1. The patient has the right to impartial access to treatment or hospital accommodations regardless of race, creed, sex, age, disability, disease process, national origin, or sources of payment.

2. The patient has the right to considerate, respectful care at all times and under all circumstances in recognition of his/her personal dignity. The patient’s individuality will be respected, psychosocial and spiritual needs considered, and differences in the cultural and educational background will be taken into account, as well as any specialized or age-specific needs. The patient or his/her representative has the right to participate in developing and implementing the plan of care.

3. The patient has the right, within the law, to his/her privacy by:
a. Refusing to talk with or see anyone who is not officially connected with the healthcare facility or directly involved in his/her care.
b. Wearing appropriate personal clothing or religious items, as long as they do not interfere with diagnostic exams, his/her treatment, or do not pose a danger to him/her.
c. Expecting private surroundings during interviews and examinations.
d. Expecting any discussion or consultation about his/her care to be done discreetly as possible with no one present that is not directly involved in his/her care without his/her permission.
e. Expecting that his/her medical health record be read by only those directly involved in his/her treatment or the monitoring or assessment of its quality and by others only with his/her written authorization.
f. Expecting reasonable provision of protective privacy when needed for his/her personal safety.

4. The patient has the right to receive care in a safe setting and expect reasonable safety in the hospital environment.

5. The patient has the right to know the names of those who are providing his/her care and who are primarily responsible for Patient Rights and Responsibilities. Retrieved that care, treatment, and services.

6. He/she has the right to refuse participation in research or experimental procedures. (In instances where the patient is under a legal disability, these rights will, when feasible, be accorded, as well, to the party legally responsible for medical decisions respecting the patient).

7. The patient has the right to receive information from his/her primary provider regarding his/her diagnosis to the degree that it is known, his/her treatment, any known prognosis, and outcomes of care, including unanticipated outcomes. He/she has the right to expect this information in language and terms that he/she can understand. When it is medically inadvisable to give such information to the patient, it should be made available to a legally authorized person.

8. The patient has the right to see visitors and to communicate with others outside the health care facility by telephone or in writing. The patient may designate visitors in accordance with the hospital policy. Visitors designated by the patient may not be denied because of race, creed, color, national origin, ancestry, age, religion, sex, gender identity, sexual orientation, marital status, or disability.

9. The patient who does not speak English has the right, whenever reasonably possible, to an interpreter.

10. The patient has the right to participate in decisions and ethical issues concerning his/her care and to be given information by his/her physician concerning his/her medical condition, suggested treatments or procedures, and any risks or side effects. Where medically significant, the patient should be informed of alternatives in his/her care or treatment. In instances where the patient is under a legal disability, these rights will, when feasible, be accorded, as well, to the party legally responsible for medical decisions respecting the patient. The patient should give voluntary, competent, and informed consent to any contemplated procedure. In the event that the patient is incapable of giving consent, appropriate consent will be sought, whenever possible, from his/her legal guardian or another authorized person.

11. The patient, at his/her own request and expense, has the right to consult with another physician.

12. The patient may refuse treatment to the extent permitted by law. If he/she or his/her guardian refuses treatment that prevents the provision of appropriate care, according to professional standards, his/her physician, upon reasonable notice, may terminate the relationship with the patient.

13. The patient has the right to produce or formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives. In the advance directive, the patient may provide guidance as to his/her wishes concerning provision of care in certain situations; alternatively the patient may delegate decision-making authority to another individual, as permitted by State law. He/she has the right to the same medical care, whether he/she has an advance directive or not.

14. The patient, or his/her next of kin or legally responsible person, has the right to complete information and explanation concerning any need for his/her transfer to another facility and the alternative to such a transfer. The facility to which the patient is to be transferred must first have accepted the patient for transfer. The patient has the right to be informed by his/her physician of any continuing health care requirements following discharge from the hospital. In instances where the patient is under a legal disability, these rights will, when feasible, be accorded, as well, to the party legally responsible for medical decisions respecting the patient.

15. The patient has the right to request an itemized explanation of his/her bill for hospital services.

16. The patient has the right to information regarding the hospital rules and regulations applicable to his/her conduct as a patient.

17. The patient has the right to file a complaint or grievance with the hospital. The patient has the right to information on how to issue a complaint and the hospital mechanism for reviewing and resolving patient complaints.

18. The dying patient has a right to comfort, dignity, appropriate treatment and pain management, and the acknowledgment of his/her psychosocial and spiritual needs and those of his/her family.

19. The patient has a right to have a family member or representative of his/her own choice and his/her physician notified promptly of his/her admission to, or discharge, or transfer from the hospital. The patient may refuse notification to his/her physician of an admission, discharge, or transfer from the hospital.

20. The patient has the right to access information contained in his/her clinical records within a reasonable time frame.

21. The patient has the right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff.

22. The patient has the right to information about pain associated with disease process, treatment, and procedures to be performed, and short and long term pain relief measures. Included in this is the expectation that pain will be managed to the level that he/she considers acceptable.

OTHER
1. The patient has the right to be free from all forms of abuse, neglect, and exploitation.

2. The hospital informs the patient of the name of the physician(s), clinical psychologist(s),or other practitioner(s) who will provide his/her care, treatment, and services.

3. The patient or his/her representative has the right to participate in the development and implementation of the plan of care including the discharge plans or pain management plan.

4. The patient has the right to the confidentiality of his or her clinical records.

5. The hospital respects the patient’s right to and need for effective communication.

6. The hospital respects the patient’s right to receive information in a manner he or she understands. The hospital provides information in a manner tailored to a patient’s age, language, and ability to understand. The hospital provides information to the patient who has vision, speech, hearing, or other cognitive impairments in a manner that meets the patient needs. The hospital provides language interpreting and translation services.

7. The hospital respects the patient’s cultural and personal values, beliefs, and preferences and accommodates the patient’s right to religious and other spiritual services.

8. The hospital protects the patient and respects his or her rights during research, investigation, and clinical trials. He/she has the right to refuse participation in research or experimental procedures. In instances where the patient is under a legal disability, these rights will, when feasible, be accorded, as well, to the party legally responsible for medical decisions respecting the patient.

9. The right of a patient to have visitors may be limited or restricted when visitation would interfere with the care of the patient and/or the care of other patients.

GUIDELINES FOR HOSPITAL VISITORS
10. The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. A patient has the right to delegate his/her right to make informed decisions to another person (as allowed under State law).

11. The hospital honors the patient’s right to give or withhold informed consent, including to give or withhold informed consent to produce or use recordings, films, or other images for purposes other than his or her care. The patient has the right to request that the production of recordings, films, or other images cease. The hospital will comply with law and regulations when making or using recordings, films, or other images of patients.

12. The patient has the right to review or revise his/her advance directives.

13. The patient has the right to information on how to issue a complaint and the hospital mechanism for reviewing and resolving patient complaints. The patient has the right to lodge a grievance with the State agency that has licensure survey responsibility for the hospital directly, regardless of whether he/she has first used the hospital’s grievance process. The patient has the right to file a grievance with the QIO directly, regardless of whether he/she has first used the hospital’s grievance process.

14. The patient has a right to have a family member, friend, or other individual of the patient’s choice present for emotional support during the course of stay unless the individual’s presence infringes on others’ rights, safety, or is medically or therapeutically contraindicated.

15. Hospitals are expected to take reasonable steps to determine the patient’s wishes concerning the designation of a representative. Unless prohibited by applicable State law:

a. When a patient who is not incapacitated has designated, either orally to hospital staff or in writing, another individual to be his/her representative, the hospital must provide the designated individual with the required notice of patients’ rights in addition to the patient. The explicit designation of a representative takes precedence over any non-designated relationship and continues throughout the patient’s inpatient stay or outpatient visit, unless expressly withdrawn, either orally or in writing, by the patient.
b. In the case of a patient who is incapacitated, when an individual presents the hospital with an advance directive, medical power of attorney, or similar document executed by the patient and designating an individual to make medical decisions for the patient when incapacitated, then the hospital must, when presented with the document, provide the
required notice of its policies to the designated representative. The explicit designation of a representative takes precedence over any non-designated relationship and continues throughout the patient’s inpatient stay or outpatient visit unless the patient ceases to be incapacitated and expressly withdraws the designation, either orally or in writing.
c. When a patient is incapacitated or otherwise unable to communicate his or her wishes, there are no written advance Patient Rights and Responsibilities. Retrieved 4/29/2022.
directive on file or presented, and an individual asserts that he or she is the patient’s spouse, a domestic partner (whether or not formally established and including a same-sex domestic partner), parent (including someone who has stood in loco parentis for the patient who is a minor child), or other family member and thus is the patient’s representative, the hospital is expected to accept this assertion, without demanding supporting documentation, and provide the required notice to the individual, unless:
i. More than one individual claims to be the patient’s representative. In such cases, it would be appropriate for the hospital to ask each individual for documentation supporting his/her claim to be the patient’s representative. The hospital should make its determination of who is the patient’s representative based upon the hospital’s determination of who the patient would most want to make decisions on his/her behalf. Examples of documentation a hospital might consider could include but are not limited to the following: proof of a legally recognized marriage, domestic partnership, or civil union; proof of a joint household; proof of shared or comingled finances; and any other documentation the hospital considers evidence of a special relationship that indicates familiarity with the patient’s preferences concerning medical treatment;
ii. Treating the individual as the patient’s representative without requesting supporting documentation would result in the hospital violating State law. State laws, including State regulations, may specify a procedure for determining who may be considered to be the incapacitated patient’s representative and may specify when documentation is
or is not required; or iii. The hospital has reasonable cause to believe that the individual is falsely claiming to be the patient’s spouse, domestic partner, parent, or other family member.

MINORS
1. The minor has the right to family involvement in the assessment, treatment, and continuity of care.

2. A parent is required to stay with minors with the exception of infants in the Newborn or NICU nurseries; Pediatric Security

3. Educational services are arranged by Social Work staff if needed.

PATIENT RESPONSIBILITIES
1. The patient has the responsibility to provide, to the best of his/her ability, accurate and complete information regarding his/her medical history, current condition, hospitalizations, medications, known communicable diseases, and other matters relating to his/her health.

2. The patient should report any unexpected changes in his/her condition to the responsible nurse and physician. He/she should make it known whether he/she clearly understands a suggested treatment or procedure, expected outcomes, and the level of discomfort or pain expected with a treatment or procedure. He/she should have a clear understanding of what is expected of him/her.

3. The patient should discuss with his/her physician and nurse options for pain management and report to his/her physician and nurse when pain is not relieved to the level of tolerance of comfort that he/she finds manageable.

4. The patient is responsible for following the instructions given by his/her physician, nurse, or allied health personnel in carrying out the treatment or care plan. He/she is responsible for keeping appointments or notifying the physician if he/she cannot do so.

5. When treatment is refused by the patient, he/she is responsible for his/her actions and for any consequences of his/her refusal of treatment or refusal to follow his/her physician’s instructions.

6. The patient is responsible for assuring that the financial obligations of his/her health care are fulfilled promptly.

7. The patient is responsible for following the hospital rules and regulations affecting patient care and conduct.

8. The patient has the responsibility for being considerate of the rights of other patients and hospital personnel. He/she is expected to assist with the control of noise, and to comply with the smoking policy of the hospital and policies regarding visitors. The patient is responsible for the care of the property of the healthcare facility and other persons.

9. The patient has the responsibility to contribute to the maintenance of a safe environment and to notify his/her physician and /or nurse of any issue affecting a safe environment.

The care of patients is dependent on individual circumstances and no policy or procedure can detail or describe each circumstance. Thus, the guideline is not a statement of the standard of care and should not be interpreted as such. It is meant to be a guideline only and should never be a substitute for the exercise of judgment.