CLINTON HOSPITAL AUTHORITY
Clinton Regional Hospital
WEDNESDAY FRIDAY, JANUARY 24, 2024, 12:00 P.M. WEICHEL CONFERENCE CENTER, CLINTON REGIONAL
HOSPITAL
AMENDED AGENDA
If there is any potentially known conflict of interest relevant to a matter requiring action by the Board, the trustee(s) shall call it to the attention of the Board at this time and said trustee(s) shall not vote on the matter.
All items listed under the Consent Agenda Items are deemed to be non-controversial and routine in nature by the Board of Trustees. The following items will not be discussed but will be approved by one motion of the Board of Trustees unless any Board member desires to discuss an item, at which time it will then be removed and thus placed as a Regular Agenda Item for consideration and approval on this Agenda. The Consent Agenda Items consists of the following items:
A. Approval of Minutes January 5, 2024, Special Meeting
III. BUSINESS ITEMS (Discussion, Consideration, and Possible Action Regarding):
A. Administrative reports
1. Hospital Report - Update
A. Financial Statement
A. Medical Executive Committee Minutes 1/22/2024
B. Medical Staff Committee Reports-Discussion and Action
C. Credentialling Privileges –
1. Daniel Harris PA -Emergency Room
2. Dwayne Schmidt MD-Cardiology
3. Dave' Mayank MD -Cardio-Pulmonary Director
4. Bart Rowlett MD- Supervisor of Radiology Services
5. Laura Miller APRN-Hospitalist
B. Medical Staff Policy (state policy name)-Discussion and Action
A. Quality Assurance/Performance Program Meeting Minutes 1/22/2024
B. Life Safety Meeting Minutes
C. Policy and Procedures Approval
1. Blood Utilization & Emergency Release Policy
2. Tissue Specimens
3. Required Tissue Examination
4. Blood and Blood Product Lookback and Recall Notification
5. Support for Caregivers
6. Pain Management
7. Adverse Event Investigation and Reporting Scope of Activities
8. Quality Assurance Quality Improvement Plan
9. Employee Health Program
10. Systems Risk Assessment Tool
11. Acceptable Abbreviations
12. Acceptable Abbreviations List
13. Incomplete Medical Records
14. Filing of Incomplete Medical Records
15. Chart Analysis
16. Medical Record Content
17. Medical Record Guidelines for Physicians
18. Entries in the Medical Record
19. Delinquent Medical Records
20. Release of Medical Information
21. Request for Information Release Form
22. Correspondence Procedures
23. Release of Information when Consent is Not Required
24. Patient Access to Medical Records
25. Certificate of No Record
26. Certificate of No Records Form
27. Declaration of Custodian for Medical Records Form
28. Chart Request
29. Medical Record Request Form
30. Incomplete Chart Removal
31. No Information Blocking
32. Incomplete Record Filing
33. Filing System
34. Medical Record Retention
35. Medical Records Security During Evacuation Procedures
36. Discharge Procedures
37. Initial or Computer Key Identification
38. Physician Stamp
39. Removal of Records
40. Medical Records Review Function
41. Printing Patient Chart
42. Scanning, Storage, Accessibility and Security
43. Medical Records Check List
44. Medical Records Check List for Outpatient Surgery
45. Location of Medical Records Form
46. Patient Orders
47. Data Protection and Confidentiality Guidelines for Departments
48. Confidentiality of Patient Information
49. Health Date Integrity
50. Healthcare Confidentiality Principles
51. HIV Antibody Test Results
52. Release of HIV Antibody Test
53. Authorization for Disclosure of the Results of the HIV Test Form
54. Guidelines for Isolation Precautions
55. Quick Reference List of Disease Requiring isolation Precautions.
56. Standard Precaution
57. Antibiotic Stewardship Leader Appointment/Authority Statement
58. Antibiotic Stewardship Program
59. Infection Control Nurse Job Description
60. Cardio-Pulmonary Director appointment /Authority Statement and Job Duties
61. Outpatient Scheduling
62. Process for Rep0roting Reportable Disease to the State of Oklahoma
63. Admission Steps To Do
64. Red Flag
65. Obtaining And Verifying Physician Orders
66. Authorization to Use and Disclose Protected Health Information
67. Outpatient Registration
68. Miscellaneous Physicians
69. Medicare Outpatient Observation Notice
70. Form Instructions for the Important Message from Medicare
71. Inpatient Admissions Policy
72. Registration
73. Discharge Planning
74. Discharge Follow-Up
75. Assessing the Discharge Planning Process
76. 72 -Hour Discharge Follow Up Phone Call Form
77. Discharge Follow Up Survey Phone Call Form
78. Code Black
79. Utilization Review Plan
80. Visitation Policy
81. Patient Rights
82. Scope of Pharmacy Services
83. CRH Formulary Action Request
84. Access to Copies of Your Medical Record Form
85. Denial Letter For Direct Access to Medical Record
86. Telephone Request of Patient Medical Information
87. Response to a Subpoena for Medical Records
88. Response to a Subpoena Duces Tecum Form
89. Human Resource Discipline and Termination of Employment
90. Admission Interview Form
91. Cardio-Pulmonary Scope of Services
Any matter not known about, and which could not have been reasonably foreseen prior to the posting of this agenda. (If any, as authorized pursuant to Section 311.9 of the Oklahoma Open Meeting Act.)
IX. ADJOURN
FILED THIS 22ND DAY OF JANUARY 2024 AND POSTED ON THE BULLETIN BOARD IN THE LOBBY OF THE CLINTON CITY HALL AND THE FRONT DOOR AT THE CLINTON REGIONAL HOSPITAL ON JANUARY 22, 2024 AT 11:55 A.M.
AMENDED AGENDA FILED ON THIS 22ND DAY OF JANUARY 2024 AND POSTED ON THE BULLETIN BOARD IN THE LOBBY OF THE CLINTON CITY HALL AND THE FRONT DOOR AT THE CLINTON REGIONAL HOSPTIAL ON JANUARY 22, 2024, AT 2:15 P.M.