Health Information Management

Tip: Develop protocols for enforcing direct supervision requirements

APCs Weekly Monitor, October 30, 2009

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All diagnostic tests require some level of physician supervision. Staff members need to know the level of supervision required for each test and they must ensure that the tests receive the proper level of supervision.
 
Facilities can assist staff members by creating department protocols for each direct supervision test and establishing a protocol that requires the presence of a physician on campus. For facilities with multiple campuses, this means ensuring that the supervising physician is on the campus where the procedure will occur.
 
Sometimes, a physician may be involved in another procedure or en route to the department when a test is scheduled to begin. An established protocol for enforcing supervision requirements will help department staff members who may be asked to start a procedure without the physician present.
 
Once protocols are in place, the facility must communicate this information to every physician. Protocols and their enforcement will help staff members work with physicians to ensure that the appropriate level of supervision is provided.  
 
This tip was adapted from the article “Hospital outpatient departments need to know who is supervising” in the November issue of Briefings on APCs.



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