SECTION 310:667-9-9. Medical staff bylaws

(a)   Bylaws shall be adopted to govern and enable the medical staff to carry out its responsibilities.

(b)   The bylaws of the medical staff shall be a precise and clear statement of the policies under which the medical staff regulates itself.

(c)   Medical staff bylaws, rules and regulations shall include the following:

(1)   A descriptive outline of medical staff organization.

(2)   A statement of the necessary qualifications which physicians and licensed independent practitioners shall possess to be eligible for medical staff privileges to work in the hospital, and/or the duties and privileges of each category of medical staff.

(3)   A procedure for granting and withdrawing privileges to physicians and licensed independent practitioners.

(4)   A mechanism for appeal of decisions regarding medical staff membership and privileges.

(5)   A definite and specific statement forbidding the practice of the division of fees under any guise whatsoever.

(6)   Provision for regular meetings of the medical staff.

(7)   Provision for keeping accurate and complete medical records.

(8)   A provision that all patient tissue removed in the hospital, except tissue specifically excluded by medical staff policy, shall be examined by a pathologist and a report made of this examination.

(9)   Provision for performing and documenting a routine examination of all patients upon admission and recording of pre-operative diagnosis prior to surgery.

(10)   A rule permitting a surgical operation only on consent of the patient or his or her legal representative, except in emergencies.

(11)   A rule providing that, except in emergency, consultation is required as outlined above.

(12)   A regulation requiring physicians' and licensed independent practitioners' orders be recorded and signed.

(13)   If dentists and oral surgeons, podiatrists, psychologists, or other allied health professionals are to be admitted to staff membership, the necessary qualifications, status, privileges, and rights of this group shall be stated in the bylaws.

[Source: Added at 12 Ok Reg 1555, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok Reg 1664, eff 6-12-03]