reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 9 - Medical Staff › Section 310:667-9-7 - Other staff

Current through Vol. 41, No. 20, July 1, 2024
(a) In larger
				hospitals, and in some smaller hospitals, the medical staff may include one (1)
				or more of the categories in addition to the active staff. This in no way
				modifies the duties and responsibilities of the active staff.
(b) The categories of staff other than active
				may include the following:
(1)
Honorary
				staff.
The honorary staff shall be composed of former active staff,
				retired or emeritus, and other physicians and practitioners of reputation whom
				the hospital desires to honor.
(2)
Consulting staff.
The consulting staff shall be composed of
				recognized specialists willing to serve in such capacity. A member of the
				consulting staff may become a member of the active staff, but only if another
				appointment is made.
(3)
Associate staff.
The associate staff shall be composed of those
				members who use the hospital infrequently or those less-experienced members
				undergoing a period of probation before being considered for appointment to the
				active staff.
(4)
Courtesy
				staff.
The courtesy staff shall be composed of those who desire to
				attend patients in the hospital but who, for some reason not disqualifying, are
				ineligible for appointment in another category of the staff.
(5)
Non-physician practitioners.
The medical staff may designate a category of staff membership for
				non-physician practitioners who are approved to provide services in an allied
				health profession. The roles of those persons approved by the medical staff for
				this category of membership shall be clearly defined in accordance with OAC
				310:667-5-2.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 9 - Medical Staff › Section 310:667-9-8 - Medical staff officers

Current through Vol. 41, No. 20, July 1, 2024
(a)
				There shall be such officers as may be necessary for the governance of the
				staff. These officers shall be members of the active staff and shall be elected
				by the active staff, unless this is precluded by medical staff
				policy.
(b) The officers shall be
				elected from and by the active staff or appointed in accordance with medical
				staff policy on the basis of ability and willingness to assume responsibility
				and devote time to the office.
(c)
				Where officers are elected, the process for election shall be delineated in the
				bylaws.
(d) The chief of staff
				shall:
(1) Have direct responsibility for the
				organization and administration of the medical staff, in accordance with the
				terms of the medical staff constitution, bylaws, rules and
				regulations.
(2) In all
				medico-administrative matters, act in coordination and cooperation with the
				hospital administrator in implementing the policies adopted by the governing
				body.
(3) Be responsible for the
				function of the clinical organization of the medical staff and keeps or causes
				to be kept careful supervision over the clinical work in all
				departments.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 9 - Medical Staff › Section 310:667-9-9 - Medical staff bylaws

Current through Vol. 41, No. 20, July 1, 2024
(a) Bylaws shall
				be adopted to govern and enable the medical staff to carry out its
				responsibilities.
(b) The bylaws of
				the medical staff shall be a precise and clear statement of the policies under
				which the medical staff regulates itself.
(c) Medical staff bylaws, rules and
				regulations shall include the following:
(1)
				A descriptive outline of medical staff organization.
(2) A statement of the necessary
				qualifications which physicians and licensed independent practitioners shall
				possess to be eligible for medical staff privileges to work in the hospital,
				and/or the duties and privileges of each category of medical staff.
(3) A procedure for granting and withdrawing
				privileges to physicians and licensed independent practitioners.
(4) A mechanism for appeal of decisions
				regarding medical staff membership and privileges.
(5) A definite and specific statement
				forbidding the practice of the division of fees under any guise
				whatsoever.
(6) Provision for
				regular meetings of the medical staff.
(7) Provision for keeping accurate and
				complete medical records.
(8) A
				provision that all patient tissue removed in the hospital, except tissue
				specifically excluded by medical staff policy, shall be examined by a
				pathologist and a report made of this examination.
(9) Provision for performing and documenting
				a routine examination of all patients upon admission and recording of
				pre-operative diagnosis prior to surgery.
(10) A rule permitting a surgical operation
				only on consent of the patient or his or her legal representative, except in
				emergencies.
(11) A rule providing
				that, except in emergency, consultation is required as outlined
				above.
(12) A regulation requiring
				physicians' and licensed independent practitioners' orders be recorded and
				signed.
(13) If dentists and oral
				surgeons, podiatrists, psychologists, or other allied health professionals are
				to be admitted to staff membership, the necessary qualifications, status,
				privileges, and rights of this group shall be stated in the bylaws.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 9 - Medical Staff › Section 310:667-9-10 - Committees-general

Current through Vol. 41, No. 20, July 1, 2024
The structure of committee organization is a decision to be
				  made by the medical staff as long as the required committee functions are
				  carried out. A small staff may function as a
				  committee-ofthe-whole.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 9 - Medical Staff › Section 310:667-9-11 - Executive committee

Current through Vol. 41, No. 20, July 1, 2024
(a) The executive
				committee (or its equivalent) shall coordinate the activities and general
				policies of the various departments, act for the staff as a whole under such
				limitations as may be imposed by the staff, and receive and act upon the
				reports of the medical records, tissue, and such other committees as the
				medical staff may designate.
(b)
				The committee shall meet at least nine (9) months out of each calendar year and
				maintain a permanent record of its proceedings and actions.
(c) Committee membership shall be made up of
				the officers of the medical staff, chiefs of major departments or services, and
				one (1) or more members elected at large from the active medical
				staff.
(d) The committee's
				functions and responsibilities shall include but not be limited to the
				following:
(1) Consider and recommend action
				to the administrator on all matters which are of a medico-administrative
				nature.
(2) Investigate any reports
				of breach of ethics by members of the medical staff, as referred to this
				committee by the credentials committee.
(3) Act as the program committee for staff
				meetings, unless this responsibility is delegated to a specific
				committee.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 9 - Medical Staff › Section 310:667-9-12 - Credentials committee

Current through Vol. 41, No. 20, July 1, 2024
(a) The credentials
				committee (or its equivalent) shall review applications for appointment and
				reappointment to all categories of the staff as often as needed and at least
				biennially. It shall delineate the privileges to be extended to the applicant
				and make appropriate recommendations to the governing body according to the
				procedure outlined in the hospital's medical staff bylaws.
(b) The committee shall recommend individuals
				for initial appointment, hospital privileges, promotions, demotions, and
				reappointments.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 9 - Medical Staff › Section 310:667-9-13 - Medical records committee

Current through Vol. 41, No. 20, July 1, 2024
(a) The
				medical records committee (or its equivalent) shall supervise the maintenance
				of medical records at the required standard of completeness. Routine review and
				monitoring of records may be performed by hospital medical records staff or
				through the quality improvement program. On the basis of documented evidence,
				the committee shall review and evaluate the completeness of the
				record.
(b) The committee shall be
				available to meet as often as necessary and shall submit a written report of
				meetings to the executive committee.
(c) The committee's members shall represent a
				cross section of the clinical services. In large hospitals, each major clinical
				department may have its own committee.
(d) Membership shall be staggered so that
				experienced committee physicians shall always be included. Senior residents may
				serve on this committee.
(e) Review
				of the record for completeness may be performed for the most part by medical
				record staff. In addition, on-the-spot scanning of current inpatient records
				for completeness shall be performed.
(f) The committee shall:
(1) Recommend to the medical staff the
				approval of, use of, and any changes in form or format of the medical
				record.
(2) Advise and recommend
				policies for medical record maintenance and supervise the medical records to
				insure that details shall be recorded in the proper manner and that sufficient
				data shall be present to evaluate the care of the patient.
(3) Insure proper filing, indexing, storage,
				and availability of all patient records.
(4) Advise and develop policies to guide the
				medical record administrators or medical record staff, medical staff, and
				administration so far as matters of privileged communication and legal release
				of information are concerned.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 9 - Medical Staff › Section 310:667-9-14 - Tissue committee

Current through Vol. 41, No. 20, July 1, 2024
(a) The tissue
				committee (or its equivalent) shall review and evaluate all surgery performed
				in the hospital on the basis of agreement or disagreement among the
				pre-operative, post-operative, and pathological diagnoses, and on the
				acceptability of the procedure undertaken. Reviews may be conducted by hospital
				staff or conducted as a part of the quality improvement program. All reviews
				shall be conducted based on criteria established by the committee.
(b) The committee shall be available to meet
				as often as necessary and shall submit a written report to the executive
				committee.
(c) This committee's
				work shall include continuing education through such mechanisms as utilization
				of its findings in the form of hypothetical cases or review of cases by
				category at staff meetings or publishing in coded form physicians' standings in
				the hospital regarding percentage of cases in which normal tissue is
				removed.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 9 - Medical Staff › Section 310:667-9-15 - Pharmacy and therapeutics committee

Current through Vol. 41, No. 20, July 1, 2024
(a) A pharmacy and therapeutics committee (or
				its equivalent), composed of physicians, licensed independent practitioners,
				pharmacists, and registered nurses, shall assist in the formulation of broad
				procurement, storage, distribution, use, and safety procedures, and all other
				matters relating to drugs in hospitals and shall advise the medical staff and
				the pharmacist.
(b) The committee
				shall meet at least quarterly and shall:
(1)
				Serve as an advisory group on matters pertaining to the choice of
				drugs.
(2) Monitor and enforce
				stop-order policies.
(3) Monitor
				and control the use of preventive antibiotics and the use of antibiotics in the
				presence of infection.
(4) Develop
				and review periodically a formulary or drug list for use in the
				hospital.
(5) Establish standards
				concerning the use and control of investigational drugs in research and the use
				of recognized drugs.
(6) Evaluate
				clinical data concerning new drugs or preparations requested for use in the
				hospital.
(7) Make recommendations
				concerning drugs to be stocked on the nursing-unit floors and by other
				services.
(8) Provide information
				to the medical staff on the relative cost of equivalent or generic
				medicines.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 9 - Medical Staff › Section 310:667-9-16 - Meetings of the medical staff

Current through Vol. 41, No. 20, July 1, 2024
(a)
				Meetings that include the medical staff shall be held at least monthly to
				review, analyze, and evaluate the clinical work of its members.
(1) The number and frequency of these
				meetings shall be determined by the active staff and clearly stated in the
				bylaws of the staff.
(2) Attendance
				requirements for each individual member of the staff and for the total
				attendance at each meeting shall be clearly stated in the bylaws of the staff,
				and attendance records shall be kept.
(3) Adequate minutes of all meetings shall be
				kept.
(4) The method adopted to
				insure adequate evaluation of clinical practice in the hospital shall be
				determined by the medical staff, e.g. quality improvement meetings, meetings of
				medical records and tissue committees in which clinical practice is discussed
				and evaluated and reports made to the active staff, active staff meetings,
				etc., and shall be clearly stated in the bylaws.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 9 - Medical Staff › Section 310:667-9-17 - Departments

Current through Vol. 41, No. 20, July 1, 2024
(a) Division of staff into services or
				departments to fulfill medical staff responsibilities promotes efficiency and
				is recommended in general hospitals with seventy-five (75) or more beds. Each
				autonomous service or department shall be organized and function as a
				unit.
(b) Medical staff members of
				each service or department shall be qualified by training and demonstrated
				competence and be granted privileges based on their individual training and
				competence.
(c) In those hospitals
				where the review and evaluation of clinical practice are done by committees of
				the medical staff or by monthly meetings of the entire staff, departmental
				meetings shall be optional. In those hospitals where the clinical review is
				done by the departments, each service or department shall meet at least once a
				month. Records of these meetings shall be kept and shall become part of the
				records of the medical staff.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok
				  Reg 1664, eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 9 - Medical Staff › Section 310:667-9-18 - Chief of service or departments

Current through Vol. 41, No. 20, July 1, 2024
(a) The
				chief of service or department shall be a member of the service or department,
				qualified by training and by definition in the medical staff bylaws. The chief
				of service or department shall be responsible to the medical staff as to the
				qualifications of service or department members. He or she shall make
				recommendations to the department for the professional care of patients and
				make recommendations to the medical staff as to the planning of hospital
				facilities, equipment, routine procedures, and any other matters concerning
				patient care.
(b) Each chief of
				service shall be selected as required by medical staff bylaws or hospital
				policies based on recommendations of the medical staff.
(c) Duties and responsibilities of the chief
				shall include, in addition to those cited above:
(1) Responsibility for arranging and
				expediting inpatient and outpatient departmental programs embracing
				organization, educational activities, supervision, and evaluation of the
				clinical work.
(2) Responsibility
				for enforcement of the hospital medical staff bylaws, rules and regulations,
				with special attention to those pertaining to the chief's department.
(3) Maintaining the integrity of the medical
				records in the department.
(4)
				Representing the department, in a medical advisory capacity, to the
				administration and governing body.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 11 - Quality Improvement › Section 310:667-11-1 - General

Current through Vol. 41, No. 20, July 1, 2024
There shall be an ongoing, comprehensive quality improvement
				  program, approved by the governing body, which shall identify problems in the
				  facility, suggest solutions, and monitor results.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 11 - Quality Improvement › Section 310:667-11-2 - Quality improvement plan

Current through Vol. 41, No. 20, July 1, 2024
(a) A
				written quality improvement plan shall be developed, approved, and implemented
				by the governing body with advice from the medical staff. The plan shall
				include but not be limited to the following:
(1) Methods of evaluating all patient
				services to assure quality of care, including those provided under
				contract.
(2) Methods of evaluating
				off-site health care organizations for appropriateness of use and the degree to
				which the services aid in the provision of quality patient care.
(3) Evaluation of all surgeries, inpatient
				and outpatient.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 11 - Quality Improvement › Section 310:667-11-3 - Quality improvement committee

Current through Vol. 41, No. 20, July 1, 2024
A quality improvement committee (or its equivalent) shall
				  meet at least quarterly to evaluate the quality of patient care and address
				  problems identified by the various services. All organized hospital services
				  shall report findings to the committee on at least a quarterly basis or more
				  frequently if findings require immediate action by the
				  committee.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 11 - Quality Improvement › Section 310:667-11-4 - Quality improvement implementation

Current through Vol. 41, No. 20, July 1, 2024
There shall be documentation that the hospital has taken
				  action to address problems identified by hospital services. There shall be
				  documentation that the hospital is monitoring the effectiveness of the proposed
				  solutions.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 11 - Quality Improvement › Section 310:667-11-5 - Communication

Current through Vol. 41, No. 20, July 1, 2024
The facility shall establish mechanisms to communicate
				  quarterly quality improvement summaries to the governing body and to the
				  medical staff.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 13 - Infection Control › Section 310:667-13-1 - Infection control program

Current through Vol. 41, No. 20, July 1, 2024
Each hospital shall establish an infection control program to
				  provide a sanitary environment and avoid sources and transmission of
				  infections. The program shall include written policies and procedures for
				  identifying, reporting, evaluating and maintaining records of infections among
				  patients and personnel, for ongoing review and evaluation of all aseptic,
				  isolation and sanitation techniques employed in the hospital, and development
				  and coordination of training programs in infection control for all hospital
				  personnel.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok
				  Reg 1664, eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 13 - Infection Control › Section 310:667-13-2 - Infection control committee

Current through Vol. 41, No. 20, July 1, 2024
The infection control committee (or its equivalent) shall
				  meet at least quarterly. If central services are discussed such as the dietary
				  service, employee health, engineering or maintenance, housekeeping, laundry,
				  material management, surgical services, pharmacy, or laboratory, at least one
				  individual with appropriate background who can speak for the relevant
				  department(s) attends the meeting or is consulted.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok
				  Reg 1664, eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 13 - Infection Control › Section 310:667-13-3 - Policies and procedures review

Current through Vol. 41, No. 20, July 1, 2024
(a) The
				infection control committee shall evaluate, revise as necessary, and approve
				the type and scope of surveillance activities utilized at least
				annually.
(b) Infection control
				policies and procedures shall be reviewed periodically and revised as
				necessary, based on current scientific knowledge, accepted practice guidelines,
				and applicable laws and regulations.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok
				  Reg 1664, eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 13 - Infection Control › Section 310:667-13-4 - Policies and procedures content

Current through Vol. 41, No. 20, July 1, 2024
The policies and procedures outlined by the infection control
				  program shall be approved by the infection control committee and contain at
				  least the following:
(1) A requirement
				that a record of all reported infections generated by surveillance activities
				include the identification and location of the patient, the date of admission,
				onset of infection, the type of infection, the cultures taken, the results when
				known, any antibiotics administered and the physicians and practitioners
				responsible for care of the patient.
(2) Specific policies related to the handling
				and disposal of biomedical waste.
(3) Specific policies and procedures related
				to admixture and drug reconstitution, and to the manufacture of intravenous and
				irrigating fluids.
(4) Specific
				policies regarding the indications for and types of isolation to be used for
				each infectious disease. These policies shall incorporate the concepts of
				Standard Precautions and utilize the recommended transmission-based categories
				of Contact, Airborne, and Droplet isolation procedures where deemed appropriate
				by the medical staff.
(5) A
				definition of nosocomial infection.
(6) Designation of an infection control
				officer, who coordinates the infection control program.
(7) A program of orientation of new employees
				and other workers, including physicians, and a program of continuing education
				for previously employed personnel concerning infection control. Written
				documentation shall be maintained indicating new employees have completed the
				program and that previously employed have attended continuing
				education.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok
				  Reg 1664, eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 13 - Infection Control › Section 310:667-13-5 - Universal birth dose hepatitis B vaccination

Current through Vol. 41, No. 20, July 1, 2024
All Oklahoma birthing hospitals shall implement a procedure
				  to ensure that the hepatitis B vaccination is administered to all live infants
				  within twelve hours of birth and recorded in the Oklahoma State Immunization
				  Information System. A parent or guardian may refuse hepatitis B vaccination of
				  their newborn on the grounds of medical reasons or that such vaccination
				  conflicts with their religious tenets or personal beliefs. A refusal based on
				  medical reasons shall include a statement in the medical record by a physician
				  stating that the physical condition of the newborn is such that the vaccination
				  would endanger the life or health of the child and that the child should be
				  exempt from the vaccination requirement. A refusal based on the parent's or
				  guardian's religious tenets or personal beliefs shall be documented in the
				  newborn's medical record.
Added at 29 Ok Reg 1603,
				  eff 7-12-12
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 15 - Nursing Service › Section 310:667-15-1 - General

Current through Vol. 41, No. 20, July 1, 2024
The hospital shall have an organized nursing department. A
				  registered nurse shall be on duty at all times, and registered nursing services
				  shall be available for all patients at all times.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 15 - Nursing Service › Section 310:667-15-2 - Organization

Current through Vol. 41, No. 20, July 1, 2024
There shall be an organized departmental plan of
				  administrative authority with the delineation of responsibilities and duties of
				  each category of nursing personnel.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 15 - Nursing Service › Section 310:667-15-3 - Registered nurse

Current through Vol. 41, No. 20, July 1, 2024
(a) There shall be
				an adequate number of registered nurses to meet the following minimum staff
				requirements: director of the department; assistants to the director for
				evening and night services; supervisory and staff personnel for each department
				or nursing unit to insure the immediate availability of a registered nurse for
				bedside care of any patient when needed; and registered nurse on duty at all
				times and available on-site for all patients on a twenty-four (24) hour
				basis.
(b) The staffing pattern
				shall insure the availability of registered nursing care for all patients on a
				twenty-four (24) hour basis every day.
(c) If a licensed practical nurse or nurse
				aide is assigned care of patients who do not generally need skilled nursing
				care, there shall be a registered nurse supervisor who makes frequent rounds
				and is immediately available to give skilled nursing care when needed. This
				registered nurse shall be free to render bedside care and not be occupied in
				the operating room, delivery room, or emergency room for long periods of
				time.
(d) The ratio of registered
				nurses to patients and the ratio of registered nurses to other nursing
				personnel shall be adequate to provide proper supervision of patient care and
				staff performance, based on patient acuity.
(e) A registered nurse shall assign the
				nursing care of each patient to other nursing personnel in accordance with the
				patient's acuity and the nursing staff available.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 15 - Nursing Service › Section 310:667-15-4 - Other nursing personnel

Current through Vol. 41, No. 20, July 1, 2024
There shall be other ancillary nursing personnel in
				  sufficient numbers to provide nursing support as needed under the supervision
				  of a registered nurse. The training and supervision of these personnel shall be
				  appropriate for the duties assigned.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 15 - Nursing Service › Section 310:667-15-5 - Qualifications

Current through Vol. 41, No. 20, July 1, 2024
(a) Individuals selected for the nursing
				staff shall be qualified by education and experience for the positions they are
				assigned.
(b) The director of
				nursing shall make recommendations regarding the selection and promotion of
				nursing personnel based on their qualifications and capabilities and recommend
				the termination of employment when necessary.
(c) The qualifications required for each
				category of nursing staff shall be in written policy and job descriptions and
				shall be available for review.
(d)
				The functions of nursing personnel shall be clearly defined in written policies
				and procedures.
(e) Verification of
				current licensure and credentials shall be maintained in the personnel files or
				department of nursing.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 15 - Nursing Service › Section 310:667-15-6 - Evaluation and review of nursing care

Current through Vol. 41, No. 20, July 1, 2024
(a) There shall be a continuous review and
				evaluation of the nursing care provided for patients. There shall be written
				nursing care procedures and nursing care plans for patients.
(b) Nursing care policies and procedures
				shall be written and be consistent with current standards of practice and be
				reviewed and revised as necessary.
(c) A registered nurse shall assess, plan,
				supervise, and evaluate the nursing care for each patient.
(d) Nursing care plans shall include
				assessment, planning, intervention, and evaluation. Nursing care plans shall be
				established for each inpatient and be revised as necessary.
(e) Nursing notes shall be informative and
				descriptive of the nursing care given and include assessment, interventions,
				and evaluation.
(f) Only the
				following shall be permitted to administer medications, and in all instances,
				in accordance with state and federal law:
(1)
				A licensed physician or licensed independent practitioner;
(2) A registered nurse;
(3) A licensed practical nurse; or
(4) Other practitioners, if designated by the
				medical staff and authorized by law.
(5) Facilities participating in a program for
				training nursing students may permit nursing students to administer medications
				to patients provided the facility has on file an agreement between the nursing
				school and the facility, outlining protocols for participation, scope of
				involvement, education levels of students, level of supervision, and a current
				roster of nursing students in the program. Specific details relating to the
				operation of the program shall be included in the facility's policies and
				procedures manual.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 15 - Nursing Service › Section 310:667-15-7 - Special-care units

Current through Vol. 41, No. 20, July 1, 2024
(a) Areas providing
				specialized nursing care shall be well defined by policies and procedures
				specific to the nursing services such as intensive care, coronary care,
				obstetrics, nursery, emergency services, and renal units.
(b) Specific policies and procedures shall
				supplement basic hospital nursing policies and procedures for special-care
				units. Nursing policies and procedures of special-care units shall be in
				accordance with current standards of practice and shall include but not be
				limited to:
(1) Protocol for resuscitation
				and disaster situations.
(2)
				Immediate availability of emergency equipment and drugs.
(3) Appropriate and safe storage of
				pharmaceuticals and biologicals.
(4) Programs for maintenance and safe
				operation of all equipment.
(5)
				Appropriate infection-control measures.
(6) Control of visitors and nonessential
				personnel.
(7) Documentation of
				quality improvement.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 15 - Nursing Service › Section 310:667-15-8 - Patient physical restraint

Current through Vol. 41, No. 20, July 1, 2024
(a)
				Patients may be physically restrained only by order of a physician or licensed
				independent practitioner who has determined such restraint is required to
				prevent injury to the patient or others or prevent serious disruption in the
				therapeutic environment. Orders for physical restraint shall include a
				statement of reason for the restraint and specify which approved facility
				methods and devices shall be used. Alternative measures to the use of physical
				restraints shall be evaluated prior to their use. Physical restraints shall not
				be imposed for discipline or convenience purposes.
(b) Emergency physical restraint to ensure
				the physical safety of the patient, staff, or other patients may be initiated
				by a registered nurse who obtains written or verbal consent from a physician or
				licensed independent practitioner within a time-frame specified by written
				facility policy. Verbal physical restraint orders shall be signed by the
				physician or licensed independent practitioner as soon as possible within
				twenty-four (24) hours. Physical restraint orders shall automatically terminate
				as specified by facility policy, or sooner as warranted by the patient's
				condition. If physical restraint is to continue past the time-frame specified
				by facility policy, a new order shall be obtained from a physician or licensed
				independent practitioner.
(c)
				Patients may be restrained only in accordance with documented specific policies
				established by the medical staff and the governing body. These policies shall
				include circumstances in which restraint is appropriate and specific techniques
				and devices that shall be used for restraint.
(d) Physically restrained patients shall be
				monitored as required by facility policy and justification for continued
				restraint shall be documented. A physically restrained patient shall have
				restraint devices released at time-frames specified by facility policy; and the
				patient shall be repositioned, exercised, or provided range of motion and
				toileted as necessary.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok
				  Reg 1664, eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 15 - Nursing Service › Section 310:667-15-9 - Patient chemical restraint

Current through Vol. 41, No. 20, July 1, 2024
(a)
				Patients may be chemically restrained only by order of a physician or licensed
				independent practitioner who has determined that the chemical restraint is
				required to prevent injury to the patient or others or prevent serious
				disruption in the therapeutic environment. Alternative measures to the use of
				the chemical restraint shall be evaluated prior to their use. Chemical
				restraint shall not be imposed for discipline or convenience
				purposes.
(b) Orders for
				medications used in chemical restraint shall specify the duration and frequency
				of administration and shall comply with specific stop order policies
				established by the medical staff for medications used for these
				purposes.
(c) Patients who are
				chemically restrained shall be continuously monitored to ensure that side
				effects are observed and reported to the attending physician or licensed
				independent practitioner. Monitoring observations and reports to physicians and
				licensed independent practitioners shall be documented.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok
				  Reg 1664, eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 17 - Food and Nutritional Services › Section 310:667-17-1 - Organization

Current through Vol. 41, No. 20, July 1, 2024
(a) The clinical nutritional services shall
				be under the supervision and direction of a licensed/registered dietitian on a
				full-time or consultant basis. The number of dietitians shall be adequate to
				supervise or direct the nutritional aspects of patient care and services,
				considering the size, scope, and complexity of the needs of the patient.
(1) The licensed/registered dietitian shall
				be responsible for approval of menus, including modified diets, review of
				clinical policies and procedures, evaluation of the nutritional services and
				staff education in continuing education programs.
(2) The licensed/registered dietitian shall
				provide for patient/family counseling on modified diets as needed, any required
				nutritional assessments, and development of clinical policies and
				procedures.
(3) If the
				licensed/registered dietitian is employed on a part-time or consultant basis, a
				designee for clinical aspects of patient care shall be a certified dietary
				manager or a registered dietary technician.
(4) The licensed/registered dietitian or
				designee shall enter nutritional status information into the medical
				record.
(5) Part-time and
				consultant licensed/registered dietitians shall prepare written reports
				concerning all services rendered.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 17 - Food and Nutritional Services › Section 310:667-17-2 - Services and facilities

Current through Vol. 41, No. 20, July 1, 2024
(a)
Equipment.
Equipment used in the preparation and handling of food
				in hospitals shall bear the seal of the National Sanitation Foundation (NSF) or
				comply with the requirements of the NSF (Rules and Regulations Pertaining to
				Food Establishments).
(b)
Nourishment room.
A room accessible to nursing staff shall be
				provided for the preparation and serving of light refreshments, equipped with
				equipment for warming food, refrigerator, and lavatory. This room may serve as
				the location for an ice machine.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 17 - Food and Nutritional Services › Section 310:667-17-3 - Diets and menus

Current through Vol. 41, No. 20, July 1, 2024
(a) At least three
				(3) palatable meals or their equivalent shall be served daily, at regular times
				with not more than fifteen (15) hours between a substantial evening meal and
				breakfast. Menus shall be planned and followed to meet nutritional needs of
				patients, in accordance with physicians' or licensed independent practitioners'
				orders and to the extent medically possible, in accordance with the Dietary
				Reference Intakes (DRIs) of the Food and Nutrition Board of the Institute of
				Medicine, National Academy of Sciences.
(b) Diets shall be prescribed by the
				physician or licensed independent practitioner responsible for the care of the
				patient. All modified diets shall be prescribed by the patient's physician or
				licensed independent practitioner according to the latest edition of the
				Oklahoma Diet Manual or other equivalent approved diet manual. The Oklahoma
				Diet Manual or other equivalent manual shall be approved by the
				licensed/registered dietitian and medical staff and shall be available to all
				medical, nursing, and food service personnel.
(c) Nourishments shall be available and may
				be offered at anytime in accordance with approved diet orders.
(d) Menus covering all prescribed diets shall
				be approved, dated, and periodically reviewed by a licensed/registered
				dietitian.
(1) Modified diet orders not
				covered with an approved menu shall be planned in writing, reviewed, and
				approved by the licensed/registered dietitian or designee with consultation by
				the licensed/registered dietitian.
(2) All modified diets shall be efficiently
				served under the general supervision of a licensed/registered dietitian, a
				certified dietary manager, or a registered dietary technician.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 17 - Food and Nutritional Services › Section 310:667-17-4 - Food preparation and storage

Current through Vol. 41, No. 20, July 1, 2024
(a)
				Potentially hazardous food, as defined in Chapter 257 of this Title, shall be
				maintained at one hundred-forty (140) 
				oF (approximately 60 
				oC) or above or at an internal
				temperature of forty-one 
				o F (approximately 5 
				oC) or below. A product thermometer
				shall be available (metal stem-type numerically scaled indicating temperature,
				accurate to plus or minus two (2) 
				oF and used to check internal food
				temperatures).
(b) Milk and milk
				products shall be served, handled and stored in accordance with the
				requirements of Chapter 257 of this Title.
(c) All ice which is in contact with food or
				drink shall come from a source approved by the Department, including storage,
				transportation, handling, and dispensing, which shall be in a sanitary manner,
				approved by the Department in accordance with Chapter 257 of this
				Title.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 24 Ok
				  Reg 2018, eff 6-25-07
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 17 - Food and Nutritional Services › Section 310:667-17-5 - Sanitation

Current through Vol. 41, No. 20, July 1, 2024
(a) The food and nutritional services shall
				be inspected and approved by state or local health agencies and licensed as a
				Food Service Establishment. Written reports of the inspection; e.g., Food
				Establishments Inspection Report Forms, shall be on file at the hospital with
				notations made by the hospital of action taken to correct violations.
(b) Storage, preparation, and serving of food
				shall be in compliance with the requirements of Chapter 257 of this Title,
				including adequate and proper space for each activity.
(c) The system to be used for dishwashing
				shall be approved by the Department and operated in accordance with approved
				procedures and requirements of Chapter 257 of this Title.
(d) Garbage and refuse shall be kept in
				durable, easily cleanable, insect-proof and rodent-proof containers that do not
				leak and do not absorb liquids. Adequate carriers and containers shall be
				provided for the collection and transportation, in a sanitary manner, of
				garbage and refuse from food service areas of the hospital to the place of
				disposal in accordance with the requirements of Chapter 257 of this
				Title.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 24 Ok
				  Reg 2018, eff 6-25-07
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 19 - Medical Records Department › Section 310:667-19-1 - General

Current through Vol. 41, No. 20, July 1, 2024
The hospital shall have a medical records department with
				  administrative responsibility for medical records. A medical record shall be
				  maintained, in accordance with accepted professional principles, for every
				  patient receiving care in the facility.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok
				  Reg 1664, eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 19 - Medical Records Department › Section 310:667-19-3 - Maintenance

Current through Vol. 41, No. 20, July 1, 2024
(a) A medical record shall be maintained for
				every patient admitted for care in the hospital. Such records shall be kept
				confidential.
(b) Only authorized
				personnel shall have access to the record.
(c) Written consent of the patient shall be
				presented as authority for release for medical information unless this release
				is otherwise authorized by law.
(d)
				Medical records generally shall not be removed from the control of the hospital
				except upon court order or as authorized by law. Department staff shall be
				authorized to obtain copies or review any medical record to assure compliance
				with these rules or other parts of this Title. Information from medical records
				used by the Department for regulatory purposes shall not disclose individual
				patient names.
(e) Any person who
				is or has been a patient of a physician or licensed independent practitioner,
				hospital, or other medical facility shall be entitled to obtain access to the
				information contained in all his or her medical records upon request. This
				request for medical information shall include minors when such request is made
				by the parent or legal guardian. Copies of all medical records shall be
				furnished pertaining to his or her case upon the tender of the expense of such
				copy or copies. There is an exception to the general rule that a patient has an
				absolute right to the information in or a copy of his or her medical record.
				Oklahoma law provides
...that this entitlement to medical records shall
				not apply to psychiatric records
{76 O.S. 1991, §19}.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok
				  Reg 1664, eff 6-12-03; Amended at 20 Ok Reg 1664, eff
				  6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 19 - Medical Records Department › Section 310:667-19-4 - Personnel

Current through Vol. 41, No. 20, July 1, 2024
Qualified personnel adequate to supervise and conduct the
				  activities of the medical records department shall be
				  provided.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff
				  6-26-95