Rules and Regulations of the Medical Staff - February 24 2022 (2)
4.2
Every member of the Medical Staff shall be actively interested in securing legal permission for autopsies. Particular attention shall be directed to obtaining permission when the cause of death is unclear or the course of the disease was unusual, unanticipated or unexplained. No autopsy shall be performed without proper legal consent. All autopsies shall be performed by a member of the Department of Pathology or a physician delegated by the Chairperson of the Department of Pathology to perform that duty. Autopsies in progress shall be announced as Pathology Conferences via hospital-wide page.
MEDICAL RECORDS
The Medical Record is the responsibility of the attending physician, oral and maxillofacial surgeon or podiatrist, who shall prepare it to be a timely, accurate, legible and complete record of the patient's hospitalization.
5.1
The Medical Record shall include: identification data, reason for admission, history of present illness, review of systems, past history, personal-social history, family history, special reports when available, physical examination, laboratory and radiologic data, pathologic findings, blood components, progress notes, case summary, final diagnosis, condition on discharge and follow up treatment plans, medications, diet and activity directions or limitations, and a notation as to the existence of an Advance Directive Document, its inclusion in the chart, and the designation of a healthcare representative, if any.
