Medical Staff - Rules and Regulations UCSF Medical Center

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INTRODUCTION

Section One: PROFESSIONAL AFFAIRS

I. Credentialing
II. Delineation of Privileges
III: Peer Review
IV. Performance Improvement Plan
V. Utilization Review Plan
VI. Referral Communication Standards and Procedures
VII. Consultations
VIII. House Officers

Section Two. PATIENT AFFAIRS

I. Medical Records
II. Infection Control and Communicable Diseases
III. Environment of Care Program
IV. Consents, Permits and Legal Affairs
V. Consent for Organ and Tissue Donation
VI. Notification of Recipients of Transfusions from Donors Who Are Positive for HIV Antibodies
VII. California Health Care Decisions
VIII. Patient Rights in California
IX. Ethical Considerations
X. Smoking in the Medical Center
XI. Nametags
XII. Release of Patient Information to Press/Media
XIII. Emergency Medical Treatment and Active Labor Ac

Section Three: PATIENT CARE DELIVERY

I. Admissions, Discharges, Transfers
II. Examinations
III. Physician Orders
IV. Ambulatory Care
V. Emergency Services
VI. Operating Room
VII. Assessment and Management of Potential Suicides
VIII. Restraints
IX. X-rays
X. Orders for Clinical Laboratory Tests
XI. Pathology Review of Outside Slides
XII. Administration of Radiopharmaceuticals
XIII. Management of Central Venous Catheters