Q&A

What are the pre-surgical assessment requirements? We have an eye surgeon who wants to do an abbreviated pre-surgical assessment in their office but …

If a PA or NP assists in surgery, can they write the immediate post-op notes? In addition, if they can write it, do the post-op notes have to be …

Is informed consent required for Oral Chemotherapy? We follow that process for infusion medication, but does it apply to oral chemotherapy medication …

Some hospitals require their leadership to take FEMA training but does the Joint Commission require it? Emergency Management Training In short, …

To help with decision making, an outlying emergency department may at times text EKGs to cardiologists at another location. Does TJC and CMS Allow …

If you were cited for a ligature violation, it may not be something you can correct immediately. If that occurs, you may need to request a ligature …

Our Infection Prevention group is reviewing and updating the template they use to ensure we meet all infection prevention regulations. We are looking …

We use brushes to inspect lumened instruments.  I was told by a surveyor that you cannot have brushes in prep and pack areas of central …

For approving medical staff privileges for a Governing Board Chairperson, Vice Chair, Secretary, appointment of the CEO, etc. are there defined …

The Emergency Medical Treatment and Labor Act (EMTALA) governs how patients are transferred from one hospital to another. When a patient requests a …