Common Trainee Policy and Procedure Manual RV 4 1 FINAL As of 6 2616

Common Trainee Policy and Procedure Manual
Effective 07/01/16
Trainee P&P Manual
Reviewer Title Signature
Michelle Langaker, DO Director of Medical Education
Donald Maharty, DO Vice President of Medical Education
Trainee Manual Version Control

Version Date Author Change Description
1 07/01/2015 Dawn Stull New
2 04/19/2016 Dawn Stull Review/Revised
Reviewed and Approved by Medical Education

Date: 5/17/2016
Committee:
DISCLAIMER: The content of a manual does not constitute nor should it be construed as
a promise of employment or as a contract between Harnett Health and any of its employees.
Harnett Health at its option, may change, delete, suspend, or discontinue parts or the policy
in its entirety, at any time without prior notice.
The Institution at its option, may change, delete, suspend or

discontinue portions of this manual at any time without prior
Effective 07/01/16 notice. It is the trainee’s responsibility to obtain the most current Page 2
Version 2 version of this manual. A current copy of this manual is available
in the Medical Education Department. Any changes in this manual
shall apply to existing as well as future trainees.
TABLE OF CONTENTS
1 INTRODUCTION ........................................................................................................................ 10
1.1 Welcome ........................................................................................................................................................10
1.2 History ...........................................................................................................................................................10
1.3 Orientation Schedule ..................................................................................................................................11
1.4 Changes in Policies ......................................................................................................................................11
2 OPERATIONAL POLICIES ......................................................................................................... 12
2.1 Educational Structure .................................................................................................................................12
2.2 General Objectives ......................................................................................................................................12
2.3 Expected Outcome .....................................................................................................................................15
2.4 Appointment ................................................................................................................................................15
2.5 Qualifications................................................................................................................................................15
2.6 Term of Service ............................................................................................................................................16
2.7 Trainee Contract ..........................................................................................................................................16
2.8 Status ..............................................................................................................................................................17
2.9 Educational Stipend ....................................................................................................................................18
2.10 Time Away ....................................................................................................................................................18
2.11 Absences........................................................................................................................................................18
2.12 Unauthorized/Unscheduled Absences ....................................................................................................19
2.13 Completion of Training ..............................................................................................................................19
2.14 Program Closure or Reduction .................................................................................................................19
2.15 Restrictive Covenants .................................................................................................................................20
2.16 Visa Policies & Procedures for Foreign/US Medical School Graduates ..........................................20
2.17 Revocation of Off-Duty Hours ................................................................................................................20
3 EMPLOYMENT POLICIES ......................................................................................................... 21
3.1 Equal Employment Opportunity/Diversity ...........................................................................................21
3.2 Americans with Disabilities Act ................................................................................................................21

3.3 Employee Background Check ...................................................................................................................21
3.4 Pre-Employment Evaluation .....................................................................................................................21
3.5 Post Enrollment Requirements: Years 1-4..............................................................................................23
3.6 Criminal Records .........................................................................................................................................24
3.7 Controlled Substance (DEA) ....................................................................................................................24
3.8 Physician Impairment & Substance Abuse .............................................................................................25
3.9 Licensure .......................................................................................................................................................25
3.10 Certificates ....................................................................................................................................................26
3.11 Change of Personal Data............................................................................................................................27
3.12 Chain of Communication ...........................................................................................................................27
3.13 Safety ..............................................................................................................................................................27
3.14 Personal Property ........................................................................................................................................27
3.15 Professional Activities outside the Program ...........................................................................................28
3.16 Visitors in the Workplace ...........................................................................................................................28
3.17 Weather-related and Emergency-related Closings .................................................................................28
4 DISCIPLINARY PROCESS ..........................................................................................................29
4.1 Performance .................................................................................................................................................29
4.2 Remediation Process ...................................................................................................................................31
4.3 Summary Suspension ..................................................................................................................................31
4.4 Automatic Suspension ................................................................................................................................32
4.5 Trainee Appeals Process ............................................................................................................................32
4.6 Grievance and Due Process Procedure ...................................................................................................34
4.7 Maintaining Discipline among Patients, Nurses and Employees ........................................................39
4.8 Transitions of Care (Structured Patient Handoffs) ...............................................................................39
5 STANDARDS OF CONDUCT ......................................................................................................42
5.1 Work Schedule .............................................................................................................................................42
5.2 General Guidelines ......................................................................................................................................42

5.3 Duty Hours ..................................................................................................................................................42
5.4 Harassment Policy .......................................................................................................................................42
5.5 Sexual Harassment Policy ..........................................................................................................................43
5.6 Violence in the Workplace .........................................................................................................................44
5.7 Confidential Information and Nondisclosure ........................................................................................44
5.8 Ethical Standards .........................................................................................................................................44
5.9 Dress Code ...................................................................................................................................................45
5.10 Use of Equipment .......................................................................................................................................45
5.11 Use of Computer, Phone, and Mail ..........................................................................................................45
5.12 Use of Internet .............................................................................................................................................45
5.13 Use of Computer Software ........................................................................................................................46
5.14 Smoking Policy.............................................................................................................................................46
5.15 Alcohol and Substance Abuse ...................................................................................................................47
5.16 Subpoenas, Claims, & Other Requests ....................................................................................................47
5.17 Disputes between Trainees & Medical Supervisors ..............................................................................47
5.18 Corporate Communications ......................................................................................................................48
5.19 Corporate Compliance ................................................................................................................................48
5.20 Obligation to Treat ......................................................................................................................................48
5.21 Moonlighting ................................................................................................................................................49
5.22 Departing Trainees ......................................................................................................................................49
5.23 Hospital Property ........................................................................................................................................49
5.24 Accidents to Patients...................................................................................................................................50
5.25 Nursing Service ............................................................................................................................................50
5.26 Professional Care of Hospital Personnel .................................................................................................50
6 DIDACTIC PROGRAMS .............................................................................................................. 51
6.1 Didactic Attendance ....................................................................................................................................51
6.2 Attendance Rosters .....................................................................................................................................51

6.3 Morning Report ...........................................................................................................................................51
6.4 Journal Club ..................................................................................................................................................51
6.5 OMM Lecture ..............................................................................................................................................51
7 RESPONSIBILITIES ....................................................................................................................52
7.1 Trainers ..........................................................................................................................................................52
7.2 Department ...................................................................................................................................................52
7.3 Medical Education Committee..................................................................................................................52
7.4 Administrative ..............................................................................................................................................53
7.5 Supervision....................................................................................................................................................53
8 COMPENSATION/INSURANCE POLICIES ............................................................................54
8.1 Payroll/Stipend ............................................................................................................................................54
8.2 Employee Benefits.......................................................................................................................................54
8.3 Insurance .......................................................................................................................................................55
8.4 Educational Stipend ....................................................................................................................................56
8.5 Relocation .....................................................................................................................................................56
8.6 Housing .........................................................................................................................................................56
8.7 Malpractice Insurance .................................................................................................................................56
8.8 Timekeeping Procedures ............................................................................................................................56
9 TIME-OFF BENEFITS ................................................................................................................57
9.1 Vacation Time ..............................................................................................................................................57
9.2 Family Medical Leave..................................................................................................................................57
9.3 Maternity/Paternity Leave .........................................................................................................................58
9.4 Extended Leave of Absence ......................................................................................................................58
9.5 Bereavement Leave .....................................................................................................................................59
9.6 Sick Leave .....................................................................................................................................................59
9.7 Paid Time Off ..............................................................................................................................................60
9.8 Military Reserves or National Guard Leaves of Absence ....................................................................60

9.9 Jury Duty .......................................................................................................................................................60
9.10 Professional Leave of Absence .................................................................................................................61
9.11 Additional Benefit & Leave Considerations ...........................................................................................61
10 COMPENSATION/INSURANCE POLICIES INSTITUTIONAL POLICIES.........................62
10.1 Policy & Procedure Manuals .....................................................................................................................62
10.2 Communicable Diseases .............................................................................................................................62
10.3 Reporting Requirements for Communicable Diseases .........................................................................63
10.4 Advocacy Efforts .........................................................................................................................................63
11 EVALUATIONS ............................................................................................................................64
11.1 Program Evaluation Committee and Annual Program Evaluation ....................................................64
11.2 Evaluation of Faculty ..................................................................................................................................64
11.3 Evaluation of Trainee’s Performance ......................................................................................................64
11.4 Evaluation of Training Programs .............................................................................................................66
12 MEDICAL RECORDS ..................................................................................................................67
12.1 Guidelines for Use of Medical Records...................................................................................................67
12.2 Guidelines for Documentation in the Medical Record.........................................................................67
12.3 Protected Health Information ...................................................................................................................68
12.4 Medical Staff Rules & Regulations ...........................................................................................................69
12.5 Physician’s Orders .......................................................................................................................................69
12.6 Service to In-patients ..................................................................................................................................69
13 INSTITUTIONAL RESOURCES ..................................................................................................70
13.1 Child Protection Program ..........................................................................................................................70
13.2 Employee Health Service ...........................................................................................................................70
13.3 Employee Assistance Program ..................................................................................................................71
13.4 Nursing Department ...................................................................................................................................71
13.5 Nutrition Services ........................................................................................................................................72
13.6 Pharmacy .......................................................................................................................................................72

13.7 Security ..........................................................................................................................................................73
13.8 Rehabilitation Services ................................................................................................................................73
13.9 Social Work ...................................................................................................................................................74
13.10 Communications/Information Services ..................................................................................................74
13.11 Transport of Patients ..................................................................................................................................75
13.12 Paging System ...............................................................................................................................................75
14 TRAINEE RESOURCES ..............................................................................................................76
14.1 Conferences, Rounds, Lectures.................................................................................................................76
14.2 Trainee Participation on Hospital Committees ......................................................................................76
14.3 Computer Use and Support .......................................................................................................................76
14.4 Food Services ...............................................................................................................................................78
14.5 Interpreter Services .....................................................................................................................................78
14.6 Library Facilities ...........................................................................................................................................78
14.7 On-Call Rooms ............................................................................................................................................79
14.8 Uniforms & Laundry...................................................................................................................................79
15 UNIVERSAL PRECAUTIONS .....................................................................................................80
15.1 Basic Elements of BSI ................................................................................................................................80
15.2 Nurses & Other Direct Care Providers Role in BSI System ...............................................................81
15.3 Precautions for Patients with Airborne Diseases...................................................................................81
15.4 Supplies Needed for BSI ............................................................................................................................84
15.5 Other BSI Procedures.................................................................................................................................84
16 EMPLOYEE COMMUNICATIONS ............................................................................................85
16.1 Open Communication ................................................................................................................................85
16.2 House Staff Meetings ..................................................................................................................................85
16.3 Suggestions ...................................................................................................................................................85
17 LOGS ..............................................................................................................................................86
17.1 Important Points to Remember ................................................................................................................86

17.2 What to Log? ................................................................................................................................................86
17.3 How to Log ..................................................................................................................................................87
17.4 Policy Statement ..........................................................................................................................................87
18 ACKNOWLEDGEMENT .............................................................................................................89

1 INTRODUCTION
This document has been developed by the Department of Medical Education in

order to familiarize trainees with Harnett Health’s Residency Programs. In addition
to the Common Trainee Policy and Procedure Manual, program specific manuals
highlight standards for residents and their successful completion of their assigned
residency program.
As a member of the trainee staff, you are entitled to well-defined rights and privileges
while you participate in the educational goals of the program you have selected. This
manual is a guidebook to the goals, regulations, and policies of the training program.
The goal of our training programs is to provide high quality training that gives each
trainee a foundation for future medical training while fulfilling the accrediting body’s
requirements for the selected program. In conjunction with Campbell University
Jerry M. Wallace School of Osteopathic Medicine (CUSOM), we believe our
organization has developed a curriculum that meets the goals and objectives of the
accrediting body and provides a comprehensive base for future medical training.
1.1 Welcome
Welcome to Harnett Health! We are happy to have you as a new member of our
family!
Our Mission:
“Harnett Health is dedicated to providing quality and personalized care with respect and
compassion. We are committed to making a difference throughout our communities with service
excellence”.
Our Vision:
“Harnett Health will be a Top Tier Regional Hospital System providing nationally recognized
quality primary and secondary care”.
1.2 History
Harnett Health refers to the administrative section for all the components of the
health system: the hospital, outpatient surgery centers, and hospital sponsored
practices. The Department of Medical Education is a hospital subdivision
responsible for all medical education sponsored by this institution and for the
appropriate training and experience of trainees who are assigned here through an
affiliation agreement with another institution. The DME is a physician who is

appointed by the hospital and the sponsoring academic institution to be responsible
for the education of medical trainees and students from that College.
Policies and procedures for medical education are largely determined by the accrediting
body and are applied to all training programs. The hierarchy in this program starts with
the Chief Resident, the Attending Physician, the DME, and the Vice President of Medical
Education.
Your participation in the governance of academic affairs is critical to our success.

There are two routes of access to hospital and medical staff information for trainee
physicians: (1) The medical staff committees and (2) regular meetings held by your
department and the DME.
1.3 Orientation Schedule
Trainee orientation is structured to help the individual become familiar with their
roles, responsibilities and institutional aspects of the organization. We understand
that the orientation schedule provides a great deal of information, remember – we
encourage you to ask questions and to refer to your manual and seek assistance from
the members of the Department of Graduate Medical Education.
1.4 Changes in Policies
This manual supersedes all previous trainee manuals and memos. While every effort
is made to keep the contents of this document current, Harnett Health reserves the
rights to modify, suspend, or terminate any of the policies, procedures, and/or
benefits described in the manual with or without prior notice to trainees.

2 OPERATIONAL POLICIES
2.1 Educational Structure
The training program is structured to provide trainees with the fundamental

knowledge and essential principles requisite for the application of pre-doctoral
knowledge to clinical decision-making and skills. The basic techniques of physical
examination, the necessary skills for performing clinical procedures, and the
capability to communicate clearly with patients, their families and other members of
the health care team are stressed in our training program(s).
2.2 General Objectives
During training, under the direct supervision of an attending physician, you should
attain a level of competence that will qualify you to continue your postdoctoral
training. Satisfactory levels of accomplishment must be demonstrated in the
cognitive, psychomotor, and affective aspects of patient management. Upon
satisfactory completion of training, you should be able to:
1. Obtain patient information accurately, comprehensively, and systematically;
obtain a thorough and accurate personal and family history; perform a
complete history and physical examination; maintain appropriate demeanour
and sensitivity to the patient when performing a physical examination.
2. Present a clear clinical picture, verbally and in writing, of the history, physical
examination, chief complaint, diagnostic testing, rationale for therapy based
on pathophysiology, altered/pathologic anatomy and endocrinology, and
anticipated results sequelae; present succinctly and confidently by organizing
and recording data in a concise, legible format; accurately record information
shortly after completing an examination – write clearly and legibly to ensure
that the members of the health care team can interpret the information.
3. Differentiate between important; less important; and/or, unimportant

information to be recorded on the patient’s medical record; maintain
adequate and up-to-date medical records.
4. Diagnose and treat the most commonly encountered diseases in primary care
practice; recognize, diagnose and treat the acute, life-threatening conditions
encountered by the primary care physician; differentiate less common disease
entities for diagnosis; recognize conditions which require referral and or
consultation.
5. Determine the need to perform tests for the purpose of diagnosis and
treatment of the patient’s current problem; interpret the results of
investigative tests as they apply to a patient’s condition and/or disease.
6. Develop a comprehensive, therapeutic health care plan based upon identified
disease(s), disorder(s), and defined patient needs; identify appropriate length
of stay (LOS) for each patient problem, taking into consideration diagnosis
related groups (DRGs).
7. Demonstrate logical decision making and clinical problem solving relative to

case management; develop a patient problem list and demonstrate the proper
use of problem oriented medical record (POMR) for recording progress
notes and physician orders (information written in the physician’s orders
must illustrate a logical association with the information written in the
problem list and the progress note).
8. Determine and prescribe medications; be familiar with the pharmacology of

all agents used, including indications, contraindications, appropriate dosage,
possible interactions, and proper routes of administration.
9. Select and consult with appropriate allied health professionals (e.g. dieticians,
physical therapists, occupational therapists, etc.) to assist in patient care (e.g.
nutrition, rehabilitation, activities of daily living, etc.) and propose immediate,
necessary steps in the medical management of the patient.
10. Interpret statistical data in literature as it applies to patient situations; utilize

current medical literature to gain insights into the care of the patient and
continuously update medical knowledge and medical practice skills.
11. Recognize the value of evidence-based medicine in the practice of medicine,

literature searches, patient care and education, scholarly writing, research, etc.
12. Provide health care for acute problems in the initial contact with an
assessment of the patient as well as on-going treatment of chronic problems;
follow the patient at appropriate intervals, both in the hospital and on an
ambulatory basis, modifying the original patient management plan when
necessary; determine the approximate time for discharging hospitalized
patients and necessary post-discharge care.
13. Demonstrate the psychosocial skills needed to develop trusting relationships

with individual patients and their family members; establish and maintain a
therapeutic and support rapport with the patient.
14. Promote positive interrelationships with health professionals in the

community.
15. Understand how family dynamics and interpersonal relationships affect the
health and illness of a patient; provide that support of family therapy when
required.

16. Deliver medical care to the family unit by recognizing and allaying the fears
and anxieties of the patient and family members, and attempt to understand
the impact of the patient’s background and environment on his/her wellness.
17. Understand the impact that illness of any member of the nuclear or extended
family has on the function of the family unit.
18. Identify preventive health measures and demonstrate appropriate teaching

techniques to the patient and the patient’s family; serve as an educator who
instructs patients in preventive medicine, responsibility for personal health
care and community medicine.
19. Provide care and rehabilitative programs for the chronically ill, permanently
disabled, and physically challenged and or geriatric patient; determine and
prescribe the degree of physical activity for the optimum functioning of the
patient.
20. Demonstrate osteopathic philosophy integrating anatomical, physiological,

and psychological considerations; identify and demonstrate appropriate use
of osteopathic manipulative medicine (OMM).
21. Maintain confidentiality and the uniqueness of the patient as a person.
22. Participate in community preventive medicine, health screening programs,

epidemiology, community health resources, rehabilitative centers and care for
geriatric patients.
23. Exhibit high ethical standards for medical practice; identify, analyse, and
respond effectively to ethical problems/issues that arise frequently in the
practice of medicine.
24. Assess one’s own medical competence; understand legal rules and principles
that impact the practice of medicine.
25. Understand basic practice management principles and procedures such as

billing, scheduling, record keeping, etc.
26. Understand the impact of evolving managed health care environment on the
practice of medicine.
27. Develop an understanding of the seven core competencies and how they
apply to patient care.

2.3 Expected Outcome
 To produce clinicians who are grounded in evidence-based medicine.

 To produce clinicians who are compassionate and embody what it means to
be a physician.
 To view the patient in their entirety, mind, body and spirit.
 To produce clinicians who are proficient in all seven core competencies.

 To have a program that is compliant with all accrediting body’s basic and
specialty/subspecialty standards.
 To create an environment that fosters research opportunities as well as other
scholarly pursuits.
 To train and prepare individuals for their career goals in specialty training,
hospital-based medicine, office-based medicine or fellowship training.
2.4 Appointment
Appointments to the training program are made on the recommendation of the

Medical Education Committee (MEC) and the DME.
The application process at Harnett Health is as follows:
a. Interested medical school students must apply through the National
Matching Service (NMS) through ERAS.
b. Upon receipt of information requested on the NMS and available on ERAS,
(i.e. three letters of professional reference, letter from your medical school
Dean stating you are a student in good standing, board scores, and
transcripts, the Department of Medical Education will contact applicants to
arrange an appointment for an interview;
c. Applicants are interviewed by the DME and/or members of the MEC;
d. Applicants are discussed at the January MEC Executive Session and either
accepted or denied and a rank order list is generated;
e. Harnett Health will complete the National Registration Match forms that
are returned within the appropriate timeframe;
f. Results of the Match are returned, usually in February. Contracts are mailed
out within the time allotted by the accrediting body’s match regulations.
2.5 Qualifications
The following is the policy of Harnett Health regarding the recruitment, eligibility
and selection of trainees. Each applicant must file an application through the training
program’s respective match process, provide three reference letters, a Dean's letter,
board scores, medical school transcripts, medical school diploma; and, finally, appear
for a series of interviews.
A. Qualifications. Applicants must meet the following qualifications to be

eligible for appointment to a residency-training program:
1. Graduate of an accredited medical college.
2. Have and maintain membership with the accrediting body throughout
training.
3. Prior to starting training, all trainees must pass Step II of corresponding
board.
4. Have a full and unrestricted license (training certificate) to practice
medicine in a U.S. licensing jurisdiction.
B. Selection.
1. Upon receipt of application, the Department of Medical Education
designee shall notify the applicant in writing of its receipt and any
deficiencies, if noted, within one (1) month.
2. All applicants considered for acceptance shall be scheduled for an
interview with the Selection Committee.
3. Selection of trainees shall not be based on race, gender, color, creed,
religion, national origin, ancestry, age, marital status, disability, sexual
orientation (including gender identity) or status as a protected veteran.
In selecting from qualified applicants, programs participate in an organized matching
program, where available, such as the National Trainee Matching Program (NRMP).
2.6 Term of Service
The period of service shall be one year. Under exceptional circumstances, training
may be extended through the FMLA. All leaves must be reported to the DME, the
MEC, and the accrediting body. All additional time taken off during training must
be made up at the end of the contract year.
2.7 Trainee Contract
Upon completion of the “Match”, Harnett Health’s Department of Medical

Education will send to the matched trainees, the institutional contract within 10 days
of receiving the Match results. The trainee must return this contract within 30-days
of issuance for the contract to become valid.
A trainee who breaches the contract may not serve an internship, residency or
fellowship program for a period of twelve (12) months following the date of the
breach.
Contract requirements must be met in full. Trainee’s failing to pass COMLEX Part
II prior to the start of training will result in a breach of the contract and will result in
the immediate termination of the trainee. Violation of the contract by a trainee may
result in the loss of credit for time served in the program.
All appointments are for one year or less, and may be renewed at the discretion of
the institution, upon continued evidence of satisfactory performance.
The trainee contract shall reference: (these items shall be outlined in detail
throughout this manual)
1. Responsibilities
2. Duration of appointment
3. Financial support
4. Conditions under which living quarters, meals, laundry are provided
5. Conditions for reappointment and promotion
6. Grievance and due process procedures
7. Professional liability insurance
8. Liability coverage for claims filed after program completion
9. Health and disability insurance
10. Leave of absence policy
11. Sick leave policy
12. Policy on effects of leaves on satisfying criteria for program completion
13. Duty hours policies and procedures
14. Policy on moonlighting
15. Policy on other professional activities outside the Program Director
Counseling, medical, psychological support services
16. Policy on physician impairment and substance abuse
17. Policy on sexual harassment
18. Policy closure of hospital/training programs or reduction in approved
positions
The contract will be maintained in the individual trainee’s personnel file.
All institutional human resource policies are applicable to trainees under the
discretion of the DME.
2.8 Status
You are an employee of the hospital. As an employee, you are responsible to the
Board of Directors through the DME. The hospital is liable for your acts.
Remember – during your first year of training, you do not have a license to practice
medicine outside of the institution unless on a rotation approved by the Department
of Medical Education. You will not be covered by malpractice insurance unless you
are on an approved rotation. Under no circumstances may the first year trainee
engage in moonlighting, i.e. employment outside of the hospital. Moonlighting is
grounds for immediate termination.

2.9 Educational Stipend
Each trainee will be allocated a specific dollar amount as outlined in the letter of
appointment to be used for educational expenses during the training year. These
dollars will not carry over into the next academic year. Funds will be available at the
start of training.
If the trainee is unsure whether an expense can be counted toward these educational
dollars, they are responsible for speaking with the Administrative Director and/or
DME prior to the purchase of such item.
To be reimbursed for educational expenses, the trainee must complete an
“Employee Expense Reimbursement Form”, sign and attach the original receipt(s).
Return completed form and receipts to the Medical Education Office for further
processing and tracking of educational expenses.
Note: Educational stipends may be subject to applicable taxation.
2.10 Time Away
Trainees are allocated twenty (20) days off for personal reasons during the academic
year. The following is a list of acceptable days that can be used:
Personal Days Off (PTO):
To be used for: vacation, sick, personal days, medical conferences, interviews, board
exams; not to be used for holidays when on call.
All requests for “time off” must be submitted four weeks prior to the requested time
off or within 24 hours of returning from a sick day. Failure to comply will result in
these days being made up during the weekend. All notification of time away must be
communicated in writing.
If you request time off on a day when you are scheduled for call – you are NOT
excused from call. You must find someone to take your call and make that day up at
another time. TIME AWAY DOES NOT EXCUSE YOU FROM CALL.
You may not take more than one-week vacation at a time.
Vacation requests will not be granted during Block 1 or 13 in any academic year.
Vacation time will not be granted while on in-patient rotations, i.e. in-patient internal
medicine, ICU. Exceptions may be granted on a case-by-case basis.
2.11 Absences
The trainee will not be permitted to leave the hospital premises other than during
off-duty hours without the permission of the DME or Administrative Director.
If it becomes necessary for a trainee to leave the premises during duty hours,
permission must be first obtained as stated above, arrange for another trainee to
cover the service, notify the switchboard and nursing station involved that you will
be off the premises, and the name of the trainee covering the service.
Upon returning to the hospital, the trainee is to notify the switchboard, the
Department of Medical Education and the nursing station, that you are back on duty.
If a trainee is unable to report to duty due to illness, he/she is to notify the attending
physician which with the trainee is rotating and complete the PTO form.
2.12 Unauthorized/Unscheduled Absences
An unauthorized absence from duty will result in disciplinary action. Any
unauthorized absence of three or more consecutive business days will constitute
a voluntary resignation from the program.
2.13 Completion of Training
Before departing Harnett Health at the conclusion of your training, you must
complete obligations to your program and also to the institution. An official
clearance sheet must be completed and turned into the Department of Medical
Education along with your ID badge. This form can be obtained from the Medical
Education office. It will show evidence of your completed medical records, and that
you have returned all hospital property such as keys, equipment, parking pass,
radiation dosimeter, keys, scrubs, etc. The form also requests a forwarding address,
and reminds you of your right to continuing health insurance coverage through
COBRA.
Harnett Health’s official certificates of completion are presented to departing

trainees by the DME.
Harnett Health is justified in withholding such certificate if the trainee fails to

complete the training program or if the trainee’s performance has been such as to
indicate that the trainee did not complete the program in a satisfactory manner. In
the event of illness necessitating the trainee’s withdrawal from the program, the
Department of Medical Education will issue a letter to the trainee listing rotations
that were satisfactorily completed or arrange for additional training at a later date to
complete the training.
A checklist of graduation requirements must be completed prior to issuing the

graduation certificate. This will be sent to the trainee during the last six-weeks of
training.
2.14 Program Closure or Reduction
If Harnett Health intends to reduce the size of, or close a training program, the

institution will inform the trainees as soon as possible. In the event of such a
reduction or closure, the institution will make every effort to allow trainees already in
the program to complete their education. If any trainee is displaced by the closure of
a program or a reduction in the number of trainees, the institution will make every
effort to assist the trainee in identifying a program in which they can continue their
education.
1. The training institution will immediately notify the accrediting body’s and
its trainees of a program closure or reduction in positions, which would
impact trainees prior to program completion.
2. If Harnett Health reduces in size or closes a program, every attempt will
be made to permit the current trainees enrolled in the program to
complete their training prior to such an action.
3. In the event of the hospital or program closure or reduction in positions,
that would impact trainees prior to program completion, Harnett Health
will immediately notify the accrediting body to aid in placement of the
enrolled trainees in other approved training.
Severance pay shall be provided for two months when institutional program closure
or reduction decisions prevent the trainees from program completion in that or
another geographically proximate program arranged by the institution.
2.15 Restrictive Covenants
Harnett Health strictly prohibits the request for any trainee to sign non-competition
guarantees.
2.16 Visa Policies & Procedures for Foreign/US Medical School Graduates
It is policy of Harnett Health to comply with the immigration laws of the United
States, and all trainees must obtain and maintain an immigration status that permits
employment by the Hospital in a clinical capacity if applicable.
All offers of employment are contingent on verification of the candidate’s right to

work in the United States. On the first day of work, every new employee will be
asked to provide original documents verifying his or her right to work and, as
required by federal law, to sign Federal Form I-9, Employment Eligibility
Verification Form.
2.17 Revocation of Off-Duty Hours
In the case of delinquent medical records, or other incomplete work, the trainee may
be assigned extra call by the Program Director, DME or the MEC Chairman,
pending the completion of work.
3 EMPLOYMENT POLICIES
3.1 Equal Employment Opportunity/Diversity
Harnett Health is committed to diversity that will build on the strengths of our
current workforce and continually enhance the diversity of our organization.
Members from the MEC will attend a number of hospital days throughout the year.
All trainee candidates are encouraged to apply for our training programs through the
National Trainee Matching Program.
Harnett Health is an equal opportunity employer and does not discriminate on race,
color, citizenship status, national origin, ancestry, gender, sexual orientation, age,
weight, religion, creed, physical or mental disability, marital status, veteran status,
political affiliation, handicapped persons who, with reasonable accommodation, can
perform the essential functions of the job or any other factor protected by law.
3.2 Americans with Disabilities Act
It is the policy of Harnett Health to comply with all the relevant and applicable
provisions of the Americans with Disabilities Act (ADA). Harnett Health will not
discriminate against any qualified employee or job applicant with respect to any
terms, privileges, or conditions of employment because of a person’s physical or
mental disability.
3.3 Employee Background Check
Prior to making an offer of employment, Harnett Health may conduct a job-related

background check. A comprehensive background check may consist of prior
employment verification, professional reference checks, education confirmation, and
criminal check.
3.4 Pre-Employment Evaluation
All employees of Harnett Health are required to pass a pre-employment physical.

Arrangements for a pre-employment physical will be scheduled during the week of
orientation. Record of immunizations and other health information will be
maintained in the Employee Health Record.
Harnett Health is commitment to the health and safety of its employees, as well as its
patients. This includes the assurance of a drug and alcohol-free work environment.
The Hospital has, therefore, implemented a substance abuse policy that applies to all
Harnett Health employees, making mandatory drug screening a regular part of the
pre-employment physical. Any refusal of a trainee to complete, or failure to
satisfactorily pass this screening will be turned over to the Committee of Impaired
Physicians for review.
The pre-employment examination will include a urine drug screen and a blood
alcohol test. Trainees are required to take an annual TB test and as often as
requested by the institution. Prior to starting a training program, trainees are
required to provide evidence of vaccination, immunity, or proof of medical and or
religious exemption. Immunizations to include the following:
 Rubeola (measles): If born before 1957, documentation of one (1) measles

vaccination and a recent titer (within one (1) year of matriculation) showing
sufficient levels of measles antibodies.
If born after 1957, documentation of two (2) live measles vaccination or one
(1) after 1979 measles vaccination and recent titer within 1 year.
 Rubella: Proof of immunity by laboratory evidence or recent immunization

documented.
 Mumps: Documentary evidence of immunization or proof of immunity by

laboratory evidence. History of the disease is not acceptable.
 Polio: Documentary evidence of immunization.
 Tetanus/diphtheria: Date of last vaccination. If none in the past ten (10)

years, then vaccination is needed.
 Chickenpox: History of the disease
 Tuberculosis: Results of an annual tuberculin skin test within six months

prior to matriculation and yearly thereafter.
 Varicella Vaccine: Documentary evidence that vaccine was administered

x2 with titers
Every new employee is required to have a physical examination provided by the hospital.
Employment will be conditional dependent on the results of the physical. Physician trainees
may be required to submit to periodic medical tests when warranted by the hospital during
employment.
At the time of the physical exam, trainees will receive a “Fit Test for N-95 Mask Respirator”.

3.5 Post Enrollment Requirements: Years 1-4
 Hepatitis B: All physicians in training should be immunized (series of three

{3} injections against hepatitis b virus or provide serologic proof of
immunity (titer) as part of their preparation for clinical work.) Anyone
electing not to take the hepatitis b vaccine will be required to sign an
informed denial form on a yearly basis.
 Tuberculosis: Yearly results of tuberculin skin test.
Monitoring Requirement:
1. Written proof of required immunizations must be documented through the use
of health care monitoring form prior to or at the time of enrollment of new,
transferring or visiting trainees. A copy of the official immunization records that
document certain immunizations may be attached to the form. Please do not
send originals.
2. A yearly statement of results of the tuberculin skin test signed by a physician or

other appropriate health care provider only, will be accepted.
3. Any trainee electing not to receive hepatitis B vaccine must sign a hepatitis B
informed denial statement.
4. Immunization requirements will be waived if medical or other appropriate

documentation prohibits vaccination.
5. The immunization status of all physicians in training will be confidentially stored

and monitored. Release of information will be at the individual’s consent and or
as required by the Community Corporation and clinical teaching hospitals and or
sites.
6. It shall be the responsibility of the trainee to notify the DME in the event of
exposure to or having been diagnosed with a communicable disease, which could
pose risks to patients.
Failure to comply with this policy will result in the individual being withheld from
clinical activity.
Drug and Alcohol Testing: It is the policy of Harnett Health to balance the need
to provide a safe environment for physicians, employees and patients with a
willingness to assist physicians, employees and patients who are working to
overcome chemical dependency problems. The unlawful use, possession,
distribution, dispensation, manufacture, sale or transportation of controlled
substances or alcohol is strictly prohibited at Harnett Health. Harnett Health will

require all trainees to pass a post offer physical, which includes a urine drug screen
and a blood alcohol test. A licensed lab off-site will perform post offer tests.
In addition, Harnett Health will require all physician trainees to be tested for
controlled substances and or alcohol whenever there is reasonable suspicion of a
violation of this policy. Reasonable suspicion tests will be performed in the ER at
Harnett Health.
 Trainees with chemical dependency problems will be encouraged to seek
appropriate treatment for these problems, and the appropriate leave will be
provided. Trainees returning to duty from a leave of absence related to
chemical dependency problem will be required to sign a “return-to-work”
agreement providing for random drug and or alcohol tests.
3.6 Criminal Records
When appropriate, a criminal record check is performed to protect Harnett Health’s

interest and that of its employees and clients.
 All Harnett Health entities conduct criminal background checks on all final
candidates for employment. The results of criminal background checks may
take several weeks to be processed. Trainees are permitted to begin work
before the results are received. In the event that a disqualifying conviction is
returned on a trainee, the trainee will be subject to separation from the
Hospital and terminated from the training program. This separation will
occur even if the trainee has successfully completed some period of the
training program before the results are received. The trainee’s contract will
then become Null and Void.
3.7 Controlled Substance (DEA)
Controlled Substance Licensure:

Each trainee must have a Drug Enforcement Administration (DEA) Controlled
Substance Registration Number. A temporary DEA number, which is issued to each
trainee by the Hospital and terminates at the conclusion of the trainee’s training, is a
combination of the Hospital DEA and the trainee's unique alphanumeric suffix.
Federal law mandates that use of this temporary DEA is strictly limited to the care of
patients served by trainees as part of their training program.
During orientation, each trainee will sign two (2) Prescription Signature Verification
cards before the temporary DEA number can be used. The numbers will be kept on
file in the Department of Pharmacy Services.

To obtain a permanent DEA number, contact the Drug Enforcement
Administration in Washington D.C., at (202) 633-1000.
3.8 Physician Impairment & Substance Abuse
To provide a safe environment, Harnett Health trainees have a responsibility to

report to work in a fit condition. In keeping with federal drug-free regulations,
Harnett Health is committed to a drug and alcohol free work environment. As a
health care provider, we are aware of our responsibility to our patients, visitors,
employees, and medical staff to ensure that our facilities are drug and alcohol free.
Therefore, the use, sale, purchases, negotiation of sale, manufacture, distribution,
dispensation or possession of illegal drugs or the abuse of legal drugs and alcohol is
prohibited. This policy is designed to ensure a drug and alcohol free work
environment while protecting the privacy of employees and applicants with respect
to personal health information. Trainees are required to meet the Hospital’s
requirements as defined in Human Resources Policy and Procedure.
Fitness for Duty – A confidential and mandatory referral process, which evaluates an
employee’s ability to perform their job functions when pronounced changes, which
negatively impact work performance, are demonstrated. Fit employees are those
physically and mentally able to perform the standards required of their position.
Types of impairment covered by Fitness for Duty include:
1. Psychological Impairment. Significant changes in behaviors and or

psychological state. This may include but not be limited to: threats of
harm against self or others, destruction of property or threats of
destruction, dramatic mood swings, explosive anger or acting-out
behaviors, extreme disclosure of personal information, and disorganized
thoughts.
2. Physical Impairment. Significant changes in physical ability to perform
job duties and meet the physical standards that impact current job
responsibilities. They may include, but are not limited to, diminished
ability to walk, lift, climb, operate equipment, see, hear, or any physical
deterioration that compromises the trainee’s ability to perform their job.
Refer to Medical Staff Bylaws.
3.9 Licensure
The North Carolina Medical Board must license an individual pursuing graduate
medical education training in the State of North Carolina. As of October 2011, the
Medical Board has placed qualifications on board examination passage (Reference:
Board Adopts Three Attempt Rule for Exams). Please refer to the North Carolina
Medical Board for further information.
The individual may either hold a Certificate (permanent license) to practice medicine
and surgery in North Carolina, or apply to the Board for a Training Certificate
(temporary license). The Medical Education Office will provide the necessary
application forms for the Training Certificate, but responsibility for timely
completion and fee payment lies with the applicant. A Training Certificate is valid
only for a period of one year, but may be renewed annually for a maximum of five
years.
The Training Certificate allows trainees to follow the schedule of prescribed services,
rotations, and clinical activities that have been issued by their educational programs.
Please be advised of the following limitations regarding temporary licensure:
A trainee without a permanent license cannot “moonlight.”

Permanent licensure can be initiated by contacting the North Carolina Medical Board
at (800) 253-9653. The Office of Medical Education must be kept informed of any
change in licensure status.
3.10 Certificates
Each trainee, at the completion of service, will receive a certificate certifying that the
trainee has performed all the requirements set forth by the accrediting body, the
attending staff, administration of Harnett Health and the appropriate college of each
specialty training program.
The Hospital is justified in holding such a certificate back only if the trainee fails to
complete the training program including all required paperwork or if the trainee’s
performance has been such as to indicate that the trainee is not yet adequately
prepared to advance to the next level. Under no circumstances will the hospital
arbitrarily refuse to issue such a certificate for relatively minor reasons. In the event
of illness necessitating the trainee’s withdrawal from training, the hospital will supply
a letter to the trainee listing rotations that were satisfactorily completed.
The certificate of completion will include:
Name of Institution
Name of Sponsoring Institution
Trainee’s Name
Dates of Completion (start/end)
Type of program
Signatures of Institution, Sponsoring Institution, Program Director &
DME/VPME

3.11 Change of Personal Data
It is the responsibility of each trainee to report any changes in name, address or

phone number to the Department of Medical Education and their respective training
program. Efficient distribution of W-2 forms, benefits information, and other
important hospital mailings is dependent upon the data an employee has provided
and timely submission of reimbursement items as well as end-of-year tax
information.
3.12 Chain of Communication
Trainees shall follow the “Chain of Communication” policy of Harnett Health.
When necessary the CEO presides over all areas and is the final step in the chain of
command. When issues and or problems occur, the trainee should contact and speak
with:
1. Attending Physician
2. Program Director or Associate Program Director
3. Director of Medical Education
4. Vice President of Medical Education
5. CEO
3.13 Safety
Harnett Health strives to provide its employees, patients, and visitors with a safe and
healthy environment. Should conditions or hazards be identified that pose an
immediate threat to life, health or safety, the situation must be immediately and
appropriately addressed and report to the Safety Officer.
3.14 Personal Property
Harnett Health assumes no risk for any loss or damage to personal property and
recommends that all employees have personal insurance policies covering the loss of
personal property left in the Department of Medical Education.

3.15 Professional Activities outside the Program
Trainees may be required to attend educational programs based on the training

program’s requirements. The Medical Education Office of such activities will notify
trainees.
3.16 Visitors in the Workplace
For safety, insurance, and other business considerations, only authorized visitors are
allowed in the workplace. When making arrangements for visitors, employees should
request that visitors enter through the main reception area and sign in.
The hours and regulations for visiting are published and given to all patients.
Recommendations for individual exceptions to the regulations should be made to the
Nursing Supervisor.
Trainees have the obligation to discuss and answer questions about a patient’s
condition with those who have a legal right to know. Information concerning a
patient is privileged and confidential and should not be divulged to anyone except
individuals specifically designated by the patient. Non-designated friends, relatives
and visitors are not entitled to such information, but their inquiries must be handled
in a friendly and tactful manner.
3.17 Weather-related and Emergency-related Closings
At times, emergencies such as severe weather, fires, or power failures can disrupt
company operations. In such instances, Executive Staff will decide on the closure
and Harnett Health will provide the official notification to the employees.

4 DISCIPLINARY PROCESS
4.1 Performance
If the Program Director and/or DME believe that corrective action is warranted,
they may do one or more of the following:
1. Written Reprimand
2. Remedial Program Recommendation
Recommended Leave of Absence/Suspension/or at any time during training, the
Program Director and/or DME may determine that the trainee is not meeting the
standards of the program or the profession, for reasons that may include, but are not
limited to:
1. Lack of professional competence, insufficient medical knowledge, or

technical skills needed to carry out their duties and responsibilities;
2. Any conduct that is detrimental or potentially detrimental to Harnett
Health’s patients or employees;
3. Demonstrated inability to work with others or behavior that is reasonably
likely to be disruptive to Hospital operations;
4. Activities or professional conduct that are reasonably likely to be in violation
of the Medical Staff Bylaws, Medical Staff Rules and Regulations, or any
other Hospital policies and procedures; and,
3. Dismissal of the Trainee

4. Recommended Non-Renewal of Contract
Written Reprimand
A written reprimand will either be given to or mailed to the trainee, and a

copy will be placed in the trainee's personnel file.
Remedial Program Recommendation
If a remedial program is required, the trainee shall be so informed in a

meeting with the Program Director/DME. At that meeting, the trainee's
deficiencies will be identified, a remedial program will be established, and a
time frame for completion of the remedial program will be discussed and
documented.
A copy of this document will be given to the trainee, and a copy will be
placed in the trainee's personnel file. The remedial plan may include
limitations or restrictions on the amount and level of the trainee's patient
care activities. Such action may necessitate extension of the trainee's
educational program. At the end of the remedial period, the trainee will
receive an evaluation. At that time, the Program Director and/or DME may
or may not take further corrective action.
Recommended Leave of Absence/Suspension/or Dismissal of the

Trainee
The Program Director in discussion with the DME may recommend a Leave
of Absence, Suspension, or Dismissal of the trainee. The Leave of Absence
or Suspension may be with or without pay. Suspension shall be without pay.
Such recommendation will be made in writing, accompanied by any written
documents necessary to support the recommendation, and will be filed with
the MEC. The recommendation will include a time frame for a Leave of
Absence or Suspension. The DME, or his designee, will convene an Initial
Review Panel within 10 calendar days of the recommended action, which will
include the DME (who will chair the Panel), a member of the MEC (or
representative), and representatives of the Hospital’s Law Department and
Human Resources. Prior to the meeting, the Panel Chair will review the
submitted documents, and determine a list of individuals who the Panel may
wish to interview. These individuals will be notified to be available in the
event the Panel wants to interview them. The Panel will present its
recommendation to the DME, who will issue a decision for Leave of
Absence, Suspension or Dismissal of the trainee.
In the event the DME upholds such recommendation, the action shall
become effective immediately. During the period of Suspension without pay,
or Leave of Absence without pay, the trainee will not receive any payment, or
other compensation. Health-related benefits will continue if the trainee elects
to pay for them directly. In all cases of Suspension or Leave of Absence, the
trainee will not be permitted any Hospital privileges, nor be permitted to
attend Conferences or Rounds. The period of Leave of Absence or
Suspension will result in an extension of the trainee’s educational program.
In the event the DME rejects the recommendation, and the DME imposes
no other sanction or action, the record of the event will be expunged from
the trainee’s personnel file.
Recommend non-renewal of the contract.
If the MEC determines that a trainee is not meeting the standards of the
program, it may make a recommendation for non-renewal of the trainee’s
contract. The recommendation must be submitted in writing to the DME,
and will include the basis on which the action is being taken, along with any
written documents necessary to support the recommendation. All written
information regarding the recommendation will become part of the trainee’s
personnel file. If the DME determines that there is sufficient reason not to
renew the contract, they will notify the appropriate individuals of such action
and will so inform the trainee in writing. Recommendations for non-renewal
should be made no later than four months prior to the end of the trainee’s
current contract. If the primary reason(s) for non-renewal occur(s) within the
four months prior to the end of the current contract, every effort will be
made to ensure that the program provides its trainee with as much written
notice of the intent not to renew as circumstances will reasonably allow. A
trainee receiving notice of non-renewal of contract may implement their right
to due process through the Appeals Process, as presented in this manual. In the
event the DME rejects a recommendation for non-renewal of contract, the
trainee’s contract will be renewed for the following year.
No appeal is available when the action is to reprimand or institute a remedial

program for the trainee. A decision to impose a leave of absence, suspend,
dismiss, or fail to renew the trainee’s contract shall entitle the affected trainee
to the Appeals Process contained in this manual.
Where a trainee receives notice of a corrective action under the terms in this
Manual, inclusive of any amendments to this manual that are in effect on the
date of receipt of the notice, this manual shall govern, irrespective of any
later amendments or revisions to the manual.
4.2 Remediation Process
If a remedial program is required, a meeting will be scheduled with the trainee and
respective program director. The purpose of the meeting will be to identify and
discuss the deficiencies of the trainee. The remedial program will be discussed along
with the period of completion.
The remedial plan may include limitations or restrictions on the amount and level of
the trainee’s patient care activities. Such action may necessitate extension of the
trainee’s educational program. At the end of the remedial period, the trainee will
receive an evaluation. At that time, the respective program director and/or DME
may or may not take further corrective action.
The trainee will receive a copy of the remediation plan that will describe the action
along with methods to improve and the timeframe to complete the plan. A copy of
the remediation will be placed in the trainee’s personnel file.
4.3 Summary Suspension
The MEC or DME shall have the authority, whenever action must be taken
immediately in the best interest of patient care or the Hospital, to summarily suspend
all or any portion of the privileges of a trainee, and such summary suspension shall
become effective immediately upon imposition.
At the discretion of the DME, such suspensions may be with or without pay
depending on the allegations and the facts and status of any applicable investigation.
The DME will convene an Initial Review Panel within 10 calendar days of the
suspension. The Panel will include the DME (who will Chair the Panel); the Director
of Human Resources, a member of the MEC (or representative); the Clinical
Department Chairman (or representative); and a representative of Human Resources.
The Panel may request an interview with the suspended trainee. Whoever summarily
suspended the trainee will provide written documents necessary to support the
recommendation. The panel will decide whether to reverse, modify, or sustain the
Summary Suspension.
A trainee who has been summarily suspended shall be entitled to all of the rights
provided in the Appeals Process contained in this Manual.
4.4 Automatic Suspension
A suspension of a trainee shall be imposed automatically if action by the North

Carolina Medical Board results in revocation or suspension of the trainee’s license or
temporary certificate. Such automatic suspension shall become effective immediately
upon action by the North Carolina Medical Board. During the suspension, the
trainee will be on “unpaid leave status” and, in order to continue health benefits, will
need to pay the premium directly since, in the absence of a paycheck, deduction of
that premium is not possible. If the license or temporary certificate is reinstated, the
trainee may apply for readmission into the program. If readmission into the program
is denied, the trainee is entitled to all the rights provided in the Appeals Process
contained in this manual.
4.5 Trainee Appeals Process
A. Whenever a Corrective Action that can be appealed (Leave of Absence,

Suspension, Summary Suspension, Dismissal, Failure to Renew Contract,
Failure to be Re-accepted into Program after Termination of Automatic
Suspension) is imposed on a trainee, the DME shall provide written
notification to the trainee, either in person or by certified mail, return receipt
requested, of the Corrective Action. Such notice shall contain a specific
statement of the grounds for such Corrective Action and shall refer to the
trainee’s right of appeal as set forth below.
B. To appeal a Corrective Action, the trainee must submit, within ten (10)
calendar days after receiving such notice, a written request either in person or
by certified mail, return receipt requested to the DME for a hearing before
an Appeals Committee. No electronic requests will be accepted.
C. Upon receipt of a written request for a hearing, the DME shall appoint an
Appeals Committee consisting of seven individuals, five of whom will have a
vote. The DME will Chair the committee. If the trainee requesting the
Appeal Hearing is from the same Department as the DME, the Vice
President of Medical Affairs or appointed designee will function as the Chair.
The voting members will include:
a. A trainee who is a member of the MEC from a Clinical Department

different from that of the trainee requesting the Appeal Hearing,
b. Two (2) Residency Program Directors from different Departments
than that of the trainee requesting the Appeal Hearing;
c. A representative from Human Resources; and,
d. A Medical Staff Member from a different Clinical Department than
that of the trainee requesting the Appeal Hearing and that of the two
Program Directors on the Committee.
The non-voting members will be:

a. The DME; and,
b. A trainee, from a different Department, at a similar level of training
as the trainee who filed the Appeal. The non-voting trainee member
may participate in all aspects of the deliberations prior to the vote.
D. The DME will appoint the Administrative Director or Coordinator of the

Office of Medical Education to serve as Secretary, who will keep minutes of
the meeting. The DME, or designee, will determine the date, time, and place
of the meeting.
E. No later than ten (10) business days after receipt of the trainee's request for a
hearing, the DME or designee, shall notify the trainee by certified mail,
return receipt requested, of the date, time, and place of the hearing.
F. The hearing shall be held no fewer than 30- and no more than 45-business
days after receipt of the trainee's request for a hearing. A hearing for a trainee
who is under suspension shall be held as soon as the arrangements may
reasonably be made, but not later than 30-calendar days from the date of
receipt of the request for a hearing, unless extended by mutual consent.
G. From the date upon which the DME receives the trainee's request for a
hearing until the date of the hearing, the training director or DME, or
designee, shall permit the trainee, upon their request, to examine and
duplicate any written materials that relate in any way to the suspension,
termination, or corrective action. No later than ten (10) business days prior
to the scheduled hearing date, the parties shall provide each other with a list
of witnesses that each intends to call at the hearing. A maximum of three (3)
witnesses each may be called by the trainee and by the claimant to appear in
person. An unlimited number of witnesses, however, may submit written
testimonials for review by the Appeals Committee.

H. At the hearing, the trainee's personal presence is required. The trainee may be
aided or represented by another trainee in the Hospital's Medical Education
program or by a member of the Hospital's Medical Staff. None of the parties
to the appeal shall be aided or represented at this hearing by an attorney.
I. At the hearing, both the claimant and the trainee may make opening
statements. The claimant shall then present their case supporting the
corrective action. The trainee shall then present their case opposing such
suspension, termination, or corrective action. All parties may make closing
arguments.
J. At the hearing, both the claimant and the trainee may present written
evidence, examine witnesses, and cross-examine witnesses. The Rules of
Evidence that govern proceedings in a court of law shall not apply.
K. Within five (5) business days after the hearing, the Committee Chair (i.e., the
DME) shall prepare and send to both the claimant and the trainee, by
certified mail, return, receipt requested; a written decision which shall affirm,
modify or reverse the trainee's corrective action. This decision shall be by a
majority vote of the Committee members and shall be based solely upon the
written and oral evidence presented by the claimant and the trainee at the
hearing. The DME shall receive a copy of the written decision.
L. The decision of the Committee shall be final and binding upon both the
claimant and the trainee.
M. A trainee who has been suspended or dismissed from a training program and
who has instituted an appeal as provided herein may resume clinical practice
only if recommended in writing by the Appeals Committee.
N. The trainee's failure to exercise any right provided by the Appeals Process
shall constitute an irrevocable waiver of such right.
4.6 Grievance and Due Process Procedure
The following Grievance Procedure is available to all trainees who are members of
the medical education training staff of Harnett Health. It is not applicable to trainees
from other affiliated institutions that are on rotation at Harnett Health.
1. Complaint procedures are established to protect the integrity and the

maintenance of educational standards as they relate to approved sponsoring
institutions.
2. To provide a mechanism for concerned individuals or organizations to bring
to the attention of the accrediting agency information concerning specific

actions and programs that may be in noncompliance with the accrediting
body’s educational standards.
3. To recognize the responsibility of the accrediting body to provide
responsible complainants the opportunity to use the accrediting body as a
vehicle to address specific grievances.
1. Grievances. If a trainee has reason to believe that established Hospital
policies and procedures including applicable personnel policies (with the
exception of any action, policy, practice or procedure connected with the
periodic evaluation of trainee, corrective action or appeals, as set forth in
this Manual) have been denied to the trainee or has been erroneously
applied to the trainee, or if the trainee has a problem (collectively,
hereinafter a “Grievance”) with any employee of the Hospital, any
member of the Hospital’s Medical Staff, or any other individual affiliated
or associated with the trainee’s medical education program, the following
procedure has been established for the discussion and resolution of such
a Grievance.
2. Meeting with the Administrative Director of Medical Education.
Make an appointment to discuss the Grievance with the Administrative
DME (“ADME”). The ADME will explain the established policies and
procedures to assist the trainee in determining whether a formal
Grievance should be filed. The trainee shall maintain authority over the
final decision as to whether a Grievance exists and whether a formal
Grievance should be filed.
3. Filing Grievance Notice. If, after discussing the Grievance with the
ADME, the trainee believes that a Grievance exists, then the trainee must
submit a written notice (the “Grievance Notice”) of the Grievance to the
ADME and the trainee’s respective Program Director. All Grievance
Notices must be set forth in reasonable and sufficient detail an
explanation of the trainee’s grievance. The respective trainee must
properly file all Grievance Notices no later than (30) calendar days after
the trainee discusses the grievance with the ADME.
4. Form of Filing and Disclosure of Grievance. A properly filed
Grievance Notice is one that is either: (1) personally delivered by the
trainee to each of the appropriate parties and for which the trainee
obtained a time stamped copy (reflecting the date and time of delivery of
the Grievance Notice) from each party to whom the trainee personally
delivered the Grievance Notice; or (2) mailed by certified mail, return
receipt requested to each appropriate party. The ADME may provide
copies of all Grievance Notices to the following individuals: (1) the
trainee’s Program Director; (2) the DME; and (3) the Director of Human
Resources.
5. Filing Grievance Notice with Alternate Parties and Chiefs of Staff.
If due to the nature of the grievance, the trainee reasonably believes that
it would be inappropriate to file the Grievance Notice with the Program
Director, and then the trainee shall so inform the ADME who shall then
instruct the trainee to file the Grievance Notice to the DME. In lieu of
filing the Grievance Notice with the ADME or Program Director, the
trainee may, for good cause, file the Grievance Notice directly to the
DME. “Good cause” shall be determined by the DME at their sole
discretion and the DME reserves the right to redirect the trainee to the
file the Grievance with any other party deemed appropriate by the DME.
6. Discussion with the Program Director. If the trainee filed the
Grievance Notice with their respective Program Director pursuant to
Step 3, above, then the trainee and the Program Director shall meet to
discuss the Grievance. Unless the trainee otherwise agrees, such meeting
shall occur no later than five (5) business days after the Program
Director’s receipt of the Grievance Notice. If the trainee chooses, the
ADME may accompany this meeting to assist in the discussion of the
grievance. The Program Director shall reply in writing to the trainee’s
grievance within five (5) business days after their meeting.
7. Program Director Grievance Review. At any time before, during or
after a trainee meets with their respective Program Director, such
Program Director may request the trainee to submit the names of two (2)
other trainees from whom the Program Director may want to ask about
the grievance or specific aspects thereof. In addition, the Program
Director may ask the trainee’s respective program Chief Resident to
answer questions relating to the grievance and or to be present at any
meeting pertaining to the trainee’s grievance. In the event the grievance
concerns an incident that is not directly related to the trainee’s training
program, the Program Director may request the trainee to submit the
names of two (2) Hospital employees who witnessed the incident. If a
person identified as a witness leaves the employ of the Hospital prior to
resolution of the grievance, that person shall nevertheless be recognized
and accorded an opportunity to be heard during the Grievance Process
set forth herein, provided that such person left the Hospital in good
standing.
8. Follow-Up after Discussion with the Program Director: Filing of
Continuation Notice. If the trainee is not satisfied with the Program
Director’s resolution, and desires to follow through on the grievance to
the next step, the trainee shall meet with the ADME. The ADME will
help the trainee with a further review of the grievance to enable the
trainee to make an appropriate decision whether to pursue their
grievance. If the trainee desires to pursue the grievance, then they shall
file a written notice (the “Continuation Notice”) that they wish to
continue to pursue the grievance. This Continuation Notice may include
a restatement of the Grievance Notice, but it must also further expand or
explain the trainee’s reasons for continuing to pursue the grievance. This
Continuation Notice must be filed with the ADME within 30-calendar
days after the Program Director issues their written resolution.
9. Discussion with the Director of Medical Education. After a trainee
meets with their respective supervisor, if the trainee desires to pursue the
grievance, then they shall meet with the DME. Unless the trainee
otherwise agrees, such meeting shall occur no later than five (5) business
days after the DME receipt of the Grievance Notice. If the trainee
chooses, the ADME may participate in this meeting to assist in the
discussion of the grievance. The DME shall reply in writing to the
trainee’s grievance within five (5) business days after their meeting.
10. Director of Medical Education Grievance Review. At any time
before, during or after a trainee meets with the DME, the DME shall
follow the same process as in Step 7, above, offering only the same
individuals an opportunity to be heard who were heard at Step 7.
11. Follow-Up after Discussion with the Director of Medical
Education: Filing of Continuation Notice. If the trainee is not satisfied
with the DME’s resolution, and desires to follow through on the
grievance to the next step, the trainee shall meet with the ADME. The
ADME will help the trainee with a further review of the grievance to
enable the trainee to make an appropriate decision whether to pursue the
grievance. If the trainee desires to pursue the grievance, then they shall
file a written notice (the “Continuation Notice”) to continue to pursue
the grievance. This Continuation Notice may include a restatement of the
Grievance Notice, but it must also further expand or explain the trainee’s
reasons for continuing to pursue the grievance. This Continuation Notice
must be filed with the ADME within 30-calendar days after the DME
issues the written resolution.
12. Establishment of Grievance Review Committee. The ADME will
inform the Hospital’s Director of Human Resources (or his/her
designee) in writing of the trainee’s desire to proceed on the grievance
and will provide them with a copy of the Continuation Notice. The
Director of Human Resources will then: (1) select three (3) individuals to
serve as members of the Grievance Review Committee in accordance
with Step 16, below; and (2) arrange a mutually convenient meeting time
to hold a hearing on the grievance. Subject to extenuating circumstances,
the hearing shall be held within five (5) business days after the Director
of Human Resource’s receipt of the Continuation Notice.
13. Composition and Administration of Grievance Committee. The
Grievance Review Committee shall consist of a combination of three (3)
persons: the DME, one who is a General Administrative Officer of the
Hospital, and one who is a Residency Program Director. The Grievance
Review Committee will not include anyone who has been involved in the
Grievance. The Director of Human Resources will be the chairperson of
the meeting, and shall conduct the meeting pursuant to this Grievance
Procedure and all applicable policies and procedures of Harnett Health to
ensure an orderly and fair opportunity for all parties to present their
positions.
14. Witnesses. The trainee may, at any time prior to one (1) day before the
hearing, submit to the Director of Human Resources the names of two
(2) Hospital employees who have information relating to the grievance.
These employees may be asked to appear before the Grievance
Committee either by the trainee, the Director of Human Resources or by
any member of the Committee. The DME may also request not more
than two (2) people to appear before the Committee. The trainee’s
appearance before the Committee shall be limited to: (1) making a
presentation not to exceed ten (10) minutes (unless a longer period of
time is permitted by unanimous approval of the Committee); and (2)
responding to questions posed by the Committee. Unless otherwise
permitted by unanimous approval of the Committee, neither the trainee
nor any witness shall be permitted to sit through, attend or participate in
the entire hearing. The Committee shall have sole discretion to determine
which portion(s), if any, of the hearing the trainee and or any witnesses
shall attend.
15. Additional Information Relating to Grievance. The Committee may,
in its sole discretion, interview additional individuals and or seek
additional information from other persons, organizations or entities if the
Committee believes that such actions would facilitate resolution of the
Grievance.
16. Providing Copies of Grievance. The Director of Human Resources
may, at their sole discretion; forward copies of the Grievance
Continuation Notice to all persons (including any witnesses) scheduled to
attend all or any portion of the hearing.
17. Final Decision of Committee. The Committee must use its best efforts
to give its decision in writing to the trainee within three (3) business days
after the hearing. The Committee’s decision shall be final, except in the
event such decision results in the full and final termination of the
trainee’s participation in their training program.
18. Appeals. A trainee may appeal only a final decision hereunder. Any such
appeal may be brought by the trainee only if: (1) the trainee has complied
with and exhausted all remedies pursuant to the Grievance Procedure set
forth herein; and (2) the final decision rendered hereunder expressly
imposes a Leave of Absence, Suspension, or Dismissal of the trainee or
termination of the trainee’s participation in their respective training
program at the Hospital. Any appeal hereunder shall follow and be in
accordance with the procedures set forth in the “Appeal Process” section
of this Manual.
19. Waiver of Grievance. The trainee shall waive any and all rights under
this Grievance Procedure in the event such trainee materially fails,
without good cause, to comply with any of the requirements set forth
herein, including, without limitation, missing any: (1) deadline for filing a
Grievance Notice or Continuation Notice; or (2) any meeting or hearing
with any party hereunder. “Good cause” shall be determined by the
DME in their sole discretion, acting reasonably.
20. Confidentiality. All grievances shall be kept confidential. The trainee,
ADME, Chief Resident, Program Director, Department Chair, DME and
any other Hospital employees, agents or representatives that receive a
Grievance Notice or otherwise receive or initiate information pertaining
to a grievance shall keep all such information strictly confidential and
shall disclose the same only to those other employees or agents of the
Hospital or other third parties or government agencies having a
reasonable need to know the grievance and information pertaining
thereto.
21. Modification of Time Limits. All Grievance Procedure time limits may
be modified by mutual agreement of the parties based on the absence of
one or more of the parties for good reason, such as scheduled vacation,
previously determined work schedule, illness or similar absence.
4.7 Maintaining Discipline among Patients, Nurses and Employees
Members of the trainee staff may not attempt to discipline a patient, nurse or other
employee. If a patient refuses to observe regulations or obey orders for treatment,
the facts must be reported to the attending physician and the DME. The manner of
the trainee with the patient should be gentle, polite and serious at all times in keeping
with the dignity of the profession. Situations arising with nurses or other hospital
employees that would require disciplinary action should be reported to the DME, or
in his absence, to the Director of Human Resources and CEO. Under no
circumstances are trainees to engage in arguments with the patient and/or employee.
4.8 Transitions of Care (Structured Patient Handoffs)
INTRODUCTION:
The Transitions of Care Policy has been developed to ensure the safe transfer of
responsibility for patient care. The format for transfer of care may vary, but program
standards must ensure continuous, coordinated delivery of care in settings that are
appropriate to patients’ needs, including arrangements that extend beyond the
inpatient setting into the community and the home.
DEFINITION:
A structured handoff is the process of transferring information, authority, and
responsibility for patients during transitions of care. Transitions include changes in
providers (shift-to-shift, service-to-service) or when a patient is moved from one
location or level of service to home or another level of care. Transitions may also be
prompted due to caregiver fatigue.
POLICY:
Transfer of responsibility for patient care in all the settings/situations in which
handoffs occur will follow the handoff requirements stipulated below. Further
clarification can be sought from the residency program director and/or director of
medical education. The amount of information to be included in the process will
vary depending on the functional role of the resident in patient care and the
requirements of the clinical setting and facility. Residents providing continuous and
direct care and taking responsibility for order writing require a higher level of
information exchange than those with less continuous duties, such as consultative or
supervisory services.
Guidelines for Minimal Handoff Requirements:
A handoff is the process of transferring information and authority and responsibility

for a patient during transitions of care. Transitions include changes in providers,
whether from shift to shift, service to service, or hospital or clinic to home or
outside facility. Transitions also occur when a patient is moved from one location or
level of service to another.
Both written and verbal handoffs are important, and each has a different purpose.
Written handoffs can provide detailed information that serves as a reference for the
receiving provider. Verbal handoffs allow discussion and cross-checking with the
receiving provider to be certain that he/she has understood the information being
provided.
Residency programs within Harnett Health System will have a standard handoff
policy as outlined below.
1. Identify a time and place that expected and routine handoffs will
occur, acknowledging that emergent handoffs may occur outside of
previous designated locations.
This location should have access to appropriate resources such as the
electronic medical records system. Verbal handoffs are required and written
handoffs may be required depending on transition. It is imperative that
handoffs include an opportunity for receiving physician to ask questions.
2. Comply with the structure or protocol for handoffs.

Verbal handoffs should follow a structure. The mnemonic SIGNOUT is
recommended.
• Sick or DNR? (highlight sick or unstable patients, identify
DNR/DNI patients)
• Identifying data (name, age, gender, diagnosis)

• General hospital course
• New events of the day
• Overall health status/clinical condition
• Upcoming possibilities with plan, rationale
• Tasks to complete overnight with plan, rationale
Written handoffs should be structured and organized so that information is
in a standard format for each patient. Written handoffs should include the
following information:
 Identifying information --Name, location, history number,

hospital day
 Diagnosis, procedures, condition
 Problem list
 Medications and other treatments
 Pertinent laboratory results
 Pending laboratory and other studies
 Important contact information (e.g., patient’s attending of
record, family, referring physician)
3. Transitions of Service
A transfer note MUST be provided by the sending resident when a patient is
transferred to a different level of care or service. A transfer acceptance note
most be documented by the accepting service.
4. Discharges
The discharging resident must ensure that prescriptions for discharge
medications are written and available at the time of discharge. The
discharging resident must ensure that the discharge worksheet is completed
and is accurate.
The discharging resident is responsible for ensuring that information about
clinically important laboratory, radiologic, or other results that come to a
prescriber after a patient leaves the hospital is conveyed either to the patient
or his/her primary care provider. This contact should be documented in the
medical record.

5 STANDARDS OF CONDUCT
5.1 Work Schedule
In-hospital rotations service hours are from 7:00 a.m. to 7:00 p.m. every day.
Trainees in an office setting rotation will be responsible for being in the office setting
during the teaching attending’s office hours. Scheduled times will be subject to shift
workload of attending physician and the attending physician may assign, schedule, or
adjust scheduling as appropriate to the service.
5.2 General Guidelines
All employees are urged to become familiar with Harnett Health’s rules and
standards of conduct. It is expected that all individuals will follow these rules and
standards faithfully in doing their own jobs and conducting the company’s business.
5.3 Duty Hours for Residents
A. CAMPBELL PROGRAM AND AFFILIATE INSTITUTION at all times

will adhere to the “Policy on Duty Hours” as required by the ACGME and
as contained in CAMPBELL PROGRAM House Staff Manual.
B. Duty hours are defined as all clinical and academic activities related to the
PROGRAM, i.e., patient care (both inpatient and outpatient), administrative
duties related to patient care, the provision for transfer of patient care, in-
house call activities, and scheduled academic activities such as conferences.
Duty hours do not include reading and preparation time spent away from
AFFILIATE INSTITUTION and/or CAMPBELL. Duty hours do include
all internal and external moonlighting activities.
C. Duty hours shall be limited to eighty (80) hours per week, averaged over a
four (4) week period, inclusive of all in-house call activities.
D. RESIDENTS shall be provided with one (1) day in every seven (7) days free
from all educational and clinical responsibilities, averaged over a four (4)
week period, inclusive of call activities. A day is defined as one (1)
continuous 24-hour period free from all clinical, educational, and
administrative activities.
E. Duty hour periods of PGY-1 RESIDENTS must not exceed 16 hours in

duration.

F. PGY-2 RESIDENTS and above may be scheduled to a maximum of 24
hours of continuous duty in the hospital. Residents may be allowed to
remain on site for an additional four (4) hours to provide effective transitions
in care of current patients; however, they may not be assigned additional
clinical responsibilities after 24 hours of continuous in-house duty.
G. CAMPBELL PROGRAM and AFFILIATE INSTITUTION encourage

RESIDENTS to use alertness management strategies, including strategic
napping, in the context of patient care responsibilities, especially after 16
hours of continuous duty and between the hours of 10pm and 8am.
H. In unusual circumstances and on their own initiative, PGY-2 RESIDENTS

and above may remain beyond their scheduled period of duty to continue to
provide care to a single patient. Under such circumstances – which only
include continuity of care for a severely ill or unstable patient, a transpiring
event of unusual academic importance, or humanistic attention to the needs
of a patient or family – the RESIDENT must appropriately hand over the
care of all other patients responsible for their continuing care and document
the reasons for remaining to care for the patient in question. Such
documentation must be submitted to the Director of the PROGRAM in
every circumstance.
5.4 Harassment Policy
Harnett Health does not tolerate workplace harassment. Workplace harassment can
take many forms. It may be, but is not limited to, words, signs, offensive jokes,
cartoons, pictures, posters, e-mail jokes or statements, pranks, intimidation, physical
assaults or contact, or violence.
Refer to Human Resources Policy and Procedure Manual.
5.5 Sexual Harassment Policy
It is the policy of Harnett Health to provide an employment environment free of

sexual harassment. Unwelcome sexual advances, requests for sexual favors, and other
verbal or physical conduct of a sexual nature are violations of our policy. If you
believe you have been subjected to sexual harassment, you should report it
immediately in writing to the DME and the director of human resources.
All complaints of sexual harassment will be promptly and confidentially investigated.

Any trainee who violates this policy will be subject to corrective action, based on the
severity of the violation, up to and including termination.
Any other form of repeated behavior, which the trainee perceives as harassment,
should be reported to the DME.
5.6 Violence in the Workplace
Harnett Health has adopted a policy prohibiting workplace violence. Consistent with
this policy, acts or threats of physical violence, including intimidation, harassment,
and/or coercion, which involve or affect Harnett Health or which occur on the
premises of Harnett Health or client property, will not be tolerated.
5.7 Confidential Information and Nondisclosure
The confidential nature of medical information and the patient's right to privacy are
well established. All hospital personnel are expected to treat patient-related
information in a confidential manner, sharing it only with those who have a need to
know, whether in written, oral, electronic, or any other format. Hospitals and
physicians can be held liable for the improper or unauthorized disclosure of medical
information. As such, discussion of patient-related information should be conducted
only in appropriate settings, and especially not in elevators or other public areas.
At the start of your training at Harnett Health, you will be asked to sign a
Confidentiality and Non-Disclosure Agreement, documenting your acceptance of
this policy.
The Health Insurance Portability and Accountability Act (HIPAA), passed by

Congress in 1996, require Harnett Health and its employees and business associates
to protect the privacy and security of patient health information. As all Harnett
Health employees are affected by HIPAA and subject to its penalties for non-
compliance, it is important that everyone keep abreast of new developments and
understands the overall impact and intent of the legislation.
5.8 Ethical Standards
Trainees are required to comply with Harnett Health’s Code of Conduct. Harnett
Health insists on the highest ethical standards in conducting its business. Doing the
right thing and acting with integrity are the two driving forces behind Harnett
Health’s great success story. When faced with ethical issues, employees are expected
to make the right professional decision consistent with Harnett Health’s principles
and standards. If a trainee cannot determine the correct decision, the trainee should

contact their respective program director and or the Department of Medical
Education.
5.9 Dress Code
Dress, grooming, and an overall professional appearance are important aspects of

patients' expectations, and project an image of quality healthcare. When scrubs are
worn outside of clinical areas, a white coat or similar cover-up should be worn.
Trainees must appear neat and clean at all times. The uniform for floor duty during
the day is a long white clinical coat. Coats should be worn at all times. Socks and
closed toe appropriate footwear must be worn at all times. Male and Female trainees
are required to wear professional business attire under the white clinical coat.
5.10 Use of Equipment
Harnett Health will provide employees with the equipment needed to do their job.
None of this equipment should be used for personal use, nor removed from the
physical confines of Harnett Health—unless it is approved for a job that specifically
requires use of company equipment outside the physical facility.
5.11 Use of Computer, Phone, and Mail
Harnett Health’s property, including computers, phones, electronic mail, and voice
mail, should be used only for conducting company business. Incidental and
occasional personal use of company computers, phones, or electronic mail and voice
mail systems is permitted, but information and messages stored in these systems will
be treated no differently from other business-related information and messages.
Refer to IT Department/HIPAA Policy
5.12 Use of Internet
Employees are responsible for using the Internet in a manner that is ethical and
lawful. Use of the Internet must solely be for business purposes and must not
interfere with employee productivity.
Harnett Health encourages employee use of electronic mail, the intranet and the
Internet; it creates a more efficient work environment. However, it should be clear
that:

1. Sending and receiving E-mail, Intranet or Internet messages regarding personal
matters are not permitted.
2. Under no circumstances will the E-mail system, the Intranet or the Internet be
used as a forum for inappropriate, offensive or discriminatory comments.
3. An employee should not consider the contents of his or her E-mail account
private.
4. The password used to restrict access to employees’ E-mail accounts is a
mechanism for preventing an unauthorized person from gaining access to
Harnett Health’s information rather than maintaining the privacy of employees’
messages.
5. The E-mail system, including the contents of messages and accounts, can be
monitored to:
a. Evaluate the effectiveness and operation of the E-mail system.
b. Find lost messages.
c. Recover after system failure.
d. Investigate suspected criminal acts or suspected breach of security.
e. Enforce other Harnett Health policies.
Employees, including trainees, who use email, the intranet or the Internet
improperly, will be subject to disciplinary action according to policy the Human
Resources Policy and Procedure Manual.
All Harnett Health employees must sign a form documenting that they understand
the conditions under which an email account may be used and what conduct is
permitted.
Refer to IT Department Policy
5.13 Use of Computer Software
Harnett Health does not condone the illegal duplication of software. The copyright
law is clear. The copyright holder is given certain exclusive rights, including the right
to make and distribute copies. Title 17 of the U.S. Code states that, “it is illegal to
make or distribute copies of copyrighted material without authorization” (Section
106). The only exception is the user’s right to make a backup copy for archival
purposes (Section 117).
Refer to IT Department Policy
5.14 Smoking Policy
To provide a healthier and safer environment for patients, visitors, staff, and
employees, the hospital prohibits smoking and the use of tobacco products anywhere
on any campus.
All employees are required to adhere to this policy to ensure that Harnett Health is a
healthier and safer place in which to work. To protect the health of our patients,
medical staff, hospital employees, visitors and volunteers, Harnett Health has a Zero
Tolerance Policy on smoking and the use of tobacco products.
5.15 Alcohol and Substance Abuse
It is the policy of Harnett Health that the workplace be free of illicit drugs and
alcoholic beverages, and free of their use. In addition to damage to respiratory and
immune systems, malnutrition, seizures, loss of brain function, liver damage, and
kidney damage, the abuse of drugs and alcohol has been proven to impair the
coordination, reaction time, emotional stability, and judgment of the user. This could
have tragic consequences where demanding or stressful work situations call for quick
and sound decisions to be made.
5.16 Subpoenas, Claims, & Other Requests
Trainees may periodically receive requests for information regarding a legal claim, or
potential claim, involving a patient and the Hospital. Whenever a trainee receives
such a request they will immediately contact the Department of Medical Education
who will notify Risk Management. The trainee is not to provide any written or verbal
response to such a request without authorization. This will ensure compliance with
the Hospital's procedures for release of information only to authorized persons.
Trainees may not witness wills or other legal documents for patients. Requests for
such assistance should be referred to the Administration Offices or the Nursing
Supervisor in charge.
5.17 Disputes between Trainees & Medical Supervisors
Harnett Health adheres to the AMA Council of Ethical and Judicial Affairs, Ethical
Opinion 9.055, which states, in part, “trainees should refuse to participate in patient
care ordered by their superiors in cases in which the orders reflect serious errors in
clinical or ethical judgment, or physical impairment, that could result in a threat of
imminent harm to the patient or to others.”
In such a circumstance, the trainee may refuse to provide the care ordered by the
supervisor, provided the omission will not threaten the patient’s immediate welfare.
Trainees should communicate their concerns, immediately, to the physician issuing
the orders, and to the Program Director, DME or Department Director. Trainees
who raise such a complaint will not be subject to retaliatory or punitive actions, if the
complaint was made in good faith, in the interest of patient care.
The Program Director, DME or the Department Director shall immediately notify
the Chief Medical Officer regarding the trainee’s concerns. The Chief Medical
Officer may take such action as he deems reasonable, in his sole discretion, to
investigate and resolve the situation, subject to the rights and obligations of the
parties as set forth in this Manual and the Policies and Procedures of Harnett Health.
5.18 Corporate Communications
Because of your constant relationship with patients and their visitors, your role in
establishing a positive reputation for the Hospital is important.
Patients are seldom qualified to judge the technical quality of medical care they
receive. To patients, the most important thing is usually the personal concern of each
individual they contact in the Hospital. Patients are extremely conscious of the many
little things that add up to kindness, sympathy and understanding. Harnett Health,
through the compassion and caring of its physicians, nurses, and support staff, has
consistently achieved excellent patient satisfaction ratings.
Harnett Health’s Communications (Public Relations) Department is responsible for
handling inquiries and requests from newspapers, magazines, and radio and
television stations. Refer any such request to the CEO’s office in Administration.
During evening and night shifts, the Nursing Supervisor on duty may release basic
condition reports, as permitted by law, on public record cases.
5.19 Corporate Compliance
The compliance program at Harnett Health is a comprehensive strategy to ensure

that employees and medical staff comply with applicable rules, regulations, and laws.
Refer to Corporate Compliance Policy Manual
5.20 Obligation to Treat
A primary mission of the hospital is to serve and heal all persons who need its help.
In addition to general legal and ethical requirements, hospitals participating in the
Medicare program are required to provide examinations and treatment to individuals
with emergency medical conditions, or women in labor, regardless of their ability to
pay. This is the Emergency Medical Treatment and Active Labor Act (EMTALA).
EMTALA was passed as part of the Consolidated Omnibus Budget Reconciliation
Act of 1986, and it is sometimes referred to as “the COBRA law.” This law requires
hospitals with emergency departments to provide a medical screening examination
“within the capabilities of the Emergency Department” to any person requiring one
without regard to the ability to pay. We must determine whether the person has an
“emergency medical condition” or is in “active labor.” If so, the law requires the
hospital to either:

1. Provide treatment “within the capabilities of the staff and facilities of the
hospital” as may be necessary to stabilize the emergency medical condition;
or,
2. Arrange for a transfer of that person as set forth by the law. An emergency
patient who is not stabilized can generally only be transferred if the individual
requires the transfer or if a physician certifies that the medical benefits of
transfer outweigh the risk of affecting the transfer.
Substantial penalties for violation of this law exist for both the Hospital and the
physician and the government or an aggrieved individual may enforce the statute.
5.21 Moonlighting
PGY 1 trainees are not permitted to moonlight. Other trainees must obtain
approval from their Program Director and the DME prior to moonlighting. All
requests must be submitted in writing. Understand that engaging in moonlighting
activities will require trainees to obtain a state license to practice in the state they
reside and obtain their own malpractice coverage for these activities.
Moonlighting activities will be documented on the trainee’s duty hour form and will
be counted towards the 80-hour workweek rule. Moonlighting will be considered
just cause for termination of the contract.
5.22 Departing Trainees
Upon the completion of training, the trainee is required to complete the “Clearance
Sheet” to ensure that all items are returned, that required documents are completed
and that all patient record information is fulfilled prior to the trainee’s departure
from their training program. Once all items are completed, the trainee will be issued
their training certificate indicating satisfactory completing the program, if so
warranted.
Prior to the trainee’s departure, an “exit interview” will be conducted with the trainee
to obtain information regarding their training experience as well as their thoughts of
Harnett Health. This process will help to enhance future trainees experience with
Harnett Health.
5.23 Hospital Property
No x-ray films, instruments, drugs, scrub suits or other hospital property shall be
taken from the hospital unless permission has been granted by the DME.

5.24 Accidents to Patients
The nursing staff of all accidents and incidents to patients will notify the trainee on
service.
The trainee will examine the patient immediately and report the follow up diagnostic
and therapeutic services as needed to the attending.
The trainee must record the findings on the Occurrence Report Management (ORM)
system. The ORM application is a tool you can use to collect data, speed up the
follow-up process, and help drive patient and medication safety improvement
initiatives. The enterprise-wide, web based system provides a shared platform for
healthcare facilities to automate: Patient, visitor, and staff incident data collection;
Incident/Occurrence review and follow-up plans; and Analysis, reporting, and
benchmarking of incident data.
To access the ORM, choose the icon-Harnett Health Incident Reporting, and that
will bring up the opening section of the incident reporting system. By answering
each question related to the incident that is being reported by using the drop down
arrows when appropriate and typing in any other pertinent information, the incident
can be completed and will automatically be forwarded to the department director
responsible for the area where the incident occurred.
5.25 Nursing Service
You are expected to extend professional courtesy, assistance, and cooperation to the
nursing personnel. They are respected members of a health service team whose
reason for being here is the same as your own, to provide the best service possible.
From a truly fine nurse, you stand to learn much. Should any problems arise with
the nursing service, do not take it upon yourself to correct the situation, but discuss
it with the DME.
5.26 Professional Care of Hospital Personnel

Members of the trainee staff shall not render any professional service to hospital
personnel or dependents, except under the provisions of the employee health service
plan of the hospital or with the supervision of an attending staff physician.
Trainees will please address all employees by their surnames, prefaced by Miss, Mrs.
or Mr., as that case may be, or their title, e.g. Nurse.

6 DIDACTIC PROGRAMS
6.1 Didactic Attendance

Attendance at all didactic sessions are mandatory. This includes but is not limited to
morning report, noon conference, journal club, OMM, and Friday didactics. Failure
to comply may result in time and failure.
6.2 Attendance Rosters

Attendance rosters will be prepared for each meeting, conference, and lecture, etc.,
which the trainees are required to attend. In order to document your attendance, it
is mandatory that these rosters be completed.
6.3 Morning Report

Morning report occurs from 7:30 a.m. – 8:15 a.m. on Mondays, Wednesdays, and
Fridays.
6.4 Journal Club

Journal Club is held monthly.
6.5 OMM Lecture

The Medical Education Department and Campbell University School of Osteopathic
Medicine’s OMM Department will provide formal lecture and hands-on laboratory
to review basic and advanced osteopathic techniques.

7 RESPONSIBILITIES
7.1 Trainers
 Each service has one or more trainers with responsibilities to the department,
the trainee or student and the MEC
 To meet with trainees at the beginning of each rotation to review the rotation
curriculum and its goals and objectives
 To meet and discuss with the trainee midway through the rotation the
trainee’s performance: areas of satisfactory performance and suggestions for
greater performance; as well as areas needing improvement
 To complete a performance evaluation after completion of the rotation
 To assign a reading and study program
7.2 Department
 To help organize, supervise, and carry out the teaching program for the
trainee
 Responsible for overseeing the work assignment of the trainee
 Responsible for supervising and participating in the “patient care experience”
training of the trainee
 Responsible for reviewing the patient’s workup completed and documented
on his/her patients by the trainee
 Responsible for overseeing the functions of the trainee, e.g. on duty
promptly, availability, performance, etc.
 To oversee the study program of the trainee.
7.3 Medical Education Committee

The MEC shall consist of the DME, all residency program directors at the
institution, trainee representatives who have been nominated by their peers.
Representatives from major affiliate institutions shall be members of the education
committee and shall be strongly encouraged to attend the MEC meetings when
logistically possible.
 The education committee shall meet at least 10 months of the year and
minutes of the committee meetings be maintained.
 There shall be verifiable evidence of communication between the education
committee and those representatives of major affiliate institutions where
attendance at the monthly meetings is not feasible.
 Report to the DME in writing any inferior function on the part of the
trainee, e.g. tardiness, attitude, lack of cooperation, etc. so the DME can
become involved early in the service
 To assist the DME and the Program Directors in developing the service or
changes in it to improve the training and service to the patient and the
attending physician
 To review compliance of trainee duty hours
 To participate in the interviewing and selection of trainees for each training
program
 To maintain and improve program quality
 To approve affiliations within the scope of accrediting body’s policies and
procedures
 To assist the DME in developing and implementing a high-quality
educational program for trainees
 To assist in the development of a curriculum and methods to evaluate the
educational experience of the trainees during training
 To assist in the program, faculty, trainee evaluations, as well as program
modification as needed in accordance with evaluation results
7.4 Administrative
Program Responsibilities: A trainee assigned to an attending physician will be
expected to participate in the case management of his/her patient, under direct
supervision of the trainer. This will involve rounds with the attending physician on
patients in the hospital, as well as participating in office practice under supervision.
The trainee will keep a complete log of patients seen and procedures performed in
this time period.
Trainee Responsibilities: The trainee shall obtain and write or dictate the history,
perform and record the results of the physical examinations, and state the diagnosis
on all patients assigned. The non-operative and non-specialized treatment of each
patient under his/her care is the trainee’s responsibility under the supervision of the
attending physician.
The trainee shall make rounds with the attending physician and trainee staff daily as
well as other suitable intervals. The trainee shall receive instructions, information,
criticisms, advice, suggestions and assistance from his/her superiors who thus
contribute to the trainee’s education. The trainee will be responsible for the
management of the attending physician’s patients under direct supervision.
The trainee will make daily progress notes on the record describing the patient’s
clinical course and should record all treatment or special diagnostic procedures, or
make certain they are recorded. When a patient is discharged, the trainee shall write a
concluding note, which summarizes the patient’s course in the hospital, describing
the patient’s condition on discharge and the final diagnosis.
Other Responsibilities: Refer to specific program manual for specific instructions
of patient logs.
7.5 Supervision
Refer to specific program manual for supervision policy.

8 COMPENSATION/INSURANCE POLICIES
8.1 Payroll/Stipend
After registration through the Medical Education office, all trainees are on the
Harnett Health payroll and commence with being paid an annual stipend. The
stipend amount appropriate to a trainee's contracted Post-Graduate Year (PGY)
level will be stated in his/her contract. These established stipend amounts are
reviewed annually and amended from time to time. For information on the
compensation schedule, please consult the Medical Education Office.
Payrolls are prepared and dispersed through direct deposit based on hospital policy
and procedures.
At the time of registration, each trainee must complete applicable tax and
employment forms as directed by Human Resources, and submit supporting
documentation.
DIRECT DEPOSIT:
Harnett Health requires direct deposit of payroll, with a bank of your choice. The
necessary enrollment forms can be obtained from Human Resources.
TAX/SOCIAL SECURITY DEDUCTIONS:

Harnett Health is required by law to withhold applicable income taxes from your
pay. The Hospital pays its social security tax assessed by the federal government on
your wages. You pay a matching amount through payroll deduction. The amount of
your contribution to social security as well as amounts withheld for applicable
income taxes will appear on your paycheck stub.
8.2 Employee Benefits

Parking: Parking is available free of charge to all Harnett Health employees. When
you hold a parking permit, you assume responsibility for observing all parking
regulations. All employees will park in designated employee lots. Failure to do so
may result in disciplinary action. The parking permit must be returned to Medical
Education Office in order to cancel your parking assignment. Any questions
concerning parking or appeals of parking violations should be brought to the prompt
attention of the Security Department.
I.D. Badges: Human Resources/Security issues Photo identification badges to all

Harnett Health trainees. You are expected to wear your I.D. badge at all times while
on duty. The proper way to wear your badge is above your waist with the
photo/name side showing. Contact Security for replacement I.D. badges.
Flexible Spending Accounts: Flexible spending accounts are available for pre-tax
payment of employee’s health and dental premiums, and certain un-reimbursed
medical and/or dependent care expenses. Enrollment in the flexible spending benefit
must be within the first 30 days of employment or during the annual election period.
You are able to designate the amount of money that you wish to have placed in a
flexible spending account. Note: IRS rules require that any money left in your
account at the end of the plan year will be forfeited. Please plan carefully so
that you will be able to use all the funds you set aside.
Retirement Savings Plan: Refer to the Summary Plan Description for further details.
8.3 Insurance
Harnett Health offers trainees a flexible benefits program, which offers a wide
selection of benefits and allows you the flexibility to select the benefits that best meet
your individual needs. From time-to-time, the specifics of the benefit programs
change. For this reason, you should obtain copies of each Summary Plan Description
(SPD) directly from Human Resources.
HEALTH INSURANCE: Trainees are eligible to enroll in the Health Insurance

Program during the first 30-days of employment. Trainees who enroll in one of the
plans pay pre-tax premiums through payroll deduction. The effective date of the
coverage is the first-day of the month, on or after, the trainee’s hire date.
CONTINUATION OF MEDICAL COVERAGE: COBRA: On termination of

your contract with Harnett Health, you may arrange for continued coverage under
the Consolidated Omnibus Budgeted Reconciliation Act, which guarantees an
employee the right to uninterrupted coverage by his/her employer’s medical
insurance for up to 18 months after termination. Regular coverage ends on the last
day of the month in which you leave the employ of Harnett Health. If you elect to
continue coverage, you must pay the entire cost. Information on COBRA is available
through the Harnett Health‘s Human Resources Department.
DENTAL INSURANCE: Dental coverage is available for purchase for you and
your family. You are able to choose from two dental plans, basic and comprehensive.
Your contribution is payroll deducted on a pre-tax basis. Coverage is effective the
first day of the month coinciding with or following your employment date.
PROFESSIONAL LIABILITY INSURANCE: The Hospital furnishes professional

liability insurance to trainees without cost to them. This insurance covers trainees
during the time they are within and acting on behalf of Harnett Health, following
schedules that have been issued by their Program Directors. Trainees are also
covered for legal actions relating to their residency training, which are initiated after
they leave the program.
LIFE INSURANCE: The Hospital provides $10,000 of group term life insurance at
no charge. Additional coverage up to three times your annual base salary is available
for purchase, as well as dependent life insurance. You become eligible for coverage
the first of the month following your employment. You can also purchase Voluntary
AD&D Insurance.
SHORT-TERM DISABILITY (STD): You are eligible for this benefit on the first of
the month following your employment. Employees have several choices regarding
waiting periods for Short Term Disability, which include a 14 day, 30 day, 60 day, or
90 day waiting period. Premiums are calculated based on the waiting period and age
of the employee. This benefit is purchased with after-tax dollars.
LONG-TERM DISABILITY (LTD): The first day of the month following your
employment you are eligible to purchase long-term disability insurance. Benefits are
purchased with after tax benefits.
8.4 Educational Stipend

Trainees will receive an educational stipend as set forth by the Department of
Medical Education.
8.5 Relocation
Relocation expenses for trainees entering Harnett Health’s residency programs are at
the expense of the individual trainee.
8.6 Housing
Housing and all of its associated fees, utilities, etc. are the responsibility of the
trainee.
8.7 Malpractice Insurance

Trainees are covered under the Harnett Health malpractice insurance as it relates to
residency training. Trainees participating in activities outside the scope of the
Residency Training Program will not be covered under the Hospitals malpractice
coverage.
Activities outside the Residency Training are strictly prohibited unless prior approval
is obtained from the Program Director and the DME. Participation in activities
outside the Residency Training Program without the expressed written consent of
the Program Director and DME are grounds for immediate dismissal.
8.8 Timekeeping Procedures

By law, Harnett Health is obligated to keep accurate records of the time worked by
employees. Trainees must fill out the appropriate time log for their monthly activities
through the residency tracking system. The time logs must be completed in
accordance with the Harnett Health time-reporting guidelines.

9 TIME-OFF BENEFITS
9.1 Vacation Time
Vacations are granted and scheduled at the discretion of the department to which the
trainee is assigned. Vacation allowance is 20-days per academic year. A “PTO
Request” form needs to be completed for all time away from the Medical Center.
9.2 Family Medical Leave
In accordance with the “Family and Medical Leave Act,” Harnett Health’s unpaid
leave-of-absence policy supports up to twelve workweeks of leave during a 12-
month period for the following:
• Pregnancy/birth of a child
• Placement with an employee of a child for adoption or foster care
• Caring for a spouse, same-sex domestic partner, child, or parent with
a “serious health condition”
• The employee’s own “serious health condition”
The 12-month period is measured forward from the date your first FMLA leave
begins. To be eligible for FMLA, you must first have been employed at Harnett
Health for at least twelve months and have worked 1,250 recorded hours in the 12
months preceding the leave. You must apply for this leave and Human Resources
must approve it. The forms are available in the Human Resources office.
If eligible for FMLA, FMLA must be applied for concurrently with any leave due to
maternity or paternity, short or long-term disability, and leave pursuant to “Extended
Leave of Absence” in the Trainee Manual.
Leave under this provision only protects your job, i.e., job security. It does not
provide any income guarantee or entitlement. Time taken off for leave may extend
the training period as necessary to comply with the appropriate accreditation
guidelines.
While on FMLA, trainees are entitled to up to twelve weeks of Harnett Health-

subsidized benefits only (see “Benefits While on Leave”). See Human Resources
Policy and Procedure Manual.
Note: Trainees are allotted 20-days off per year. Additional training will be
required for time taken beyond this allotment.

9.3 Maternity/Paternity Leave
Time off for Maternity Leave will be subject to the Leave of Absence Policy located
in the Harnett Health Human Resources Policy and Procedure Manual. It is the
trainee's responsibility to notify the Program Director at least 60-days in advance of
anticipated utilization of a maternity/paternity leave. Time taken off for a
maternity/paternity leave may extend the training period, as necessary, to comply
with appropriate accreditation guidelines. The department to which the trainee is
assigned must approve any leave of absence. If eligible for FMLA, FMLA must be
applied for at the same time a maternity/paternity leave is requested.
9.4 Extended Leave of Absence
Depends on how many months completed:
Trainees with extraordinary and long-term personal or family tragedies may be

granted extended leave without pay and without loss of previously accepted
residency position or status for periods of up to one year in the following
circumstances:
1. Terminal illness.
2. Permanent disability
3. Complications of pregnancy that threaten maternal or fetal life.
4. Other “devastating conditions” or personal tragedies from which
eventual recovery and/or return to regular employment may be
reasonably expected.
If extended leave is requested, the residency Program Director will provide the
trainee written information regarding its potential impact on:
1. Requirements for successful program completion.

2. Requirements for board eligibility.
The Program Director will also provide written information regarding availability of
alternative accommodations, such as reduced hours, night-call accommodations,
modified rotation schedules and part-time scheduling.
Eligibility for extended leave will be determined on a case-by-case basis by the

Residency Program Directors and/or Committee for that department. In case of a
dispute, a panel consisting of three Program Directors and two Chief Residents of
other departments shall be convened by the DME to hear arguments on both sides
and make a final determination.
If extended leave or other accommodations are granted, the Residency Program
Director will prepare written documentation of the circumstances and conditions of
these accommodations, as well as the necessary requirements for the trainee to
return to full active status.
9.5 Bereavement Leave
Trainees are eligible to receive up to three (3) consecutive scheduled workdays off
with pay in the event of the death of an immediate family member. The three days
should be scheduled between the dates of the death through the day following the
funeral. You must immediately notify your Program Director and the Department of
Medical Education of your need for bereavement/funeral leave.
Paid bereavement leave is provided for immediate family members who are defined
as: spouse, children, stepchildren, parents, stepparents, brothers, stepbrothers,
sisters, stepsisters, grandparents, grandchildren, and parents-in-law.
You may request time off if additional days of bereavement leave are required or to
attend the funeral of other family members or friends.
Additional time off, whether paid or unpaid, must be arranged through your
Program Director and the DME is based on the ability of your department to staff
adequately during your absence. See Bereavement Policy, located in the Human
Resources Policy and Procedure Manual.
9.6 Sick Leave
Full-time employees who become incapacitated due to illness, injury or other forms
of medial disabilities, may be granted a Medical Leave, not to exceed one (1) year.
After one (1) year of Medical Leave of Absence status access to health and other
elected insurance plans is terminated. The employee is removed from the active
payroll, and Human Resources will notify the employee of his/her post employment
rights.
The employee requesting medical leave must submit a certification of health care
provider, identifying the reason for the medical leave, with prognosis and expected
return to work date. This certification must be returned within ten (10) days of

Harnett Health giving notice that certification is required. Going beyond ten (10)
days will cause Harnett Health to make a decision on the leave status without the
information on the certification or to even deny the leave request. If circumstances
exist where even a diligent, good faith effort on the part of the employee will not
produce the certification in that time frame, then the employee should notify his/her
Department Director as soon as he/she becomes aware of the delay.
Harnett Health reserves the right to request a second opinion (at no cost to the
employee) on any request for Medical Leave.
Every effort will be made to retain an employee’s original position while on Medical
Leave. However, it may be necessary to fill the position with a full-time employee
before the leave terminates. In these instances, Harnett Health will make every
attempt to place the employee in a similar position on the same shift, with the same
rate of pay, as before the leave commenced, and in accordance with any federal or
state laws, regulations or statutes that contain return to work compliance
requirements. Refer to Human Resources Policy and Procedures for complete
details.
9.7 Paid Time Off
Holidays: Holidays are granted and scheduled at the discretion of the Medical
Education Department. The Hospital recognizes the following holidays: New Year’s
Day, Easter, Independence Day, Thanksgiving Day, Easter, Memorial Day, Labor
Day, and Christmas Day.
9.8 Military Reserves or National Guard Leaves of Absence
Employees who serve in U.S. military organizations or state militia groups such as
the National Guard may take the necessary time off to fulfill this obligation and will
retain all of their legal rights for continued employment under existing laws.
Note: Efforts will be made on a case-by-case basis to give appropriate time off
while assuring program compliance upheld. Depending on situation,
additional training may be required.
9.9 Jury Duty
If you receive a notice that you are to report for jury duty, notify your Program
Director and the Department of Medical Education immediately so coverage can be
arranged for you. Harnett Health will pay you your regular salary for the length of
time connected with either the selection process or jury duty. Upon returning to
work, written proof of your jury duty must be submitted to your Program Director
and the Department of Medical Education in order to be reimbursed.
9.10 Professional Leave of Absence
Unpaid professional leave of absence is granted at the discretion of the Program

Director of each residency program. Time taken off for leave may extend the
training periods as necessary to comply with appropriate accreditation guidelines.
9.11 Additional Benefit & Leave Considerations
Effect of Leave for Satisfying Completion of Program:
Time taken off for any leave may extend the training period, as necessary, to comply
with appropriate accreditation guidelines. Trainees should check with their Program
Director to make sure they are not in jeopardy of needing to extend their training
and, therefore, changing plans for a job or fellowship opportunity.
Trainees are not automatically guaranteed re-entry into the training program and
therefore should discuss future arrangements with their Program Director prior to
commencing a leave of absence.
An employee remains eligible for health benefits during the time he/she is on unpaid
leave. During the time the employee is not receiving pay, the usual payroll deduction
obviously cannot be made. The employee, therefore, is responsible for direct
payment of benefits costs. The Benefits Office must receive a check or the
appropriate amount before the 15th of each month to assure uninterrupted coverage.
An employee requiring further leave after FMLA has expired, or an employee

exercising any of the other forms of unpaid leave, assumes full cost of any insurance
coverage.
Any leave of any kind must be coordinated through Human Resources and
notification to the Department of Medical Education is required.
required for time taken beyond this allotment
10 COMPENSATION/INSURANCE POLICIES INSTITUTIONAL
POLICIES
10.1 Policy & Procedure Manuals
The Human Resources Policy and Procedure Manuals (HP&P), as well as a Management
Policy and Procedure Manual can be found in the Department of Medical Education
and the Department of Human Resources. These manuals contain Hospital policies
concerning standing orders for each clinical service, medications, laboratory and X-
ray routines, isolation, fluid intake, transfusion, and infusion procedures, permits and
legal forms, visiting regulations, and many other Hospital policies and routines
pertinent to your professional activities.
These manuals should be reviewed at the start of your clinical service. Trainees are
held responsible for the performance of their duties in conformance with these
policies and routines.
Each Residency Program is required to develop and maintain the policy and
procedure manual for their Residency Program. These manuals are to be reviewed
with the trainees at the start of their training program.
The program director is required to update these manuals on an annual basis (more
often if required). The trainees are to receive notification of any policy change at the
time of change. Program Directors are to ensure that the Department of Medical
Education has a current copy of each manual and distributes updates of policies and
procedures as they occur.
Each trainee will sign an “Acknowledgement of Receipt” (Section 18) attesting that
they have received and reviewed their residency program manual. This
acknowledgement will be maintained in each trainee’s personnel file located in the
Department of Medical Education.
Trainees are required to remain current on all policies and procedures as they occur
for the hospital and their residency program.
10.2 Communicable Diseases
A record shall be maintained of all infections, and or communicable disease acquired

within this facility. All diseases that are required to be reported shall be reported to
appropriate health department officials through the Infection Control Practitioner
via order entry, who will complete the appropriate interviews and paperwork.

10.3 Reporting Requirements for Communicable Diseases
Who shall report?

Reports of modifiable diseases required by law and those listed as Class A and Class
B shall be reported to the board of health by the infection control department. A
person in charge of a hospital, dispensary, clinic, or other institution providing care
or treatment, having knowledge of such case, shall report the disease unless he/she
has evidence that it has already been reported. When no physician is in attendance, it
shall be the duty of any individual having knowledge of a person suffering from a
disease presumably communicable or suspected of being communicable to report
forthwith to the board of health all the facts relating to the case, together with the
name and address of the person who is ill.
10.4 Advocacy Efforts
The Ethics Committee of Harnett Health assists in resolving ethical problems in

patient care through its interdisciplinary Ethics consultation Service (ECS), a
subcommittee of the Hospital Ethics Committee (HEC). The ECS is available to all
hospital care professionals, patients, patient’s families, and other patient
representative/surrogate.
Although primary responsibility for identifying and resolving problems in the clinical
setting rests with health care professionals in concert with patients or their
representative/surrogate, hospital staff is encouraged to seek timely involvement of
the ECS in ethically troublesome situations. The hospital assures that persons
requesting ethics consultation may do so without intimidation or fear of reprisal.
The recommendation of the ECS is advisory only. The process of ethics

consultation is intended to supplement and support – not supplant – existing
institutional mechanisms for making decisions and resolving conflicts in clinical
practice.

11 EVALUATIONS
All components of a trainee’s program must be evaluated and meet the guidelines set
for by the accrediting body. This evaluation must be related to the educational
objectives of the program and shall include clinical experiences, intellectual abilities
and skills, and attitudes and interpersonal relationships.
11.1 Program Evaluation Committee and Annual Program Evaluation
All trainees are required to complete periodic evaluations of the faculty with whom
they work. The number of faculty evaluations each trainee completes will vary
depending on service assignments and/or the size of the attending staff. Evaluations,
which are retained in the Department of Medical Education, are an important
component of the professional review of each supervising and training physician.
1. Each residency program has a Program Evaluation Committee (PEC) which:
(a) Plan, develop, implement and evaluate the educational activities of the
program
(b) Review and make recommendations for revision of competency based
curricular goals and objectives
(c) Address areas of non-compliance with accrediting body’s standards
(d) Annually assess the effectiveness of the program’s education of residents
using evaluations of faculty and residents
(e) Performs annual program evaluation.
11.2 Evaluation of Faculty
All trainees are required to complete periodic evaluations of the faculty with whom
they work. The number of faculty evaluations each trainee completes will vary
depending on service assignments and/or the size of the attending staff. Evaluations,
which are retained in the Department of Medical Education, are an important
component of the professional review of each supervising and training physician.
11.3 Evaluation of Trainee’s Performance
1. Trainees will be evaluated upon the completion of each rotation by the attending
on each rotation. (This evaluation shall be signed by the assigned faculty member
and the trainee; and reviewed by the program director and DME).
2. The Program Director, DME and the MEC shall review the performance of
every trainee on a quarterly basis to ensure that educational objectives are being
met.
3. Prior to early termination of a trainee contract, the institution shall provide the
trainee with appropriate warning and counseling. The assigned faculty member is
responsible for documenting deficiencies and attempting to resolve concerns
with the trainee.
4. In cases of early termination of a trainee contract, the DME shall provide the
trainee with documentation regarding which rotations, if any, were completed
satisfactorily. In cases of early termination or unsatisfactory completion of a
trainee contract, the accrediting body must be promptly notified.
5. If the trainee is accepted into another training program, that program’s DME has
the authority to determine which, if any, rotations from previous accrediting
body-approved programs will be accepted for advanced standing.
A record of these evaluations will be permanently maintained in the Department of

Medical Education.
If a trainee requires an explanation or interpretation of his/her education records,

he/she should make such a request directly to the Residency Program Director or to
the DME.
Trainee evaluations will be based, in part, on at least the following:
1. Academic Performance:
a. Whether the trainee has sufficient medical knowledge;

b. Whether the trainee possesses adequate and appropriate technical
skills;
c. Whether the trainee is able to use medical knowledge and/or
technical skills effectively in providing medical care; and
d. Whether the trainee has any deficiency that may affect his/her clinical
or academic performance.
2. Hospital Standards:
a. Whether the trainee has abided by the Trainee Manual, the Medical
Staff By Laws, and the Medical Staff Rules and Regulations;
b. Whether the trainee demonstrates ability to work cooperatively with
others;
c. Whether the trainee has followed the established practices, policies
and procedures of the Hospital; and
d. Whether the trainee has abided by the Corporate Code of Conduct
and applicable standards of professional responsibility.

11.4 Evaluation of Training Programs
This process is used to monitor the educational process of each training experience.
1. At the completion of each rotation, the trainee shall evaluate the rotation.
2. The DME/program director/appropriate designee shall evaluate each
rotation with the trainee quarterly. The DME shall determine the amount
of work being required of the trainees to ensure that they are not
overburdened with routine responsibilities and that they have the
opportunity to observe a sufficient variety of cases.
3. The MEC shall evaluate the trainee training programs quarterly. When
necessary, the committee shall approve affiliations within the scope of
the accrediting body policies and procedures.
Evidence of these evaluations will be maintained in the Department of Medical

Education.

12 MEDICAL RECORDS
The importance of complete and accurate medical records and an orderly and
efficient system of charts control (to assure accessibility) cannot be overemphasized.
At the beginning of the trainee’s service, personal instructions in the use of dictation
equipment and the policies of the Hospital will be given by Medical Records. If a
problem arises in connection with medical records, the staff will be glad to assist you.
12.1 Guidelines for Use of Medical Records
Medical records are privileged and confidential documents and must be safeguarded
according to Hospital Medical Records policies and procedures. The handling of
medical records shall be governed by the following guidelines:
1. Medical records must be available to Medical Records personnel day or night.

They must:
a. Remain in specified patient care areas.
b. Be readily accessible in case of emergency.
2. Medical records may be removed from the Medical Records Department only for
the following purposes:
a. For direct patient care, either for admission to the Hospital.
b. For case study or other uses by a Department or individuals authorized
to requisition medical records. Trainee for use only within the Medical
Records Department may requisition medical records for study or
dictation.
3. Medical records may not be removed from the Hospital except for legal
purposes, and then only in the custody of authorized Medical Records personnel.
4. Medical records must be kept intact on in-patient floors and in the clinics, and
must not be taken apart or pages removed or rearranged.
12.2 Guidelines for Documentation in the Medical Record
The Hospital maintains a “unit” record (containing all inpatient, outpatient, and
Emergency Department information). Trainees are reminded that medical records
are legal documents, and the physicians may at some future date be cross-examined
in court under oath on the notes he/she has written. Personal opinions, or non-
medical judgments, should not be expressed in the medical record on any matters
except those that pertain to the medical care of the patient.
Rules for Entries into the Medical Record:
ENTRIES MUST BE LEGIBLE.

1. Use of the hospitals EMR (Meditech) is the preferred method of documentation.
2. Entries must be signed, dated, and timed.
3. Entries must be complete and accurate.
4. If applicable, entries must be recorded only on officially approved Harnett
Health forms that are provided on the divisions or in the clinics.
5. Entries should be made chronologically with minimal blank spaces left between
entries to avoid bulky records.
6. If applicable, chemical, abrasive or other erasures or alterations, that delete the
original entry, create an impression of a falsified record and render the record
valueless to the patient or to the Hospital in the event of litigation. Drawing a
SINGLE LINE through the part to be corrected and the new entry made in
proper sequence, or above or below the incorrect entry should make corrections.
The reason for the correction, if not obvious, should be noted in the margin. All
corrections should be signed, dated and timed by the individual making the
correction.
7. Entries should not contain facetious, libelous, or otherwise inappropriate,
subjective remarks.
8. Entries must be signed, not initialed. Your printed name, Department/Division,
PGY level and pager number should follow each signature, e.g. Jane Doe, PGY
II, Med Trainee.
Refer to HHS Documentation Policies and Procedures-Guidelines for

Documentation in the Medical Record.
12.3 Protected Health Information
Medical records are considered Protected Health Information and are privileged and
confidential documents and the information must be safeguarded against
unauthorized release according to Hospital and Medical Records policies and
procedures. Information regarding a patient's care and treatment shall not be
divulged without the written consent of the patient, parents or guardians of minors,
or executors of estates of decreased individuals. The Medical Records Department
will handle all medical correspondence:
1. All insurance forms.

2. Request for various medical certificates.
3. Request for case summaries and other specified medical record
information.
4. Letters to schools, unions, or places of employment.
5. Birth certificates/Proof of Birth letters.
No trainee shall give out any information relative to the Hospital or
concerning any patient in the Hospital to a representative of the press. Such
communications are issued by Corporate Communications.

12.4 Medical Staff Rules & Regulations
In addition to being familiar with the content of the Hospital's “Administrative

Policy and Procedure (AP&P)” Manuals, and the System Manual, trainees should
review the most current copy of the Rules and Regulations of the Medical Staff.
These are available in the Department of Medical Education and the Medical Staff
Department.
12.5 Physician’s Orders
Orders must be written clearly, legibly and completely in permanent ink and signed
by the attending physician or trainee responsible for the patient's care. All orders
written must be done so on Physician's Order Sheet and must include the date and
time written, the physician’s or trainee’s signature. Supplemental verbal discussion of
orders between the physician and nurse or other professional is encouraged to
provide clarity. Orders must be specific for diagnostic or treatment procedure and
include generic name of medication. The time (when appropriate), frequency,
duration, and date to be carried out should be included. For medication orders will
be in concert with Pharmacy P&P Manual.
Physician orders must be written on hospital approved physician order forms

according to medical staff bylaws. Any order discrepancy, or clarification that is
required, will be done by clinical staff with ordering physician in accordance with
medical staff bylaws and Harnett Health Policy and Procedures for medical orders.
12.6 Service to In-patients
Trainees assigned to inpatients units must follow the guidelines of the Harnett
Health’s Medical Staff Rules and Regulations. Specifically, trainees must evaluate
admissions or transfers to critical care areas based upon the patient’s condition and
within 24-hours in general care divisions. Trainees must evaluate inpatients and write
progress notes at least daily. When a patient is seen with an attending, the trainee
should chart that in the progress note.
Trainees should answer pages as soon as possible, and respond to emergency

consultations and Emergency Department requests within 30 minutes. Trainees are
encouraged to consult with an attending or any time he/she is uncertain about a
patient care issue.

13 INSTITUTIONAL RESOURCES
13.1 Child Protection Program
Child Abuse and Neglect:

State laws require that all health care providers, including trainees, report suspected
child abuse or neglect. The social worker shall be alerted by the nursing staff,
physician, unit clerk, or any other staff member or interested party, as to the
suspicion of child abuse/ neglect, via telephone or EMR, Monday through Friday
normal working hours of the department. During off hours and weekends the Shift
Director shall be alerted.
Upon receipt of the referral the Social Worker/Shift Director shall report to the
department, review the medical record of the child involved and observe the child.
If the child shows visible signs of trauma the emergency department shall be notified
to take photographs of the child.
The Social Worker/Shift Director shall communicate with the nursing staff and
physician as to the incidence of the child’s admission to the hospital and injuries or
illness involved.
The Social Worker/Shift Director shall notify the appropriate Protective Services
Unit and report the case of suspected abuse/neglect and release photographs and
medical information as necessary.
For complete details, refer to Social Services P&P Manual or the Management P&P
Manual.
13.2 Employee Health Service
The Employee Health/Occupational Medicine Service provides a variety of health-

related services, including post-offer pre-placement physical examinations, evaluation
and treatment of workplace injuries and illnesses, exposure surveillance and updating
immunizations.
At various times throughout your employment, you will be asked to report to the
Employee Health Service for screening such as the annual PPD skin test for
tuberculosis surveillance. You may also, because of your work duties or area, be
asked to have other specific screening tests and exams, many of which are mandated
by state or federal agencies.
The Employee Health Service provides medical evaluations and treatment for work-
related injuries, which include exposure to blood and/or body fluids (e.g., sharps
injuries, splashes, exposures to communicable disease, falls, etc.). It is the
responsibility of Employee Health Service to determine:
 When an employee with an injury or infection requires work restriction

or work exclusion
 When an employee is ready to return to work after an injury or infectious
illness
Employee Health Clinic is a means for evaluating and maintaining the overall good
health of its employees. Employees suffering illness, injury, exposure to toxic
substances or a curable or incurable blood or air-borne communicable disease while
on duty must report it immediately. An Incident Report must be completed for any
of the above situations within 24-hours of occurrence or knowledge of occurrence.
In cases of potential exposure to potential blood borne or air-borne pathogens, an
Occurrence Report is completed and followed according to the Infection Control
Manual.
13.3 Employee Assistance Program
The Employee Assistance Program (EAP) is offered to all hospital employees as well
as immediate family members. The EAP is private and confidential. Although there
is no cost for services, there may be fees associated with other services and resources
to which you may be referred. Refer to Human Resource Policy and Procedure
Manual for additional information.
13.4 Nursing Department
The goal of the Department of Nursing is three-fold: to give quality care to patients,
to provide an exemplary learning climate for students and staff, and to promote a
spirit of inquiry in nursing. The nursing staff is committed to the concept of
collaboration in the delivery of quality patient services and welcomes opportunities
to work together with trainees to achieve this goal.
The Department of Nursing at Harnett Health is decentralized to promote clinical
specialization and accountability for nursing care as close to the point of service as
possible.
The Vice President of Patient Care Services directs nursing at Harnett

Health.
Nurse Directors support the Vice President of Patient Care Services in their
roles as managers of individual clinical areas.

The Vice President of Patient Care Services is the corporate officer
responsible for assuring a consistent standard of nursing care throughout
Harnett Health.
13.5 Nutrition Services
The Department of Nutritional Services is responsible for the overall nutritional care
of all patients. Registered, licensed dietitians provide that nutritional care which
includes screening patients to identify those at actual or potential risk, development
of care plans to address problems identified, education of patients for home
management of established dietary treatment regimes, and referral for ambulatory
follow-up as necessary. The department is also responsible for the preparation and
distribution of food to all hospitalized patients. A selective menu is utilized and every
effort is made to accommodate special requirements. Commonly used normal and
therapeutic diets are described in the Harnett Health Diet Manual. Diet Manuals are
located on the HHS public drive.
Dietitians are available for consult about individual patient's nutritional

status/therapy plan and should be consulted whenever a patient requires dietary
modification other than or in addition to those described in the Diet Manual. Orders
for home-going patient education should be written at least 36 hours in advance of
anticipated discharge of the patient to allow adequate time for full instruction.
Inpatient dietitians can be contacted by calling the Nutrition Services office.
13.6 Pharmacy
The Department of Pharmacy Services has the responsibility for the procurement,
storage, distribution and control of all medications for patients of the Harnett
Health. The Department provides information and assistance on the clinical use,
pharmacokinetics, administration, and adverse reactions of medications.
Policies and procedures for pharmaceutical services are developed by the

Department of Pharmacy Services, reviewed by the Pharmacy and Therapeutics
Committee, approved by the Medical Executive Committee and appear in the
Hospital Policy and Procedure Manual.
Pharmaceuticals are dispensed only to inpatients, outpatients, and patients in the

Emergency Department
The Department of Pharmacy Services and the Pharmacy and Therapeutics

Committee maintain the Formulary. It is a continually revised list of drugs that are
the most; safe and effective for use at Harnett Health. The Formulary contains a list
of available drugs by generic name and an alphabetic cross-reference of trade names.

Each trainee must sign the DEA registration log in order receive a PIN for the
hospital DEA number. The Department of Pharmacy Services requires an example
of your signature for the purpose of authentication/verification of your
prescriptions.
The Department of Pharmacy Services is responsible for distributing hospital

controlled substance prescription pads. The pads must be obtained during normal
hours and require a signature.
Clinical Pharmacy Services provided by the pharmacy include, but not limited to,
dosage adjustment recommendations for patients with renal dysfunction, facilitating
the conversion of patients to oral medications as soon as possible after admission,
review of culture and sensitivity reports for appropriate antibiotic usage, as well as
providing drug information for both staff and patients.
13.7 Security
Loss of hospital, patient, or personal property under any circumstances should be

reported to Security. Although the Hospital can assume no financial responsibility
for personal losses, every reasonable safeguard will be provided. Thefts or any other
incidents should be reported immediately to Security for investigation. Also,
suspicious persons should be reported immediately for investigation.
Trainees should exert a constant interest in the personal safety of patients and in the
proper protection of their property. Please help Harnett Health provide a safe and
secure environment for all patients, visitors, and employees.
13.8 Rehabilitation Services
The Department of Rehabilitation Services includes: Occupational Therapy (OT),

Physical Therapy (PT), and Speech-Language Pathology (SLP).
The Services include comprehensive and individualized assessment and treatment of

inpatients, skilled care and outpatients. Programs are designed to identify, correct,
improve, and/or alleviate acute or chronic dysfunction and to promote optimal
health for orthopedic, cardiac, pulmonary, congenital, vestibular and neurological
disorders. Functional goals may be short-term at each rehabilitation settings to
prepare the patient to move through the continuum of rehabilitation care to another
level and setting.
Referral Process:
1. Inpatient referrals for PT, OT, and SP require a physician’s order in the
patient’s medical record with the dysfunction or impairment for treatment.
2. Outpatient Referrals information should include:
a. Patient Name
b. Physician Name
c. Date of Birth
d. Diagnosis
e. Medical Record Number
f. Description of the problem to be treated/precautions
Printed Forms are available.
13.9 Social Work
Social Workers are assigned throughout the hospital to assist patients and their
families with personal, emotional, marital, family, or other problems that are often
related to illness and their ability to gain maximum benefit from health care services.
In addition to counseling, social workers collaborate with physicians, nurses, and
other health care workers in medical care plans for patients. With their thorough
knowledge of available health and welfare resources in the community, they can help
with arrangements for rehabilitation services, care in the home, nursing homes,
tutoring, specialized infant and children's services, or other post-hospital assistance.
The social worker must be notified in cases of suspected child or elder abuse or in
cases of domestic violence.
13.10 Communications/Information Services
Telephone System:
The Communications/Information Services Department is comprised of a complex
network of processor and computer supported telecommunications systems. The
system supports direct incoming and direct outgoing dialing from most telephones,
bypassing the hospital operator. To access an outside line you must dial 9 first.
The trainee’s quarters are equipped with telephones that trainees may use to conduct
their business. The Medical Center’s operators make a determined effort to direct
incoming calls to the correct extension. However, if you customarily cannot be
reached at a specific hospital extension, the operators will use the digital paging
system.
The audible overhead paging system is designed for emergency business and used by
the hospital operators only. The hospital operator will not accept messages.
If you have a pager problem or need a new battery the hospital operator will be able
to assist you.

13.11 Transport of Patients
For patients transferred from a patient care area, the mode of transport and
necessary equipment will be determined by each patient’s nurse, based on the
patient’s physical condition, activity restrictions and pre/post procedure care
considerations.
Trainees needing assistance with transporting patients may refer to the nursing staff
on each unit for assistance.
13.12 Paging System
Signal Calls: The telephone operators at Harnett Health have been instructed not to
call students or trainees from lectures, conferences, or meetings, except when the call
is very urgent. Therefore, when such a call is made, it is an urgent call insofar as the
operator knows and must be answered at once.
If a trainee is unable to answer the page he/she should have one of the personnel in
the area call the operator, explain the circumstances and take a message.
The emergency codes for the medical center are:
Medical Alert – Code Blue = Coronary or Respiratory Arrest

Facility Alert – Code Red = Fire
Facility Alert – Mass Casualty = Disaster, External/Internal
Facility Alert – Hazardous Spill
Security Alert – (Type of Threat)
Security Alert – Code Pink = Infant/child abduction
Security Alert – Armed Intruder
(These priorities identify types of patients coming in and the response needed by the
hospital staff.)
The paging system may be used in the follow manner:

Code Blue (Location): This is a call for cardiac arrest and must be answered
immediately by all available personnel. Report immediately to the location mentioned
and render services that are needed within your training and skills. If sufficient
physicians are available on the scene when you arrive, return to your regular duty. If
you are the first physician on the scene, take charge of the proceedings until a more
senior physician arrives. Remember – Nursing supervisors and ER Code Team
personnel will be of great assistance to you if you are not sure how to proceed.
Trainee (by name) STAT (Operator will state what phone or area): The trainee will
answer to that STAT page.

14 TRAINEE RESOURCES
14.1 Conferences, Rounds, Lectures

There are regularly scheduled Conferences, Seminars, Rounds, Lectures,
Demonstrations, etc., presented throughout the year under the auspices of the
Hospital, each Residency Training Program and the Department of Medical
Education. Notification of these meetings is published in advance. Refer to
Residency Training Program manual for specific didactic programs and attendance
requirements.
14.2 Trainee Participation on Hospital Committees
Trainees are assigned to monthly medical staff committee meetings and are
encouraged to be active participants if these committees.
14.3 Computer Use and Support
Harnett Health utilizes EMR as the primary information system in the clinical area.
EMR applications include Nursing Documentation, PCI (Patient Care Inquiry),
Laboratory, Order Entry, Radiology, Admissions, Medical Records, and Pharmacy,
among others. There are other departmental specific clinical applications such as
PACS for Radiology. Additional training will be provided for clinicians required to
use departmental systems. All systems are supported twenty-four hours a day. Calling
the Help Desk or the Switchboard by dialing “0” can access technical assistance. You
may also be assigned an email account and access to the Internet. Use of email and
the Internet are subject to the Harnett Health Confidentiality Policy (Refer to
Human Resource Policy & Procedure Manual).
The following information is presented as an overview only. Detailed information is

available from Information Services and copies of all policies are available in the
Information Services Department.
Patient Confidentiality and Security

Patients have the right to absolute privacy of their clinical records. All access should
be by clinical care providers only and never by curiosity seekers or friends,
neighbors, relatives or co-workers not involved in the patient’s clinical care. You are
privileged to access patient records with which you have legitimate clinical links. At
the same time your user ID and passwords are assigned, you will be asked to sign a
confidentiality agreement. The agreement verifies your understanding of what
constitutes a breach of access and the consequences of such a violation. All
computer access is through use of an individually assigned sign-on ID and unique
password. For security reasons, your ID or password is never to be shared or
borrowed. Use of this user ID establishes user identity and all transactions are
tracked and logged to determine appropriateness of those transactions. Information
Services constantly runs reports to track users and their access. Audit trails are
maintained to allow for periodic audits of clinical transactions, as well as those on the
Internet.
Some patients are designated as “confidential”. When one wishes to access the
information for these patients, a screen warns the user that the patient is confidential
and asks if (s)he wishes to precede. Extra caution must be exercised in this case.
Access to any patient data is subject to the Harnett Health Confidentiality Policy
(Refer to Human Resource Policy & Procedure Manual).
Process for Obtaining Access

When you arrive at Harnett Health, the Medical Records Department representative
will notify the Information Services Department of your need for access. When you
have signed the Confidentiality Agreement, you will be assigned your user ID and
password. A representative of Information Services will schedule a training class for
EMR and other applications as required before you are allowed to sign-on. If for any
reason your privileges are suspended or revoked, your computer access will be
affected accordingly.
Electronic Signature
Harnett Health will create an electronic signature for you, which associates each
provider with system/patient activity. Individual PINs for the electronic signature
and any other passwords, which are created, are to be treated as confidential and are
NOT to be shared among other individuals. Any violation or inappropriate use of
personally issued sign-on or electronic signature codes is considered a breach of
confidentiality and is subject to disciplinary action. Immediate notification should be
made to the Information Services Department if you suspect that your code or
password has been lost, stolen, or used by anyone other than its issued user.
EMR Clinical Menu

Access to multiple clinical menu options is available through EMR after completion
of the required security forms and training. Menu options include retrieval of patient
clinical results from radiology and laboratory, designated nursing documentation,
medication information, visit history and demographics.
Security Considerations
The security of the Harnett Health network is of primary concern. For this reason,
various processes are in place to protect the network, including:
 Internet use is limited to job-related access only, and non-related sites are
blocked.
 Mobile computing and storage devices that contain or access information
resources at Harnett Health are strictly monitored. Information Services must
approve them prior to connecting to the information systems at Harnett Health.
Mobile computing and storage devices include, but are not limited to: laptop
computers, personal digital assistants (PDAs), plug-ins, Universal Serial Bus
(USB) port devices, Compact Discs (CDs), Digital Versatile Discs (DVDs), flash
drives, modems, handheld wireless devices, wireless networking cards, and any
other existing or future mobile computing or storage device. Portable computing
devices and portable electronic storage media that contain confidential, personal,
or sensitive Harnett Health information must use encryption or equally strong
measures to protect the data while it is being stored.
 No one is allowed to download anything to or install anything on any Harnett
Health computer.
Details of these considerations may be obtained from the Information Services

department (HIPAA Security Policy and Departmental Policies).
14.4 Food Services
Cafeteria
Cafeteria services are available at each hospital.
NOTE:
Trainees having breakfast and/or lunch are required to obtain their meals prior to
the start of morning or noon lectures. Once the lecture has started, trainees are not
permitted to leave for meals. This is disruptive and disrespectful to the lecturers.
Vending Machines
Vending machines are available and open 24 hours per day. Items available for
purchases are snacks, and beverages.
14.5 Interpreter Services
Family members and friends may not translate for a patient when medical
information is being discussed. Federal law requires all language interpreters used by
hospitals to be proficient in their field and competency-tested; so that they can
ensure that the medical information being shared with the patient has been translated
accurately. In addition, offering a third party interpreter to patients allows the patient
to keep personal medical information confidential.
14.6 Library Facilities
Harnett Health trainees will have access to Campbell University Jerry M. Wallace
School of Osteopathic Medicine’s medical library. Library access will be arranged
during orientation.

14.7 On-Call Rooms
Every effort is made to ensure acceptable accommodations in a pleasant and restful

environment to trainees while on call. Every room is marked with a standardized
sign. Security measures other than those already in place are also the responsibility of
the individual departments.
It is the responsibility of each trainee to inform the Department of Medical
Education of any failed equipment needs and/or services required or not being
tended to.
14.8 Uniforms & Laundry
Harnett Health will furnish each trainee with two lab coats during orientation.
Trainees requiring scrubs must consult their individual training departments for
instructions on obtaining them.
Exception – Any personal effects that are contaminated with patients‘ bodily fluids
will immediately be placed in containers marked CONTAMINATED and handled in
the same manner the hospital cleans all other contaminated linens, etc. These
contaminated articles are not to leave the hospital. The hospital will provide scrub
attire for the trainee to wear should it be needed. This includes socks and shoes.

15 UNIVERSAL PRECAUTIONS
Universal precautions exist to provide the same high level of infection precaution for
all patients. Body Substance Isolation (BSI) provides a consistent approach to
managing body substances for all patients and is essential to prevent transmission of
potentially infectious agents.
The BSI system focuses on body substances (blood, feces, urine, wound drainage,
oral secretions, etc.) from the hands of personnel, primarily by increased blood use
and hand washing. Thus, the system eliminates many of the ritualistic practices
associated with traditional isolation systems while increasing the use of barriers for
all contacts with body substances.
The BSI system is consistent with recommendations from the Centers for Disease
Control to consider all blood and body fluids as potentially infectious, regardless of
the patient’s diagnosis. In order to follow these recommendations, use of barriers
must focus on the care provider’s interaction with the patient at the time, rather than
on the diagnosis of the patient, which was the cornerstone of the traditional isolation
systems.
It makes more sense to consider all blood and body substances as potentially
infectious, rather than to practice precautions only on patients diagnosed with certain
infectious diseases, because the infection status of all patients’ blood cannot be
known for most infectious diseases.
In addition, colonized body sites and secretions are a major reservoir for
multiple-drug resistant organisms easily transmitted from patient to patient
on the hands of personnel. The BSI system also reduces the risk of such
transmissions by the consistent use of barriers whenever any such substances
are likely to be in contact with the caregiver’s hands.
15.1 Basic Elements of BSI
The BSI system includes the following elements and shall be followed by all
personnel at all times, regardless of the patient’s diagnosis.
Use individual judgment in deterring when barriers are needed. Each individual must
establish his/her own standards for consistent use of barriers. These personal
standards should be based on the individual’s skills and interactions with the patient’s
body substances, non-intact skin, and mucous membranes.
1. Wear gloves when it is likely that hands will be in contact with body
substances, blood, urine, feces, would drainage, oral secretions,
sputum, and vomitus.

2. Protect clothing with a plastic apron when it is likely that eyes and/or
mucous membranes will be splashed with body substances (e.g.,
when suctioning a patient with copious secretions).
3. Wear masks and/or eye protection when it is likely that eyes and/or
mucous membranes will be splashed with body substances (e.g.,
when suctioning a patient with copious secretions).
4. Each physician needs to evaluate his/her own interactions with the
patient and use barriers as appropriate, based on anticipated contact
with body substances, not the patient’s diagnosis of infection.
5. All physicians need to know their own chickenpox and rubella status.
The Emergency Department screens all new house staff for rubella
and encourages rubella vaccine to those with a negative antibody
result. New house staff with a negative or questionable history for
varicella will have a varicella antibody titer included in their pre-
employment blood work and encourage varicella vaccine to those
with negative results. All house staff must participate in the Medical
Center’s annual TB testing program.
All physicians who have frequent contact with blood or body fluids should be
immunized against hepatitis B.
15.2 Nurses & Other Direct Care Providers Role in BSI System
Each nurse needs to evaluate his/her own interactions with the patient and use
barriers as appropriate based on anticipated contact with body substances, not the
patient’s diagnosis of infection. Use the guidelines above to make these judgments.
If the patient has a disease that is transmitted in whole or in part by the airborne
route, the nurse is responsible for triage of persons wishing to enter the patient’s
room.
If the patient is ambulatory and is soiling the environment with body substances, the
patient should be placed in a single room.
All direct care providers need to know their own chickenpox and rubella status and
must participate in the Medical Center’s annual TB skin testing program.
All direct care providers who have frequent contact with blood or body fluids
should be immunized against hepatitis B.
15.3 Precautions for Patients with Airborne Diseases
a. Private Room
b. Stop sign alert on door
c. Door Closed
When a patient is suspected of or known to have a disease transmitted in whole or in
part by the airborne route, the physician should request a private room and write the
diagnosis or “rule out” diagnosis on the order sheet. This will prompt the nurse to
notify the admitting office so that the patient may be relocated in an appropriate
room. The nurse will place a “stop sign alert” on the door to the patient’s room. The
“stop sign alert” instructs anyone about to enter the room to “wear a mask when
entering”.
When the patient is known or suspected of having chickenpox/varicella place a

“stop sign alert” with special Chickenpox Alert on the door of the patient’s room. If
the person wishing to enter has never had chickenpox, he/she should not enter the
room with or without a mask, because masks do not guarantee protection. If you
have had chickenpox, you may enter the room without a mask and provide care
using the BSI system.
The airborne route transmits the following diseases in whole or in part. Patients with
these diseases need to be assigned to a private room and have a “stop sign alert”
posted on the door. The door should remain closed.
For disease marked with an asterisk (*), all care providers who are not immune to
these diseases should not enter the room of these patients.
Note: When a patient leaves the hospital room to go to any other area, the patient
must wear masks. For all other entities it would be necessary to place a mask
on the patient while he/she is being evaluated.
Disease Duration of Airborne Comments
Precautions
** Chickenpox (Varicella) Until all lesions are Persons who are not
crusted. susceptible do not need to
wear a mask. Exposed
susceptible patients should
be isolated beginning 10
days after exposure until21
days after 1st exposure.
Epiglottitis, due to For 24 hours after start
Haemophilus influenza of effective antibiotic
therapy.
**Herpes – Duration of illness Localized lesions in
zoster/varicella localized immuno-compromised
in immuno-compromised patients frequently become
patient, or disseminated disseminated. Because
such dissemination is
unpredictable, use the same
precautions as for
chickenpox.
**Measles (rubeola) For 4 days after start of Persons who are not
rash, except in immuno- susceptible do not need to
compromised patients, wear a mask. Promptly
for whom precautions report to Infection Control
should be maintained for Nurse
duration of illness.
Meningitis For 24 hours after start Call Infection Control
of effective antibiotic Nurse
therapy.
Neisseria menigitidis For 24 hours after start Promptly report to
(meningococcus), known of effective antibiotic Infection control Nurse
or suspect therapy.
** Mumps (Infectious For 9 days after onset of Persons who are not
parotitis) swelling. susceptible do not need to
wear a mask. Call
Infection Control Nurse
Pertusis (Whooping For 7 days after start of Call Infection Control
cough) effective antibiotic Nurse
therapy.
Pneumonia – For 24 hours after start
Haemophilus in infants of effective antibiotic
and children any age therapy.
Pneumonia – For 24 hours after start Promptly report to
Meningococcal of effective antibiotic Infection Control Nurse
therapy.
Tuberculosis – In most instances, Patient must be placed in
Pulmonary confirmed or duration can be guided properly ventilated room.
suspect by clinical response and a Admitting office should be
reduction in numbers of notified for proper room
TB organism on sputum placement. Particular
smear. Usually this respiratory masks must be
occurs within 2-3 weeks worn when entering TB
after chemotherapy has isolation room. Prompt
begun. When the patient use of effective
is likely to be infected antitubercular drugs in the
with ING-resistant most effective means of
organisms, apply limiting transmission. Call
precautions until patient Infection Control Nurse
is improving and sputum
smear is negative to TB
organism.

15.4 Supplies Needed for BSI
Gloves Disposable non-sterile gloves

Sharps Container Rigid container for immediate disposal of all sharps
Aprons/Gowns Disposable plastic aprons/gloves
Eye Protection Disposable goggles. After use the goggles should be washed
by the patient care provided in the future use.
Masks Surgical Masks to be used if care provided is likely to be
splashed in face by body substances.
Stop Sign Alert One sign is to be placed on the door to the room of the
patient with an airborne disease or a leukopenic patient.
Chickenpox Alert Sign If patient has chickenpox/varicella, place sign with
chickenpox alert on door.
Plastic Bags Small clear bags obtained from housekeeping to be used in
transporting procedure trays to Central Supply for
sterilization.
Barrier Gowns Reusable fabric barrier gowns will be distributed on laundry
carts. These gowns are to be used when more extensive
covering of clothing is needed. Gowns are returned to soil
linen bags.
NOTE: Signs are to be taken down and returned to the storage location when patient no
longer needs airborne precautions. If additional signs are needed, contact Infection Control
Office.
15.5 Other BSI Procedures
Soiled linen: All soiled linen is to be put into individual laundry bags, closed securely,
transported in carts, and put down the linen chute or designated areas.
Central Service Reusable Items: All miscellaneous reusable equipment to be returned

to the Central Supply Department is to be placed in a marked basin on shelf located
in soiled utility room.
NOTE: Any fluid filled container that is not disposable should be emptied
into hopper on unit prior to returning to Central Service. All special trays are
to be placed in a clear plastic bag and left in soiled utility room.
Disposal of waste from patient rooms and ICU: Follow infectious waste
management policy.
Further questions or concerns regarding infection control should be referred

to the infection control manual and/or infection control nurse.

16 EMPLOYEE COMMUNICATIONS
16.1 Open Communication
Harnett Health encourages employees to discuss any issues they may have with a co-
worker directly with that person. If a resolution is not reached, employees should
arrange a meeting with their direct supervisor. If the concern, problem, or issue is
not properly addressed, employees should contact the Human Resources
Department. Any information discussed in an Open Communication meeting is
considered confidential, to the extent possible while still allowing management to
respond to the problem. Retaliation against any employee for appropriate usage of
Open Communication channels is unacceptable.
16.2 House Staff Meetings
In order to keep the communication channels open, the Department of Medical

Education implements a once-a-month house staff meeting. Trainees receive
communications from the Department about the agenda and discussion topics every
month.
16.3 Suggestions
The Department of Medical Education encourages all trainees to bring forward their
suggestions and good ideas about making Harnett Health a better place to work and
enhancing service to Harnett Health customers. Any employee who sees an
opportunity for improvement is encouraged to talk it over with their Program
Director and DME. The Department of Medical Education can help bring ideas to
the attention of the people in the organization that will be responsible for possibly
implementing them. All suggestions are valued.

17 LOGS
It is important to realize the essential nature of logging. The principal objective for
this is:
1. To document to certifying agencies that you have accomplished a significant

amount of clinical exposure and expertise to have graduated and/or be
certified/credentialed;
2. To document for the Department of Medical Education, the individual
program directors and trainers, that the education program is serving their
individual educational goals and providing the trainee with adequate
opportunity to learn. Outside accrediting inspection agencies do, in the
normal course of their review process, examine trainee logs;
3. To document your experience for the purpose of applying for hospital
privileges in the future. It is your personal future! Do not assume that by
doing rotations at any particular institution that privileges will automatically
flow so that logs need not be kept. Documentation is frequently important
when providing letter of reference for future training programs and/or when
applying for staff privileges.
17.1 Important Points to Remember
Responsibility of logs including archival lie exclusively on the shoulders of the

individual trainee, and is an accrediting body requirement for graduation from the
program.
Log entries should be easily verifiable. It is a normal course of the hospital

internship inspection for an inspector to request records. Charts are pulled for
verification that the trainee participated in the care of a patient. Therefore, the logs
should include some evidence of the level of involvement in the case. The medical
record as well should reflect documentation of participation by the trainee.
17.2 What to Log?
Any pertinent encounter, whether it is a hospital visit, office visit, or house call,
should be recorded. Include the patient’s name, identification number, or other
indicator as well as the diagnosis or multiple diagnoses and level of involvement.
Issue of diagnosis is often time critical because only the principle diagnosis is often
recorded. However, patients frequently present with multiple health issues. To
attest to a diversity of experience, it is important to include any supporting secondary
diagnoses.

Procedures are particularly important. Institutions when credentialing frequently
request documentation of experiences. For this purpose, procedures are the most
critical activities to be logged.
Any outside educational experience including: Academy meetings, educational

seminars, and programs that are not held in-house or recorded in any other manner.
We do maintain records internally of lectures, presentations and meetings. All
activities out of the institutional walls would be lost unless included in your logs.
On-call experiences are often looked upon as secondary activities, but are still a part
of your net clinical experience. Therefore, they should be recorded as well.
It is mandatory that reading, lectures, case presentations, or journal clubs, etc.
attended and/or presented be documented in your log.
17.3 How to Log
Be as specific as possible. Include name or initials, date, place, preceptor, and level
of involvement. This last item is most important for procedures that you may want
privileges for (i.e., observed 15 C-sections, participated or assisted in 20, did 2 under
observation). All entries supported by hospital medical record number, date, time,
location, preceptor, level of participation. You may want to mention complications
or other related specifics that you handled.
In short, logs help to aid the function of the program, but most directly benefit you.
Keep them current, and complete them in an organized manner. The Program
Director may call for the logs at any time during the year for spot review. They are
your responsibility.
17.4 Policy Statement
To underscore the importance of this activity and to insure timely compliance, the
policy on log and evaluation completion will be on the same basis as any medical
record within the hospital. The educational objective here exceeds assuring
mechanical compliance with submitting logs. It is designed to encourage a physician
early in his career, the ability to follow through with the medical record in a timely
manner.
1. Patient logs and preceptor evaluations are to be in at the completion of each

rotation recorded within seven (7) days of completion of a rotation.
2. Time log is due to the Medical Education Department immediately upon
completion of the rotation.
3. For longitudinal experiences that extend over the year period, it is expected
that they be completed within fifteen (15) days of the completion of an
academic year.

4. If logs are not completed in a timely manner, suspension from the education
program may take place immediately upon direction of the DME.
Exception to the rule:
1. Catastrophic illness where the trainee is not physically able to complete

logs
2. Catastrophic illness prohibits his/her preceptor from filling out the
evaluation form. Consideration will be given to late reports only if an
explanation is provided by the preceptor, in writing, and accompanies the
log and evaluation.

18 ACKNOWLEDGEMENT
I acknowledge that I have received a copy of the Harnett Health’s Common Trainee
Policy and Procedure Manual, and I do commit to read and follow these policies.
I am aware that if, at any time, I have questions regarding the Common Trainee
Policy and Procedure Manual, I should direct them to the Administrative DME or
the DME.
I know that Harnett Health policies and other related documents do not form a
contract of employment and are not a guarantee by Harnett Health of the conditions
and benefits that are described within them. Nevertheless, the provisions of such
Harnett Health company policies are incorporated into the acknowledgment, and I
agree that I shall abide by its provisions.
I also am aware that Harnett Health, at any time, may on reasonable notice, change,
add to, or delete from the provisions of the company policies.
________________________________ ___________________________
Trainee’s Printed Name OGY Level
________________________________ ___________________________
Trainee’s Signature Date


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Common Trainee Policy and Procedure Manual RV 4 1 FINAL As of 6 2616

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Common Trainee Policy and Procedure Manual

Michelle Langaker, DO Director of Medical Education

Donald Maharty, DO Vice President of Medical Education

Trainee Manual Version Control

Reviewed and Approved by Medical Education

The Institution at its option, may change, delete, suspend or

1.1 Welcome ........................................................................................................................................................10

1.2 History ...........................................................................................................................................................10

1.3 Orientation Schedule ..................................................................................................................................11

1.4 Changes in Policies ......................................................................................................................................11

2 OPERATIONAL POLICIES ......................................................................................................... 12

2.1 Educational Structure .................................................................................................................................12

2.2 General Objectives ......................................................................................................................................12

2.3 Expected Outcome .....................................................................................................................................15

2.4 Appointment ................................................................................................................................................15

2.6 Term of Service ............................................................................................................................................16

2.7 Trainee Contract ..........................................................................................................................................16

2.8 Status ..............................................................................................................................................................17

2.9 Educational Stipend ....................................................................................................................................18

2.10 Time Away ....................................................................................................................................................18

2.12 Unauthorized/Unscheduled Absences ....................................................................................................19

2.13 Completion of Training ..............................................................................................................................19

2.14 Program Closure or Reduction .................................................................................................................19

2.15 Restrictive Covenants .................................................................................................................................20

2.17 Revocation of Off-Duty Hours ................................................................................................................20

3 EMPLOYMENT POLICIES ......................................................................................................... 21

3.1 Equal Employment Opportunity/Diversity ...........................................................................................21

3.2 Americans with Disabilities Act ................................................................................................................21

The Institution at its option, may change, delete, suspend or

3.4 Pre-Employment Evaluation .....................................................................................................................21

3.5 Post Enrollment Requirements: Years 1-4..............................................................................................23

3.6 Criminal Records .........................................................................................................................................24

3.7 Controlled Substance (DEA) ....................................................................................................................24

3.8 Physician Impairment & Substance Abuse .............................................................................................25

3.9 Licensure .......................................................................................................................................................25

3.10 Certificates ....................................................................................................................................................26

3.11 Change of Personal Data............................................................................................................................27

3.12 Chain of Communication ...........................................................................................................................27

3.13 Safety ..............................................................................................................................................................27

3.14 Personal Property ........................................................................................................................................27

3.15 Professional Activities outside the Program ...........................................................................................28

3.16 Visitors in the Workplace ...........................................................................................................................28

3.17 Weather-related and Emergency-related Closings .................................................................................28

4 DISCIPLINARY PROCESS ..........................................................................................................29

4.1 Performance .................................................................................................................................................29

4.2 Remediation Process ...................................................................................................................................31

4.3 Summary Suspension ..................................................................................................................................31

4.4 Automatic Suspension ................................................................................................................................32

4.5 Trainee Appeals Process ............................................................................................................................32

4.6 Grievance and Due Process Procedure ...................................................................................................34

4.7 Maintaining Discipline among Patients, Nurses and Employees ........................................................39

4.8 Transitions of Care (Structured Patient Handoffs) ...............................................................................39

5 STANDARDS OF CONDUCT ......................................................................................................42

5.1 Work Schedule .............................................................................................................................................42

5.2 General Guidelines ......................................................................................................................................42

The Institution at its option, may change, delete, suspend or

5.4 Harassment Policy .......................................................................................................................................42

5.5 Sexual Harassment Policy ..........................................................................................................................43

5.6 Violence in the Workplace .........................................................................................................................44

5.7 Confidential Information and Nondisclosure ........................................................................................44

5.8 Ethical Standards .........................................................................................................................................44

5.9 Dress Code ...................................................................................................................................................45

5.10 Use of Equipment .......................................................................................................................................45