Medical Director, Medical Staff Leadership and Physician Services
Sets out how the Agency designates its medical director (who is also the leader of the medical staff under Michigan rules) and the physician designee, what they are responsible for, the Michigan requirement that a physician review each patient's medical history and initial assessment no more than 15 days before or 2 days after admission and validate the terminal prognosis, how a physician is designated for each patient, how physician services are available 24 hours a day, and how hospice physicians work with attending physicians.
About this policy
- Policy number
- MI-HSP-MD-01
- Version
- 1.0
- Main rule
- Mich. Admin. Code R 325.45351
- Library
- Michigan hospice · 59 policies
- Category
- Governance
- Sections
- 20
In short
- Dr. Morgan Sample is the medical director. When unavailable, Dr. Riley Sample takes over.
- A physician must review each new patient's history and first assessment no more than 15 days before or 2 days after admission. Admitting nurses check this is recorded.
- Every patient has a named physician responsible for medical care. Write the name in the record at admission.
- If the attending physician cannot be reached, call the on-call hospice physician. A physician is available 24 hours a day.
What's inside
20 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (Mich. Admin. Code R 325.45351; 42 CFR §418.102)
- 5. Qualifications and Verification
- 6. Responsibilities of the Medical Director
- 7. Physician Review Within the Admission Window
- 8. Validating the Terminal Prognosis
- 9. A Physician Responsible for Each Patient
- 10. Availability Around the Clock
- 11. Working With Attending Physicians
- 12. Reporting Disciplinary Action
- 13. Responsibilities
- 14. Records and Compliance Monitoring
- 15. Staff Training
- 16. References
- 17. Related Policies and Forms
- 18. Approval
- 19. Revision History
An inspector may ask
- Show me the written designation of your medical director and of the physician who acts when the medical director is unavailable.
- Show me, for this patient, when a physician reviewed the medical history and initial assessment. Was it within 15 days before or 2 days after admission?
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