7 AAC 12.210. Medical staff

(a) A hospital described in 7 AAC 12.200 must have a medical staff.

(b) The medical staff shall organize and adopt, with the approval of the governing body, bylaws and rules which provide for

(1) eligibility for medical staff membership, and recommending appointments to the governing body;

(2) appointment of committees, including executive, credentials, medical records, tissue and transfusion, infection control, pharmacy and therapeutics, and utilization review committees, which shall keep written minutes of their meetings, including committee activities and recommendations; and

(3) election of officers, including a chief of staff, and quarterly meetings, with minutes and records of attendance to be maintained for at least five years.

(1) recommend annually to the governing body the appointment of and the medical and surgical privileges for each member of the medical staff;

(2) ensure that a physician is available to respond to an emergency at all times;

(3) place each patient under the care of a member of the medical staff;

(4) require that an order of a physician, including a telephonic or other oral order, be reduced to writing and initialed or signed by the attending physician within 24 hours after the order;

(5) ensure that the use of an investigational drug is properly supervised by a member of the medical staff, that an informed consent form provided by the sponsoring company or agency is used, and that complete records on the drug, including protocol and side effects, are maintained;

(6) establish procedures for circumstances in which consultation is required;

(7) establish standards for care by residents, interns, and medical students in accordance with a residency training program approved by the Council on Education of the American Medical Association, the American Dental Association, or applicable specialty boards;

(8) review at regular intervals clinical and scientific work, medical services, and maintenance of accurate medical records; and

(9) establish guidelines for referral to a pathologist of tissues removed by surgery.

History: Eff. 11/19/83, Register 88

Authority: AS 18.20.010

AS 18.20.060

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