Imagine you work at a hospital just outside of Disney World in Orlando, FL. Chances are a significant number of your patients will be from out of town. If they’re hospitalized, it is unlikely that their personal physicians will be aware of this. It’s even possible that their own families may not know. So what are your hospital’s responsibilities should this occur?

Basically, CMS [§482.13(b)(4)] expects that for every inpatient admission, your hospital must ask the patient whether a family member or representative should be notified about the admission. If the patient says yes, and identifies the family member or representative to be notified, then notice must be provided promptly to the designated individual. This requirement does not apply to outpatient settings.

Your hospital must also ask the patient whether his/her own physician should be notified. In the case of scheduled admissions, the patient’s own physician likely is already aware of the admission. However, if the patient requests it, your hospital must promptly notify the designated physician, regardless of whether the admission was scheduled in advance or emergent. This requirement also does not apply to outpatient settings.

"Promptly" means as soon as possible after the order to admit the patient has been given. Notice may be given orally in person, by telephone, by e-mail or other electronic means, or by other methods that achieve prompt notification. It is not acceptable for the hospital to send a letter by regular mail. If a patient is unable to receive notification of this right due to their condition on admission, then notice should be provided to a surrogate decision maker or – if no decision maker is available – to the patient as soon as their condition permits.

Your hospital must document that the patient, unless incapacitated, was asked no later than the time of admission whether he or she wanted a family member/representative and/or personal physician notified, and the date, time and method of notification when the patient requested such, or whether the patient declined to have notice provided. If the patient was incapacitated at the time of admission, the medical record must indicate what steps were taken to identify and provide notice to a family member/representative and to the patient’s physician.

Rick's clinical background is in critical care nursing with a focus in cardiovascular and trauma service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance.

Rick is a regular speaker at numerous state and national conferences on the federal regulations and accreditation standards, and is host of CIHQ's popular monthly webinars addressing key compliance challenges in today's environment.

Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing with a Master's Degree in Health Services Administration.