Healthcare Accreditation Certification Program Newsletter
January 2020


Patient Rights - Part One

By: Traci Curtis RCP, HACP
We've long known that patients must be informed of their rights. Traditionally we have done this by describing these rights on the back of the condition of admissions form, or by listing them in a brochure or patient handbook. Historically, this requirement mainly applied to the patient. Now, we need to include surrogate decision-makers.
When CMS revised the regulations around patient rights in September 2011, they included a requirement to inform patients of their right to appoint a representative to make healthcare decisions on their behalf - even if they are capable of doing so themselves.
A representative (surrogate decision maker) can be a spouse, adult child, parent, sibling, or an individual as a result of a civil union. The representative can be appointed by the patient verbally or in writing. Information regarding the right to appoint a representative must be provided to the patient upon admission. If a patient wishes to exercise the right then the appointed representative must be informed of, and provided a copy of, the patient's rights. The challenge for organizations is to be able to demonstrate that they comply with this regulation.
In order to demonstrate compliance, organizations need to query patients as part of the admission process, and document not only if they wish to exercise this right, but who the individual representative is, and that he/she was provided a copy of the patient's rights.
Another compliance challenge involves the right of the patient to have his/her family or personal physician notified of his/her admission to the hospital. This is required even when the admission is elective. The medical record must contain documentation that, not only was the patient informed of this right, but the patient's wishes regarding notification of their personal physician were determined and acted upon.
The best strategy we've seen for compliance is to tie the above requirements to the admission registration process. At the time of registration, the patient should be asked the following:
  • Do you wish to appoint a representative to make health care decisions on your behalf?
  • Do you wish to have your representative, family member notified of your admission?
  • Do you wish to have your personal physician notified of your admission? If the patient says yes, then a good faith effort should be made.
Documenting this information will keep surveyors and a deficiency with this regulation at bay. Stay tuned to our blog page for part two of our series on patient rights when we tackle the right to visitation.
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