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Medical Staff Rules and Regulations

04 Dec 2022

Approved Changes to the Rules and Regulations Regarding Progress Notes for the Extended Care Unit

By: On behalf of the Salem Hospital Medical Executive Committee

An urgent Common Ground was released to the Salem Hospital Medical Staff on November 10, 2022, regarding changes to the Rules and Regulations which can be located here. The changes were posted for 14 days for Medical Staff feedback. The Medical Executive Committee reviewed feedback and voted to approve the changes on November 24, 2022. Final approval of the revisions were approved by the Board of Trustees on December 1, 2022. 

Effective December 1, 2022, the Salem Hospital Rules and Regulations, Article VI Part E: Progress Notes have been adopted. A full copy of the Rules and Regulations can be located on the Medical Staff Office department page via the Salem Hospital intranet. Below is an excerpt of the adopted language regarding the Extended Care Unit.


The attending provider of record or the covering provider shall be required to make daily face-to-face rounds on their hospitalized patients, followed by the documentation of their observation in a progress note.

Progress notes must be documented no less than daily, and must be documented on the day of the encounter, with the following limited exceptions: 

  1. Patients who meet discharge criteria, who remain in the hospital other than due to medical necessity, when progress notes and face-to-face visits must be documented at least every other day.
  2. Patients in the Extended Care Unit who are awaiting discharge must have documented progress notes and face-to-face visits at least every seven days.

Regardless of exception, an additional progress note is required for any immediate change in patient status, defined as:

  1. Any change in condition of the patient that requires the provider to perform a bedside evaluation,
  2. ICU-to-floor transfer, or if there is a change in provider,
  3. Floor-to-ICU transfer.