You DO NOT need to print and initial the attestation forms found within the electronic courses in this section.

You WILL need to complete the electronic attestation form after reviewing ALL orientation materials on this page (Attestation: Orientation Part I).

To complete the courses below, you will need to view them on a device with audio capabilities.

 Course #1  [10-15 minutes]

• Infection Control
• Bloodborne Pathogens
• Isolation
• 200% Accountability Statement
• Hazardous Materials Statement

Course #2  [20-25 minutes]

•  Introduction to Mission Integration (Heritage and Values)

Course #3  [45-60 minutes]

• Privacy and Security (HIPAA)
• Policies and Handbook
• Hazard Communication Program
• Active Shooter Response

Course #4  [90 minutes]

• Ascension Mission Integration and Heritage
• Security in the Workplace
• High Reliability - Quality
• Personalized Care
• Diversity/Language Services
• Human Resources

Added 09/01/2017 

As a voluntarily organized Medical Staff, the Columbia St. Mary’s (“CSM”) Medical Staff Bylaws (“Bylaws”) are very important for you to read and understand. They confer certain rights, as well as responsibilities that you will want to be aware of and abide by during your practice at CSM.

The Bylaws, established and approved by the CSM Medical Staff and also approved by the CSM Board of Directors (“Board”), provide a structure for the self-governance of the Medical Staff. They also define the means for the Board to be able to maintain authority and responsibility for the quality of medical care provided to patients in the Hospitals and Hospital owned and/or operated ambulatory facilities and the ethical and professional conduct of the CSM Medical Staff.

For more information, please refer to the current CSM Medical Staff Bylaws found at the link below:

Columbia St. Mary's Medical Staff Bylaws (04/05/2017)

Added 09/01/2017 

Scope of Practice: Admitting/Attending/Consulting Physicians

This policy defines and outlines each of these terms and provides for a scope of practice for each role. Although the attending physician may delegate duties to a qualified designee (i.e. resident, physician assistant, nurse practitioner) within the parameters set forth in the CSM Medical Staff Bylaws and associated policies, this policy outlines the physician’s roles, in specific.

For more information, please read the full policy below:

POLICY: Patient Care – Physicians – Scope of Authority-Responsibility 

More detail regarding responsibilities for documentation can be found in the orientation section entitled, 'Medical Records: Admit & Discharge Order Requirements' and Medical Records: Documenation Requirements.'

Added 09/01/2017 

Every patient admitted to the Hospital at Columbia St. Mary's (CSM) shall be under the care of a physician, dentist or podiatrist who is a member of the CSM Medical Staff with current privileges to admit or co-admit as recommended by the Medical Staff and approved by the Board of Directors. Only physicians (MD/DO) may admit inpatients; dentists (DDS) and podiatrists (DPM) may co-admit inpatients in collaboration with a physician (MD/DO) who agrees to accept responsibility for the medical aspects of care that may be present on admission or that may arise during hospitalization of the dental or podiatric patient. [Wis. Stats. DHS 124.05 (2) (g)]

Certified nurse midwives may enter/dictate entries in the health record within the scope of their certification without physician co-signature. However, the following order entries must be entered as a verbal or telephone order from an MD/DO and co-signed by the MD/DO within forty-eight (48) hours of entry:

1. Order to admit
2. Order to discharge [Wis. Adm. Code 124.05(2)(g)]
   

Nurse practitioners, certified clinical nurse specialists, and physician assistants may also enter/dictate entries in the health record within the scope of their certification without physician co-signature. However, there are certain types of documentation that require physician co-signature, including the admission and discharge orders. Admission and discharge orders must be entered as a verbal or telephone order from an MD/DO and cosigned by the MD/DO within forty-eight hours of entry:

1. Order to admit [Wis. Adm. Code 124.05(2)(g)]
2. Order to discharge [Wis. Adm. Code 124.05(2)(g)
   

More information about medical record documentation is found in the orientation section entitled 'Medical Record Documentation Completion Requirements'.

Added 09/01/2017 

CSM Medical Staff Health Record Completion Policy & Standards

The aforementioned documents must also be authenticated in the health record (including signature, date and time) within 3 days from time of dictation or entry unless otherwise indicated, above.

To avoid incomplete records and possible suspension or automatic administrative resignation, please review important policy information below. This information is also found in the Medical Staff policy linked below:

POLICY: Health Records - Health Record Completion

1. Incomplete health record deficiencies will appear in the Provider’s electronic health record (EHR) inbox as they occur and will remain until the Provider completes them. (Note: The Provider must enter the correct search dates to view all deficiencies.)
    
2. Health Information Management (HIM) will send incomplete health record e-mails to qualifying Providers weekly. If the Provider fails to maintain a current e-mail on file as required per the Medical Staff Bylaws, the notice will be mailed via the United States Postal Service. Failure to complete deficient health records within designated timeframes may result in suspension.
    
3. The Provider shall complete all health records prior to a vacation, planned leave of absence or resignation.
    
4. The Provider willnotify HIM at EHR.vacation.hold@columbia-stmarys.org prior to the start of a vacation or other form of planned absence so health record completion activities may be coordinated prior to the Provider’s absence. Upon such notification, HIM will “stop the clock” to prevent accumulation of incomplete health records during the Provider’s absence. Suspension may occur should the Provide fail to communicate a planned absence. The clock will automatically resume on the Provider’s anticipated return date.
    
5. A Provider who is suspended:
   1. May not schedule hospital admissions, outpatient visits or procedures;
   2. May not schedule surgical procedures;
   3. May not perform consultations;
   4. May not perform hospitalist duty;
   5. May not administer anesthesia;
   6. May not work in the Emergency Department or Urgent Care (Note: The Provider must arrange ED call coverage if suspended while he/she is scheduled for ED call);
   7. May continue to care for his/her patients already in the hospital on the day of suspension until their discharge; and
   8. May perform previously scheduled surgical/invasive procedures.
       
6. The Chief of Staff may grant emergency privileges to suspended Providers.
    
7. A Provider may remain on suspension no longer than sixty (60) days; on the sixty-first (61) day, an Automatic Administrative Resignation (AAR) will be processed for that Provider. Furthermore, an AAR will be processed for those Providers who have been on suspension more than three (3) times in a rolling twelve (12) month period.

A reminder that Joint Commission, State Licensing and the Medicare Conditions of Participation require that all medical records entries be signed, dated and timed.  All verbal orders shall be signed by the person to whom it was dictated, with the name of the physician per his/her own name. The responsible medical staff member (ordering physician) shall date, time, and authenticate such orders within 48 hours (of time issued).

Medical Record documentation must not be written prior to the patient receiving the care.  Example: the post- operative procedure note cannot be filled out until after the procedure, at which time the required information should be documented and the note signed, dated and timed. Please contact Health Information Management for information on the Medical Records Delinquency Policy or to schedule a medical records orientation.

Additional information regarding health record documentation requirements may be found in the CSM Medical Staff Policy linked below:

POLICY: CSM Documentation Requirements for Medical Staff, Allied Health Professionals and Residents

Added 09/01/2017 

A reminder that Joint Commission, State Licensing and the Medicare Conditions of Participation require that all medical records entries be signed, dated and timed.  All verbal orders shall be signed by the person to whom it was dictated, with the name of the physician per his/her own name. The responsible medical staff member (ordering physician) shall date, time, and authenticate such orders within 48 hours (of time issued).

Medical Record documentation must not be written prior to the patient receiving the care.  Example: the post- operative procedure note cannot be filled out until after the procedure, at which time the required information should be documented and the note signed, dated and timed. Please contact Health Information Management for information on the Medical Records Delinquency Policy or to schedule a medical records orientation.

Please review the Policies for complete information on this topic:

POLICY: Health Record Completion

POLICY: CSM Documentation Requirements - Medical Staff, Allied Health Professionals, and Residents

Health Information Management (HIM) Contact Information

CSM Milwaukee:

Monday - Sunday/Holidays: 8:00 am - 4:30 pm

Phone: 414.585.1112
Fax: 414.585.1432

CSM Ozaukee

Monday - Friday: 8:00 am - 6:00 pm
Weekends & Holidays: 7:00 am - 11:00 am

Medicare Parts C and D General Compliance Training

Added: 02/15/2018

CSM strives to provide a restraint/seclusion free environment through development of protocols, staff education, and continuous improvement processes. Use of restraints, seclusion will be based on the patient’s assessed needs. The least restrictive methods will be employed whenever possible. Although patient clinical status, location within the hospital, and type of restraint device applied may vary, the approach taken to assure patient safety is consistent hospital-wide.

The placement of a patient in seclusion may only occur in the Behavior Medicine Unit. 

A physician’s order is required, but may not be limited to, the following:

1. A physician's order for a physical hold is required and must address the justification for physical hold use.
   
   
2. A physician's order for restraint is required prior to the initiation of restraints unless it is an emergency. In an emergency situation, a registered nurse may initiate restraint. If this occurs, an order must be obtained during the application or within minutes.
   
   
3. In the event that the attending physician was not the ordering physician, the attending must be notified as soon as possible and this notification is then documented in the Progress Notes. The order must specifically address:
   
   
   1. Time limits (not to exceed 24 hours)
   2. Type of restraint device to be applied
   3. Justification for restraint use
   4. PRN orders are not acceptable

Please note: If the initial order is received via a telephone order, the order must be authenticated by a physician within 24 hours.

1. Continued use of restraint beyond the first 24 hours is authorized by a physician. The physician may renew the original order or issue a new order if restraint use continues to be clinically justified. Such renewal is issued no less than once each calendar day and is based upon an examination of the patient by the physician. The order must include type of restraint device to be applied and justification for restraint use.
   
   
2. Restraint application will be explained to the patient and/or significant other as appropriate. If responsible adult refuses restraints, the physician will be contacted and asked to speak to the responsible adult about the risks of refusal of restraints. The refusal will be documented in the medical record along with a specific description of the patient's mental status and physical condition.
3. An electronic order in the Electronic Health Record (EHR) is to be used when restraints are ordered for an individual.

BEHAVIORS INJURIOUS TO SELF OR OTHERS

In the event that an individual requires restraint primarily to protect the patient against harm to self or others due to an emotional or behavioral disorder the following standards are to be followed. Patients may only be placed in seclusion within the Behavioral Medicine Unit.

A physician's order for a physical hold is required and must address the justification for physical hold use. A physician's order for restraint/seclusion is also required and must specifically address time limits, type of restraint device to be applied and justification for restraint/seclusion use. The order for restraint/seclusion is limited to:

1. 4 hours for patients ages 18 or older
2. 2 hours for children and adolescents ages 9-17
3. 1 hour for children under age 9
   

1. Identify ways to help the patient regain control
2. Make necessary revisions to the patient's treatment plan
3. Provide a new written order if necessary
   

Added 09/01/2017 

The informed consent conversation with the patient or authorized decision-maker is the responsibility of the licensed physician, podiatrist, dentist, or advanced practice allied health professional (operating within his or her authorized scope of practice) that will be performing the procedure or treatment. It is also this provider’s responsibility to document in the medical record that the informed consent conversation occurred.

The informed consent conversation between the physician*(hereafter listed only as physician*) and his or her patient is crucial in order to respect patient autonomy in decision-making. Informed consent follows from the right that all persons are entitled to make their own health care decisions based upon their own values and goals. This policy is consistent with the Ethical and Religious Directives for Catholic Healthcare Services, Fifth Edition. 42 C.F.R. § 482.51(b)(2).

Procedures or treatment requiring a permit signed by the patient*(hereafter listed as patient*) or the authorized decision-maker as determined by the patient’s decision-making capacity following an appropriately conducted informed consent conversation between the provider and that patient include:

1. All inpatient and outpatient surgery. The signed permit must be in the patient’s chart before surgery except in an emergency.
   
2. All procedures requiring anesthesia or moderate sedation.
   
   
3. Administration of blood or blood products. (Also refer to the CSM Blood Administration policy).
   
   
4. Ongoing or recurring “series” treatment such as, but not necessarily limited to, radiation therapy, chemotherapy, or epidural steroid injections. The procedural permit must only be signed at the initial treatment; a new permit for each treatment is not required. The original permit will last for one year from date of signing.
   

Elements Required for Informed Consent: The physician* performing the procedure or treatment is responsible for ensuring informed consent of the patient* before performing the procedure or treatment, although other health care personnel can be utilized to help provide such information such as education material to the patient*. (Joint Commission RI 2.40). The informed consent process requires discussion with the patient* of the following:

1. Indications for the proposed care, treatment, services, surgery, or invasive procedure;
   
   
2. A description of the contemplated surgery or invasive procedure including the type of anesthesia to be used;
   
   
3. The prognosis (i.e., the prospects for success) of the contemplated surgery or invasive procedure;
   
   
4. The material benefits, risks, and possible complications of the contemplated surgery or invasive procedure, care, treatment, or service;
   
   
5. The reasonable alternatives to surgery or invasive procedures, care, treatment, or service;
   
   
6. The likely effect of no treatment;
   
   
7. The likelihood of achieving goals;
   
   
8. For surgical procedures, information as to who will actually perform the contemplated surgical intervention. When practitioners other than the primary surgeon will perform important parts of the surgical procedures even when under the primary surgeon’s supervision, the patient* must be informed of who the other practitioners are and what important tasks each will conduct;
   
   
9. When indicated, limitations on the confidentiality of information learned from or about the patient.
   
   
10. After the informed consent conversation between physician* and patient* has occurred, the physician* must document that the conversation occurred in the patient’s medical record. The location of the documentation in the medical record shall be determined by the Medical Staff Council.
    

Permit: The permit must contain the following elements:

1. Name of facility where the treatment or procedure is to take place.
   
   
2. Name of specific treatment or procedure for which consent is being given.
   
   
3. Name of responsible practitioner who is performing the surgery, invasive procedure, or treatment. (EXCEPTION: The blood consent permit does not require the name of the ordering practitioner).
   
   
4. Statement that the anticipated benefits, material risk and alternative therapies related to the planned treatment or procedure was explained to the patient*.
   
   
5. Signature of the patient*.
   
   
6. Date and time the permit is signed by the patient*.
   

Witnessing the Patient’s* Signature on the Permit

1. Only the physician* can carry out the informed consent process. Non-physician* associates may assist the physician* in obtaining documentation of the process but may not take responsibility for informing the patient* of the required elements. In instances in which a non-physician is assisting with documentation of an informed consent and the patient* expresses concern about the procedure or exhibits an unwillingness to sign the permit, the physician* should be contacted immediately.
   
   
2. If the physician* has not obtained the patient’s* signature on the permit at the time of the informed consent conversation, the patient’s* signature may be obtained and witnessed by another member of the care team. Any member of the care team acting as a witness merely attests to the fact that the patient* signed the permit; the witness is not attesting to the adequacy of the informed consent conversation between physician* and patient*.
   
   
3. The physician* should never sign as witness to his or her patient’s* signature on any permit.
   

Limited English-Proficient Patients*: For patients* with limited English language proficiency, a medical interpreter should be used to assure effective communication during the informed consent process. The medical interpreter’s role is to facilitate the communication between the limited English proficient (LEP) patient* and the provider during the informed consent conversation. Whether the interpreter resource used is in-person, telephonic, or video remote interpreting, the medical interpreter’s name and/or interpreter number should be added to the permit to document that an interpreter was provided during the informed consent conversation. It is outside the scope of the interpreter’s role to act as a witness to the patient’s* signature on the permit.

Treatment without Informed Consent: In an emergency, consent for the necessary procedure or treatment is implied; unless there is prior knowledge of a patient’s wish to the contrary. The need to proceed with emergency procedures or treatments must be documented by the attending physician* making the decision.

Duration of Informed Consent

1. Surgical Procedural Permits: Signed consent permits and documentation of the informed consent conversation are valid for 30 days as long as the reason for the treatment remains the same and the patient’s condition has not changed.
   
   
2. Administration of Blood and Blood Products: Consent for the administration of blood and blood products is valid for the entire duration that a patient is initially in a CSM facility and the entire length of stay for inpatients. Should the administration of blood or blood products be necessary on a recurring basis, the signed permit is valid for one year from the date of signing. (Also refer to the CSM Blood Administration policy).
   
   
3. Recurring or Series Outpatient Procedures: An informed consent permit must be obtained prior to the first treatment. The consent permit for recurring or series outpatient procedures is valid for one year; a new permit is not necessary for each treatment. For example, the yearly limit applies, but is not necessarily limited, to recurring treatment such as radiation therapy, chemotherapy, and epidural pain management.
   
   
4. Discharge: All permits shall be considered revoked after the patient has been discharged from the CSM facility except in the case of consent permits authorizing recurring or series outpatient procedures.
   

For complete information as well as specific information for the following, please see the policy linked at the end of this section: 

• Definition of Terms
• Who May Consent
• Court Orders
• Minor Patients (under 18 years of age)
• Persons in Legal Custody
• Drug and/or Alcohol Screens
• HIV Testing

Circumstances Not Covered under Policy: For all circumstances that are not covered or are unclear as described in the full policy, contact Risk Management.

POLICY: Patient Care - Consent for Treatment/Procedures

Added 09/01/2017 

Electronic Health Record Training

Proficiency in working with the Electronic Health Record is essential to providing safe and effective care for all patients.  With this in mind, training for the Cerner Electronic Health Record system is provided and required for all members of the medical staff prior to the grant of privileges.  Please see the table below for details on who to contact to schedule training.  The length of training varies depending on your role, specialty, and individual learning needs.

Virtual Desktop (Tap & PIN)

Virtual Desktop at Ascension Columbia St. Mary's allows you to easily login to mobile carts and clinical workstations easily by using your badge and a 4-digit PIN.  Enrolling takes less than two minutes to complete.  To enroll, see the instructions in the Job Aid linked below:

JOB AID: Virtual Desktop - Getting Started, Enrolling Your CSM Badge & 4 Digit Numeric PIN

Docport Physician Portal

Docport is the Columbia St. Mary's physician communication portal.  This portal allows access to information for members of the medical staff from most devices with an internet connection.  Although much information on Docport is available without a login, there is some information that can only be accessed with a login:

- Medical Staff Member Directory

- Continuing Medical Education Archive

- Administrative Time Tracking (Medical Directors & Select Committee members only)

Instructions on how to register for an account can be found in the job aid below:

JOB AID: Docport - CSM Medical Staff Portal User Registration

PerfectServe Secure Text Messaging

PerfectServe provides a private, secure, provider-to-provider communication service that allows you to quickly and easily contact other members of the CSM Medical Staff via HIPAA-secure real-time calls and text messages. It also provides a secure method for sharing clinical photos.

PerfectServe is the only approved texting method for providers within the CSM community.  Texting PHI via standard text messages is considered a HIPAA violation - even if the information does not include a patient name or room number.

Key Benefits of PerfectServe:

• One-tap, one-number access to every medical staff member.  You only need to know their name.
• Real-time calls or secure messaging.
• Individual physician control: you choose when and how you do or don't want to be reached.
• Caller-ID privacy with patients.  When returning patient calls through PerfectServe, your office number, not mobile number will appear as the caller ID.

Additional information about how to set up and use PerfectServe can be found on the page linked below:

INFORMATION: PerfectServe Secure Text Messaging Overview

Added 09/01/2017