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Statutory Authority: Authority: AS 18.20.010 AS 18.20.060 7 AAC 12.210. Medical staff. (a) A hospital described in 7 AAC 12.200 must have a medical staff. (b) The medical staff shall organize and adopt, with the approval of the governing body, bylaws and rules which provide for

(1) eligibility for medical staff membership, and recommending appointments to the governing body;

(2) appointment of committees, including executive, credentials, medical records, tissue and transfusion, infection control, pharmacy and therapeutics, and utilization review committees, which shall keep written minutes of their meetings, including committee activities and recommendations; and

(3) election of officers, including a chief of staff, and quarterly meetings, with minutes and records of attendance to be maintained for at least five years. (c) The medical staff shall

(1) recommend annually to the governing body the appointment of and the medical and surgical privileges for each member of the medical staff;

(2) ensure that a physician is available to respond to an emergency at all times;

(3) place each patient under the care of a member of the medical staff;

(4) require that an order of a practitioner, including a telephonic or other oral order, be reduced to writing and, within three days after the order is given, be dated, timed, and either initialed or signed by that practitioner or by another practitioner responsible for the care of the patient, even if the order did not originate with the other practitioner;

(5) ensure that the use of an investigational drug is properly supervised by a member of the medical staff, that an informed consent form provided by the sponsoring company or agency is used, and that complete records on the drug, including protocol and side effects, are maintained;

(6) establish procedures for circumstances in which consultation is required;