10A NCAC 13B .3706. ORGANIZATION AND RESPONSIBILITIES OF THE MEDICAL STAFF

(a)  The medical staff shall be organized to accomplish its required functions and provide for the election or appointment of its officers.

(b)  There shall be an executive committee, or its equivalent, which represents the medical staff, which has responsibility for the effectiveness of all medical activities of the staff, and which acts for the medical staff.

(c)  All minutes of proceedings of medical staff committees shall be recorded and available for inspections by members of the medical staff and the governing body.

(d)  The following reviews and functions shall be performed by the medical staff:

(1)           credentialing review;

(2)           surgical case review;

(3)           medical records review;

(4)           medical care evaluation review;

(5)           drug utilization review;

(6)           radiation safety review;

(7)           blood usage review; and

(8)           bylaws review.

(e)  There shall be medical staff and departmental meetings for the purpose of reviewing the performance of the medical staff, departments or services, and reports and recommendations of medical staff and multi-disciplinary committees.  The medical staff shall ensure that minutes are taken at each meeting and retained in accordance with the policy of the facility.  These minutes shall reflect the transactions, conclusions and recommendations of the meetings.

 

History Note:        Authority G.S. 131E-79;

Eff. January 1, 1996.