P MUST BE PERFORMED & DOCUMENTED NO MORE THAN 30 THE RECORD IMMEDIATELY AFTER
DAYS BEFORE OR WITHIN 24 HOURS AFTER ADMISSION. H&P MUST SURGERY & A FULL OP REPORT MUST
BE DOCUMENTED BEFORE AN OPERATIVE/ INVASIVE PROCEDURE. BE COMPLETED WITHIN 72 HOURS

HISTORY & PHYSICAL IMMEDIATE POST-OP NOTE &
OPERATIVE/PROCEDURE REPORT
H&P must include: H&P Updates must include/ indicate:
Post-Op Note & Full Operative Report

1) Chief Complaint 1) Previous H&P was reviewed 1) Postoperative Diagnosis
2) Details of Present Illness 2) Patient was examined 2) Procedure(s) Performed
3) Past Medical History 3) If there are no changes in the 3) Primary Surgeon(s) & Assistant(s)
4) Specimen(s) Removed
(include current medications) patient or H&P, the update should
state the physician agrees with the (Do not leave blank; Write “None” if applicable.)
4) Allergies findings of the previous H&P and no 5) Estimated Blood Loss (EBL)
5) Inventory or Review of changes.
4) If there are changes, the update (Do not leave blank, or draw a line, or write
Body Systems should also state the physician minimum; EBL must be documented as a
6) Physical Examination agrees with the previous H&P and measurable amount or write “None”.)
document any additional changes or 6) Description of Procedure
(include heart & lungs) exceptions (required only for full op report)
5) Signature, Date, & Time
7) Impression 7) Description of Findings for each
8) Plan Do not write “no ∆” or “no changes” Procedure
9) Signature, Date, & Time without the required elements listed
above. Use the approved H&P update 8) Signature, Date, & Time
Do not “predate” an H&P before stamp.
the date of admission or Optional: Preoperative Diagnosis, Anesthesia,
surgery. Drains, & Complications

Do Not write “ditto marks”, “same”, “see
intraoperative record”, “see dictation”, “see
anesthesia record”, or “see op note” as a
substitute for the required elements.

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TELEPHONE ORDERS DISCHARGE NOTE DISCHARGE SUMMARY
Sign, date, and time within 14 Complete within 7 days of discharge Complete within 7 days of discharge
days from the date it was given.
0. Final Diagnosis & any secondary 1. Principal Diagnosis (without
SIGN, DATE, & TIME diagnoses
SIGN, DATE, & TIME ALL abbreviations & symbols)
ENTRIES IN THE MEDICAL 1. Summary & outcome of hospital 2. Principal Procedure
RECORD WHEN YOU SEE THE treatment 3. Other Procedures Performed
PATIENTS 4. Secondary Diagnoses
2. Procedures Performed 5. Reason for Admission, physical
WRITE LEGIBLY 3. Disposition of Case
4. Provisions for follow-up care findings, x-rays, lab
5. Discharge instructions to the 6. Hospital Course (include care, treatment, &

patient and/or family services)
6. Signature, Date, & Time 7. Condition of Patient & Disposition at

**Only substitute a note for a discharge
summary for patients with minor 8. Instructions to Patient at discharge
problems or interventions who require
less than 48 hours of hospitalization. (include information provided to patient & family)
9. Diet, Limitation of physical activity,

medications, & follow-up care (include post
hospital appointments, plans for post hospital care)
10.Signature, Date, & Time

 ABBREVIATIONS, ACRONYMS, AND SYMBOLS can be just as confusing as sign language
if you do not know what they mean.

 When in doubt, please SPELL IT OUT!
 We are required to use standardized terminology, definitions, abbreviations, symbols,

and dose designations so if you use an abbreviation, you can access the standardized
list by visiting Jackson Hospital’s intranet.
 Also, do not use the Joint Commission prohibited abbreviations on the “Do Not Use”
List.

STANDARDIZED MEDICAL RECORD ABBREVIATIONS

The use of abbreviations in the medical record should be kept to a minimum and must be consistent with
standardized medical abbreviations. To access standardized abbreviations, use the following steps.
1. Go to “Pinestreet.com” and select “Reference Library”.
2. Select “Web Links”.
3. Select “Abbreviation Listing Website”.
4. Click on the www.medabbrev.com link to access the website. To access the website, the

USERNAME/PASSWORD is not required.
5. Select the search type-- “Abbreviation or “Word”.
6. Type in the appropriate information in the box, such as CHF, and click “Search”.

7. Close the internet window when you have completed your search. (There is a license for
only three (3) concurrent users. Leaving the internet window open will limit access for
other users.)

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“DO NOT USE” ABBREVIATIONS LIST

YOU CANNOT USE THE ABBREVIATIONS LISTED BELOW, IN ANY FORM,
IN YOUR CLINICAL DOCUMENTATION--Upper or lower case; with or without periods.

(This prohibited list applies to all orders, preprinted forms, and medication-related
documentation.)

Do Not Use Potential Problem May Use Instead
U, u Write “Unit”
Mistaken for “0” (zero),the number “4”
(four) or “cc”

IU Mistaken for IV (intravenous) or the Write “International Unit”
number “10” (ten)
QD, Q.D., qd, q.d. Write “daily”
Mistaken for each other Write “every other day”
QOD,Q.O.D., q.o.d.,qod
Period after the “Q” mistaken for “I” and Write “Morphine Sulfate”
MS the “O” mistaken for “I” Write “Magnesium Sulfate”

MSO4 and MgSO4 Can mean Morphine Sulfate or (same as above)
Trailing zero Magnesium Sulfate Write “X” mg

(Incorrect = X.0 mg) Confused for one another Write “0.X” mg
Lack of leading zero or Decimal point is missed

Leading Decimal Decimal point is missed
(Incorrect = .Xmg)

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EMERGENCY MANAGEMENT AND SAFETY

Emergency Preparedness Coordinator: A l l i s o n M a l l o r y , Ext: 8761
(Cell 334-233-2652)

Safety Officer: Jeff Lindsey, Ext: 8867 (Cell 334-391-4642)

JACKSON HOSPITAL CODES

CALL EXTENSION 8222 TO REPORT A CODE

Code Silver: Suspect with a gun/knife threatening staff

Code STEMI: Patient having an acute heart attack

Code 1: Bomb threat

Code 3: Unmanageable Person

Code Pink: Infant or child abduction

Mr. Red: Fire/Fire Alarm

Code 33: Tornado Warning

Code 44: Code Rupture-Aortic Aneurysm Rupture

Code 66: Disaster

Code 77: Patient Elopement

Code 88: Stroke/Brain Attack

Code 99: Impending or actual cardiac and/or respiratory arrest

Code 99-P: Impending or actual cardiac and/or respiratory arrest involving a pediatric patient

FIRE PREVENTION

“MR RED”

Fire in Your Area:

R - Rescue: Rescue personnel in danger that are in the immediate area
A - Alarm: Pull the fire alarm
C - Contain: Close patient room doors and fire doors
E - Extinguish: Use an appropriate fire extinguisher & evacuate if needed.

Fire in another area

 Monitor the activity of nursing staff and ask for instructions as needed.

P.A.S.S.
• P-pull the pin in

the handle
trigger.
• A-aim at the
base of thefire.
• S-squeeze the handle
• S-sweep from side to side

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EVACUATION
IF YOUR AREA HAS TO BE EVACUATED DUE TO A FIRE, ASSIST

NURSING WITH YOUR PATIENT. YOU WILL BE INSTRUCTED
TO USE THE STAIRS DURING AN ACTUAL FIRE.

Evacuation instructions are posted near
stairwells

DO NOT USE THE ELEVATORS
HAZARDOUS MATERIALS
SPILL ACTIONS

 Notify EVS Staff immediately so that the spill can be contained.
 Read label on container for caution/warning and product name/information
 If a Safety Data Sheet (SDS) is needed, all Jackson Hospital staff has access to the SDS on

the Jackson Hospital Intranet. Ask for assistance from staff if needed.

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SAFETY MANAGEMENT

 Maintain a safe physical environment by carefully watching your environment. Report any safety
issues to the Department Director or Safety Officer.

 Back Injury prevention: OSHA (Occupational Safety and Health Administration) recommends
these preventative measures:
1. Think before you lift.
2. Reduce the size or weight of the object.
3. Avoid lifting below the knee or above the shoulder or on the side of your body.
4. Bring the load as close as possible before you lift.
5. Separate your feet. Put one slightly in front of the other.

6. Keep your back upright, bend your knees and lift with your legs.
7. Lift load straight up slowly and smoothly.
8. Avoid fast, jerky movements. Don’t twist your body while carrying a heavy load.
9. Setting the load down is as important as picking it up. Comfortably lower load by

bending your knees.
10. Use mechanical aids whenever possible, i.e. hand trucks.
11. Get help when necessary and don’t strain.
 Maintain free and clear egress paths.
 Know the location of fire extinguishers and pull stations in your area.
 Avoid blocking fire extinguishers, pull stations, med gas panels and electrical panels.
 Report any safety issues, such as trip hazards, spills, non-functioning equipment to the
Unit Director or Safety Officer immediately.

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Paragon Clinician Hub (PCH)

PCH is a Web-based information presentation and workflow management solution. The tool allows
providers to view patient information, document care, place orders, launch the medical record, and is the
hub to all clinical activity. Clinicians can securely access the system from anywhere and there is also a
mobile application available. Below is a description of the key features provided through PCH.
Getting Started

• Once logged into PCH, the Census tab will display a list of your patients.

• To retrieve your rounding report, click on the "Select An Action" dropdown to the right of the

census screen and select "Rounding Report".

Once in the Patient’s Chart

• The “Time Interval" may be altered in the overview tab in the upper right-hand corner, to

reflect different time frames.

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• Use the ordering tab to monitor Order Queue, search and enter CPOE orders and manage Favorite

Orders. Admission and Discharge Medication Reconciliation is also performed under this tab.

• Use the RxWriter tab to electronically submit prescriptions. If your prescription is unable to submit

electronically, it will be printed and must be signed. All new providers will be enrolled to ePrescribe
medications. For Controlled substances, additional setup will be required with Ashley Myers, Wayne
Domingus, or Meredith Hartin. A VIP Access token is necessary to complete the submission of
control substances. As of January 1, 2020, some pharmacies will no longer accept written controlled
substance prescriptions.

• Imaging, Results, Vitals, etc. may be accessed from the Flowsheets tab. You can also choose favorite

flowsheets: from the FLOWSHEETS tab by clicking "More Flowsheets ..." then "Manage Favorites" to
choose from the list of available flowsheets to add to your personal display. Drag and drop from the
left column to the right and order. You can also combine results from previous visits. While in the
flowsheet you would like to view, navigate to the top left of the flowsheet to the SELECT VISIT drop-
down. From there, you can choose the visits to compare with current results. Then click SELECT
VISIT to go back to your flowsheets.

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• The Profile tab allows access to the Allergies, Family History, etc.

• Documentation may be completed and viewed by clicking the Documentation tab, once in PCH.

Also, templates may be searched, and favorite templates managed after opening the
documentation tab
. The provider will add note and will then be able to view template options. The provider has
the option to pin five favorite templates to the top of the list. To add a note for charting,
drag and drop to or double click.

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• To access the Medical Record (One Content) select the MORE tab drop-down in the top middle

of the screen, then Medical Record from the list.

• Links

• Common links such as Up to Date and PDMP are available directly from this sections

Key Features

• From the census screen you can freely search through all patients by typing into the top

right search box. You can search by last name, MRN, or Visit ID. If you are looking for a
discharged patient, you must uncheck the "Include Active Only" box by hovering over
Options. You can also select “Show Advanced Search” to narrow the search by adding other
search options such as DOB.

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• To add/remove yourself or other physician as consulting click the census tab. Find the patient

you would like to add a consult and click "Assignments …" in blue on the left of the patient
window. If you are in the patient’s chart, click the "Assignments ..." in the blue on the left
panel under patient demographics select "ASSIGN ME" to assign yourself. If you need to add
another physician select "ASSIGN OTHER". Find the physician’s name in the
search then click "SAVE" in the lower right corner.

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