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Notice of Privacy Practices
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| Mt. San Rafael Hospital Patient Handbook |
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The Entire Staff of Mt. San Rafael Hospital Welcomes You!
We extend to you a cordial and warm welcome to Mt. San Rafael Hospital. Opened in 1973, our hospital is a JCAHO-accredited general hospital serving Trinidad and southeast Colorado. We are a family-centered hospital providing you with the best care and service.
Our hospital staff consists of 155 full and part-time employees, and we will answer any questions you have about your stay.
You are our guest and our first consideration. We want you to know us as caring people working together for your health and well-being. Be assured that every staff member is dedicated to making your stay a comfortable one, and assisting you to get well as soon as possible.
We hope this web resource will provide the necessary information to make your stay a pleasant one, and will better acquaint you with our hospital. If you have any questions concerning our policies and services, please call me at extension 1050, or the hospital switchboard operator can connect you to my office.
Sincerely,
Chief Executive Officer
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Your Arrival at Mt. San Rafael Hospital |
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Your doctor arranges your admission to Mt. San Rafael Hospital. Your room assignment is determined by your doctor's orders, the type of medical care you are to receive, and the availability of rooms. Your admission to the hospital will be handled without regard to race, creed, color, or national origin.
When you arrive, certain necessary information will be requested for completion of your medical record and for financial arrangements. This is essential so that all hospital departments can provide prompt service to you, and necessary information to your doctor. Be assured that all of the information provided by you will be handled confidentially.
Your doctor will probably order laboratory or x-ray tests for you. Laboratory test results can help your doctor find out: (1) if you are ill; (2) what the diagnosis is; and (3) what treatment would be best. The most common procedures test samples of blood, urine, or sputum, cultures, and biopsies. It is important to follow directions exactly so that information from your tests will be useful to your doctor.
Your Personal Needs
Toiletries, a bathrobe, and slippers are the only personal items that you will need. Patients may wear their own gowns or pajamas, but such articles cannot be laundered by the hospital. Maternity patients should arrange for the baby's clothes to be brought to the hospital on the day they are to leave.
Valuables
The hospital cannot assume responsibility for loss of personal items from your room. It is urged that you leave valuables at home. If that is not possible, you may deposit such items in the hospital vault.
Medications From Home
If any medication is required during your stay, your doctor will prescribe it for you. In the event that you brought any medication with you, please give it to the nurse. She will store it for you and will return it to you. Please be certain to inform your doctor and nurses if you have been taking medicines recently, or have any known allergies.
Treatment Permits
Each patient or personal representative of their choice must sign permits for treatments and/or operations. Parents or guardians must sign permits for minors.
Conflict Resolution
We understand that sometimes in the course of treatment, conflicts may arise regarding your health care needs. To that end, we offer the services of our Ethics Committee, which is available to aid you or your family in the resolution of these conflicts. If you feel that you require this assistance, please call extension 1070.
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Patient Rights and Responsibilities |
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Mt. San Rafael Hospital presents this policy statement to contribute to effective patient care and satisfaction of the patient.* The physicians and personnel in the hospital seek excellence of service to all patients. They recognize that the effort must include effective communication with the patient and the patient's family.
Our hospital affirms that people influence, and are influenced by, their environment, and that this interaction can contribute to either health or illness. We have a concern for, and commitment to, the betterment of the physical, psychological, social, and spiritual needs of the whole person.
The Hospital's Responsibility To The Patient:
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The hospital strives to give reasonable and respectful personal consideration to each patient. Individuals shall be accorded impartial access to treatment or accommodations that are available or medically indicated, regardless of race, creed, sex, or national origin. |
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The hospital relies upon the attending physician to keep the patient informed of the patient's diagnosis, outcomes of care (including unanticipated outcomes), and his/her prospects of recovery in terms the patient can be expected to understand. |
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The patient has the right to participate in all decisions involving his/her care or treatment, including treatment for pain. |
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The patient has the right to know the names, professional status, and experience of the staff members that are providing care or treatment to the patient. |
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The hospital's admissions procedures, statement of patient rights, information on advance directives, and information regarding the organ donor (Donor Alliance) program will be a part of the admission packet, given upon admission. |
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The patient has the right to refuse any drug, test, or treatment. |
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The patient has the right to care or treatment that is respectful, recognizes a person's dignity, and provides for personal privacy to the extent possible during the course of treatment. |
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The patient has the right to be informed, upon request and prior to the initiation of care or treatment that is non-emergent, of the charge(s) or estimated charge(s) for services that are routine, usual, or customary, based upon an average of patients admitted. |
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Patients have the right to give informed consent for all treatments and procedures. Informed consent shall include, but not be limited to, an explanation of the procedure in layman's terms and in a form of communication that the patient or patient's legal representative can understand. This includes risks and benefits and the probability of success, mortality risks, and serious side effects. |
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Patients have the right to be informed of the facility's grievance procedure. |
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The patient has the right to expect that all communications and records pertaining to their care be treated as confidential. |
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The patient has the right to a reasonable response to requests for hospital services. |
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The patient has the right to assistance in discharge planning to aid in continuity of care. |
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The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned. |
Patient's Responsibilities to the Hospital:
Patients are expected to:
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Provide information about past illnesses, hospitalizations, medications, and other matters relating to the patient's health. |
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Cooperate with all hospital personnel and ask questions if directions and procedures are not understood. |
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Be considerate of other patients, assist in control of noise and number of visitors, and adhere to the hospital's no smoking policy. |
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Provide information necessary for insurance processing; however, the patient has the ultimate responsibility for paying all hospital bills. |
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Be respectful of the property of other persons and of the hospital. |
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Assist health care personnel in their efforts to return the patient to a healthy status. |
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Maintain the confidentiality of all other patients. |
If, at any time, the patient believes that any of these responsibilities have not or may not be fulfilled, he or she may call extension 1070. If the representative is unavailable, you will be contacted within 72 hours.
* Patient/parent/guardian/surrogate, as appropriate to the individual situation.
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Visiting hours at Mount San Rafael Hospital are from 8:00 a.m. to 8:00 p.m., subject to the following restrictions:
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In order to allow our patients to rest and recuperate, it is our policy to limit visitors to two (2) per patient. |
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Children under the age of ten (10) may visit in the waiting room. |
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Safety Suggestions During Hospitalization |
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Accidents can happen anywhere, and occasionally accidental falls occur during hospitalization. We want your stay here to be as pleasant as possible. The following is a list of suggestions to minimize your risk of falling.
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Ask your nurse for help if you feel dizzy or weak when you sit upright or stand. Sometimes, you may get weak after sitting or lying for a long period of time. |
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If you get up without help, sit up for awhile before standing. When you feel O.K., rise carefully and begin to walk slowly. |
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Make sure that your clothing doesn't get in your way or cause you to fall. Clothes that are so loose that they catch on things or that need to be held up may cause you to fall. Make sure that you shoes or slippers are non-skid and fit well. |
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Follow your doctor's orders if told not to be up out of bed, or if the nurse tells you not to be up without the nurse's help. |
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Don't tamper with the side rails or restraints if they are in place. They are used to remind you that you need help to get out of bed and they help to keep you safe. |
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Even if you think you don't need help, remember that you are in the hospital and that:
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Certain medications and treatments may cause you to become weak, dizzy, or confused. |
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The hospital may seem strange to you, especially at night. Furniture and equipment may not be where you would expect it to be and may get in your way. Getting to the bathroom may be hazardous in your darkened and unfamiliar room. |
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Keeping these suggestions in mind will help us to provide the best possible care to you. |
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21 Tips To Make Your Healthcare As Safe As Possible |
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Be Involved In Your Health Care
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The single most important way you can help to prevent errors is to be an active member of your healthcare team. That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results. Some specific tips, based on the latest scientific evidence about what works best, follow. |
Medications
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Make sure that all of your doctors know about everything you are taking. This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs. As least once a year, bring your medicines and supplements with you to your doctor. Bringing in your medications can help you and your doctor talk about them and find out if there are any problems. It can also help your doctor keep your records up to date, which can help your get better quality care. |
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Make sure your doctor knows about any allergies and adverse reactions you have had to medicines. This can help you avoid getting a medicine that can harm you. |
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Make sure your doctor writes you a prescription, and make sure you can read it. If you cannot read your doctor's handwriting, your pharmacist might not be able to either. Ask your doctor to help you read it. You might ask him or her to print the medication, dose, and directions below the handwriting or on a separate piece of paper. |
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Ask for information about your medications in terms you can understand — both when your medications are prescribed and when you receive them.
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What is the medicine for? |
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How am I supposed to take it, and for how long? |
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What side effects are likely? What do I do if they occur? |
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Is this medicine safe to take with other medicines or dietary supplements I am taking? |
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What food, drink, or activities should I avoid while taking this medicine? |
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When you pick up your medication from the pharmacy, make sure it is the medicine that your doctor prescribed. Compare it with what your doctor wrote for you. Check to see if there are any differences in the written discharge medication list from the hospital and the label on the medication your pharmacy has given you. If you have any questions, ask the pharmacist to call your doctor. A study by the Massachusetts College of Pharmacy and Allied Health Sciences found that 88% of medicine errors involved the wrong drug or the wrong dose. |
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If you have any questions about the directions on your medicine labels, ask. Medicine labels can be hard to understand. For example, ask if "four doses daily" means a dose every 6 hours around-the-clock or just during regular waking hours. |
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Ask your pharmacist for the best device to measure your liquid medicine, and ask questions if you're not sure how to use it. Resources show that many people do not understand the right way to measure liquid medicines. Household teaspoons often do not hold a true teaspoon of liquid. Special devices like marked syringes help people to measure the right dose. Being told how to use the device helps even more. |
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Ask for written information about the side effects that your medicine could cause, and which ones to worry about. Medicines may have many minor side effects. You need to know what is serious. If you know what might happen, you will be better prepared if it does. That way, you can report the problem right away and get help before it gets worse. A study found that written information about medicines can help patients recognize problem side effects and then get the information to their doctors or pharmacists. |
Hospital Stays
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If you have a choice, choose a hospital that has experience with the procedure or surgery you need. Research shows that patients tend to have better results when they are treated in hospitals that have experience with the patient's condition. |
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While you are in a hospital, consider asking all health care workers who have direct contact with you whether they have washed their hands. Hand washing is an important way to prevent the spread of infections in hospitals. Yet it is not done regularly or thoroughly enough. A recent study found that when patients checked whether health care workers washed their hands, the workers washed their hands more often and used more soap. |
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When you are brought medications or intravenous solutions, always ask the nurse to check to be sure that you are the patient who is supposed to receive the medications. Research has shown that occasionally another patient's medication is mistakenly given to the wrong patient. Asking questions helps you understand your medications and treatment, and makes you part of the team. |
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When you are being discharged from the hospital, ask your doctor and nurse, dietician, or pharmacist to explain the treatment plan you will use at home. This includes learning about your medicines and finding out when you can get back to your regular activities. Research shows that at discharge time, doctors believe they have explained everything clearly, when many patients do not understand and choose not to speak up because they are afraid to look "stupid." |
Preventing Operating on the Wrong Site
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If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done. Surgery on the wrong site is rare, but even once is too often. Be sure you review with your physician which site will be operated on. |
What Are Some Other Steps You Can Take?
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Speak up if you have questions or concerns. You have a right to question anyone who is involved with your care. |
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Make sure that someone, such as your personal doctor, is in charge of your care. You need to know who is in charge and who will coordinate all your care. This is especially important if you have many health problems, or are in a hospital with many consulting doctors. |
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Make sure that all health professionals involved in your care have important health information about you. Do not assume that everyone knows everything they need to know. |
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Ask a reliable family member or friend to be there with you and to be your advocate (someone who can help get things done and speak for you of you are unable). You might consider creating a Medical Power of Attorney document. Even if you do not think you need help now, you might need it later. You will want someone speaking for you that knows what is going on. |
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More is not always better. It is a good ideal to find out why a test or treatment is needed and how it can help you. You might be better off without it. |
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If you have a test, do not assume that no news is good news. Ask about results. |
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Learn about your condition and treatment by asking your doctor and nurse, and by using other reliable resources. For example, treatment recommendations based on the latest scientific evidence are available from the National Guidelines Clearinghouse at http://www.guideline.gov. There are many resources available to you. |
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Enhancing Lives Through Organ and Tissue Donation
At the end of 1999, there were 1044 residents of Colorado and Wyoming waiting for an organ transplant. Yet there are only 85 to 90 organ donors each year from our region. More than 71,000 Americans are in need of major organs. In addition, thousands more are waiting for some type of tissue transplant for the replacement or repair of diseased or injured tissues.
Organ and Tissue Donation: Most Frequently Asked Questions
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Who can donate organs and tissues?
Almost everyone can be a donor as long as consent is given by next of kin and they are determined to be medically suitable. |
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What is the age limit for donors?
The age limit for donation is constantly changing. Today anyone who is 80 years or younger will be considered for organ/tissue donation. |
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What are the steps to becoming a donor?
You simply indicate your desire to be an organ and tissue donor on a signed donor card, driver's license, or other legal document. Most important, discuss this decision with your family so that they know to honor your wish to give the gift of life when the time comes. |
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If I sign a donor card or driver's license, will my wishes be carried out?
Even if you sign a donor card or driver's license, it is essential that your family knows your wishes. A signed consent for donation is required from the next of kin |
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What organs and tissues can I donate?
The heart, kidneys, pancreas, lungs, liver, and small intestine are the organs that can be transplanted. Corneas, skin, bone, heart valves, tendons, and ligaments are among the tissues. |
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If I sign a donor card, will it affect the quality of medical care I receive at the hospital?
Choosing to be a donor will in no way affect the quality of medical care received. Organ and tissue donation is never considered until all efforts to save a person's life have failed and the person is declared dead. |
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Will donation delay or change any funeral arrangements?
Donation does not usually cause any delay or change of funeral arrangements nor change the appearance of the body. An open casket funeral remains an option. |
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Are there any religious objections to organ and tissue donation?
No. In fact, most religious faiths endorse donation as a gift of life to fellow human beings. If you have more specific questions, contact your religions advisor. |
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Are there any costs to my family for donation?
All costs related to donation are paid by Donor Alliance. The donor family pays only for the medical care before death is declared and for funeral expenses. |
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Do issues such as race or wealth affect the availability of or access to an organ transplant?
The Organ Procurement and Transplantation Network matches donated organs with critically ill patients on the national waiting list. Medical urgency, issues of compatibility such as blood type, tissue match, and body size are considerations in determining who receives a transplant. Race or wealth are never issues, and buying or selling organs is against the law. |
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Can I be an organ and tissue donor and also donate my body to medical science?
If you are an organ donor, medical schools generally will not accept whole body donation. Whole body donations must be arranged with the medical school of your choice prior to your death. |
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Are You an Organ and Tissue Donor?
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Donor Alliance
3773 Cherry Creek North Drive, Suite 601
Denver, CO 80209
(303) 329-4747
Toll Free: 888-868-4747
Fax: 303-321-0366
www.donoralliance.org |
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An Important Message From Medicare |
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Your Rights While You Are a Medicare Hospital Patient
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You have the right to receive all the hospital care that is necessary for the proper diagnosis and treatment of your illness or injury. According to Federal law, your discharge date must be determined solely by your medical needs, not by "DRG's" or Medicare payments. |
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You have the right to be fully informed about decisions affecting your Medicare coverage and payment for your hospital stay and for any post-hospital services. |
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You have the right to request a review by a Peer Review Organization (PRO) of any written Notice of Non-Coverage that you receive from the hospital stating that Medicare will no longer pay for your hospital care. PRO's are groups of doctors who are paid by the Federal Government to review medical necessity, appropriateness, and quality of hospital treatment furnished to Medicare patients. The phone number and address of the PRO for your area is: |
COLORADO FOUNDATION FOR MEDICAL CARE (CFMC)
720 North Main Street, #315 (World Savings Building)
Pueblo, CO 81003 719-542-1015
Talk To Your Doctor About Your Stay in the Hospital
You and your doctor know more about your condition and your health needs than anyone else. Decisions about your medical treatment should be made between you and your doctor. If you have questions about your medical treatment, your need for continued hospital care, your discharge, or your need for possible post-hospital care, don't hesitate to ask your doctor. The hospital's patient representative or social worker will also help your with your questions and concerns about hospital services.
If You Think You Are Being Asked to Leave the Hospital Too Soon
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Ask a hospital representative for a written notice of explanation immediately, if you have not already received one. This notice is called a "Notice of Non-Coverage." You must have this Notice of Non-Coverage if you wish to exercise your right to request a review by the PRO. |
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The notice of Non-Coverage will state either that your doctor or the PRO agrees with the hospital's decision that Medicare will no longer pay for your hospital care. |
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If the hospital and your doctor agree, the PRO does not review your case before a Notice of Non-Coverage is issued. But the PRO will respond to your request for a review of your Notice of Non-Coverage and seek your opinion. You cannot be made to pay for your hospital care until the PRO makes its decision, if you request the review by noon of the first work day after you receive the Notice of Non-Coverage. |
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If the hospital and your doctor disagree, the hospital may request the PRO to review your case. If it does make such a request, the hospital is required to send you a notice to that effect. In this situation, the PRO must agree with the hospital or the hospital cannot issue a Notice of Non-Coverage. You may request that the PRO reconsider your case after you receive a Notice of Non-Coverage, but since the PRO has already reviewed your case once, you may have to pay for at least one day of hospital care before the PRO completes this reconsideration. |
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IF YOU DO NOT REQUEST A REVIEW, THE HOSPITAL MAY BILL YOU FOR ALL THE COSTS OF YOUR STAY, BEGINNING WITH THE THIRD DAY AFTER YOU RECEIVE THE NOTICE OF NON-COVERAGE. THE HOSPITAL, HOWEVER, CANNOT CHARGE YOU FOR CARE UNLESS IT PROVIDES YOU WITH A NOTICE OF NON-COVERAGE. |
Message To Medicare Beneficiaries
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The Omnibus Reconciliation Act (COBRA), Section 9353 c and e, requires a review of all written complaints from Medicare beneficiaries about the quality of care they have received. These complaints about the quality of care can be in regards to hospitals, skilled nursing facilities, hospital outpatient departments, ambulatory surgery centers, or home health agencies. This review is to be carried out by PRO's. |
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If you have a complaint about the quality of care you have received as a Medicare beneficiary, record your complaint in writing and send to:
Colorado Foundation for Medical Care
Attention: Special Review Programs
PO Box 17300
Denver, CO 80217 |
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If you have any questions regarding payment of your bill, charges on your bill, or questions about whether services are paid by Medicare, they should be directed to:
Billing Office
Mt. San Rafael Hospital
(719) 846-9213 |
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