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Medical Director and Attending Physicians Policy and Procedure Manual for Long-Term Care

Medical Director and Attending Physicians Policy and Procedure Manual for Long-Term Care is the only reference of its kind. It contains over 100 policies and procedures for physician participation in clinical care in long-term care, assisted living, and subacute facilities.
Key Benefits
- Identifies specific physician responsibilities and roles relative to specific clinical activities
- Provides basic administrative framework and policies for the medical director
- Provides turn-key policies and procedures that can be modified for your facility
- Saves medical directors considerable time in not having to "reinvent the wheel"
- Helps ensure better regulatory compliance through improved physician participation

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Contents
Introduction / User’s Guide

Chapter One - Medical Direction
Medical Director Roles and Functions
- Oversight and Implementation of Resident/Patient Care Policies
- Oversight and Coordination of Medical Services
- Facility Support for the Medical Director and Physicians
- Employee Health: Medical Director Role
- Notifying the Medical Director of Issues for Review
- Evaluation of Medical Director's Performance
Appendices
- Appendix A: Survey for Medical Staff
- Appendix B: Facility Concern Report to the Medical Director
- Appendix C: Medical Director Performance Review

Chapter Two – Quality Oversight
- Physician Participation in Facility Committees and Oversight Activities
- Infection Control Oversight: Physician Role
- Pharmacy and Therapeutics Oversight
- Drug Regimen Review
- Utilization Review: Physician Role
- Quality Assurance Committee: Physician Role
- Medical QA Program
- Medical Records
- Appendices
- Appendix A: Quality Reviews for Physicians and Related Healthcare Practitioners
- Appendix B: Medical Director’s Review of Care and Services
- Appendix C: Physician Performance Review
- Appendix D: Medical Director’s Summary Report to Quality Improvement Committee

Chapter Three – Infection Control
- Infection Control: Identifying Infections
- Infectious Disease: Screening
- Reporting Infections: Physician Role
- Infection Precautions: Physician Role
- Immunization and Vaccination: Physician Role
- Infectious Outbreaks: Physician Role
- Gastrointestinal Illness/Diarrheal Outbreaks: Physician Role
- Respiratory Illness Outbreaks: Physician Role
- Management of Individuals with Conditions Presenting Risks of Transmission by Blood or Body Fluids: Physician Role
- Management of Individuals with Multi-Drug Resistant Organisms (Including Methicillin Resistant Staphylococcus Aureus (MRSA) and Vancomycin Resistant Enterococcus)

Chapter Four – Provision of Medical Services
- Provision of Medical Services
- Physician Qualifications
- Attending Physician Responsibilities
- Physician Coverage and Emergency Services
- Physician Support for Resident/Patient Rights
- Admissions: Physician Role
- Initial Assessment: Physician Role
- Resident/Patient Visits
- Care Planning Process: Physician Role
- Leave of Absence: Physician Role
- Transfers and Discharges: Physician Role
- Family Management: Physician Role
- Incidents and Accidents: Physician Role
- Physician Documentation
- Physician Compliance with Confidentiality of Medical Information
- Educational Activities: Physician Support
- Trainees: Roles and Physician Supervision
Appendix
- Appendix A: Approved Abbreviations

Chapter Five - Clinical Care
- Abuse and Neglect: Physician Role in Preventing and Addressing
- Acute Condition Changes
- Anemia
- Anticoagulation with Warfarin or Low Molecular Weight Heparin
- Atrial Fibrillation
- Bowel (Lower Gastrointestinal Tract) Disorders
- Chronic Obstructive Pulmonary Disease (COPD)
- Delirium/Altered Mental States
- Dementia
- Depression
- Diabetes
- Dysphagia/Swallowing Difficulty
- Falls and Fall Risk
- Fever/Septicemia
- Functional Impairment: Physician Role
- Gastrointestinal Bleeding, Acute and Chronic
- Gastroesophageal Reflux and Other Upper Gastrointestinal Disorders
- Heart Failure
- Hydration/Fluid Maintenance
- Hypertension
- Infections
- Lab and Diagnostic Test Results: Physician Role and Follow-up
- Medication Utilization and Prescribing
- Nutrition (Impaired)/Unplanned Weight Loss
- Osteoporosis
- Pain
- Palliative/End-of-Life Care
- Pneumonia, Bronchitis, and Lower Respiratory Infections
- Pressure Ulcers/Skin Breakdown
- Prevention and Screening
- Problematic Behavior Management
- Seizures and Epilepsy
- Sensory Impairments
- Sleep Disorders
- Stroke/TIA
- Surgery Related (Pre- and Postoperative) Management: Physician Role
- Urinary Incontinence
- Urinary Tract Infections/Bacteriuria
Appendices
- Appendix A: Guidelines for Notifying Physicians of Clinical Problems
- Appendix B: Guidelines for Reporting Abnormal Test Results to Physicians
- Appendix C: Lab Test Results Notification

Chapter Six - Orders
- General Order Writing Principles
- Medication Orders: Guiding Principles
- Admission/Readmission Orders
- Verbal Orders
- Ordering and Implementing PRN Medications and Treatments
- Interim Orders for Medications and Treatments from Covering Practitioners
- Orders Related to Leaves of Absence from the Facility
- Orders for Self-Administration of Medications
- Orders for Diagnostic Tests and Studies
- Orders for Consultants
- Orders for Medications in Tube-Fed Individuals
- Orders Designating Diet
- Orders Designating Activity Level
- Orders for Anticoagulation
- Orders for Protective Devices and Restraints
- Orders for Indwelling Urinary Catheters and Catheter Care
- Orders for Feeding Tubes
- Orders for Medications to Treat Problematic Behavior and Mood
- Orders for Sedatives and Hypnotics
- Orders for Vancomycin and Aminoglycoside Antibiotics

Chapter Seven- Making Ethics Decisions
- Making Effective Ethics Decisions: Physician Role
- Identifying and Documenting Existing Care Instructions (Advance Directives)
- Determining Decision-Making Capacity
- Identifying a Primary Decision-Maker
- Presenting Treatment Options
- Research Activities and Experimental Treatments