Policies,Clinical,UWHC Clinical,UWHC-wide,Legal Affairs

Patient Rights and Responsibilities (4.34)

Patient Rights and Responsibilities (4.34) - Policies, Clinical, UWHC Clinical, UWHC-wide, Legal Affairs


UWHC policy #4.34 Patient Rights and Responsibilities
Effective Date: July 23, 2015
Version: Revision


To establish a patient bill of rights and responsibilities for all UWHC facilities, and to ensure the proper
dissemination of information to patients and families.

A. Notification of Patient Rights. Patients or their authorized representatives will receive a copy of their
Patient Rights at the time of admission to the hospital, and at the time of new patient registration in the
clinics, within a reasonable period of time.
B. Patient Rights.
1. The patient has a right to treatment regardless of race, creed, color, national origin, ancestry,
religion, gender, gender identity or expression, sexual orientation, marital status, age, newborn
status, disability or source of payment.
2. The patient has a right to emergency treatment regardless of ability to pay.
3. Except in some emergencies, the patient may not be transferred to another facility without being
given a full explanation for the transfer, without provision being made for co ntinuing care, and
without acceptance by the receiving institution.
4. The patient has a right to be treated with dignity, respect and courtesy, and to be free from all
forms of abuse and harassment.
5. The patient has a right to visual and auditory privacy and confidentiality. Personal or medical
details of the patient's condition and treatment may not be disclosed to others at any time except
to those entitled to receive the information or unless ordered by court of law or otherwise allowed
by state or federal law. To facilitate continuity of care, health information of patients of UWHC
that is maintained in electronic format is also made available to health care providers associated
with UW Health who are involved in providing services to the patient in some other settings. Such
settings include, but are not limited to, some University Community Clinics, Group Health
Cooperative, UW Medical Foundation Physician's Clinics and Meriter Hospital settings.
6. Under federal law, patients have a right to ask for restrictions on certain uses and disclosures of
their health information. However, under federal law, UWHC is not required to agree to the
request. Because of the number, complexity, and nature of the services we deliver, UWHC cannot
make any formal commitment under federal law to agree to such requests. However, outside of
federal law, in rare circumstances, informal arrangements for limited restrictions may be worked
out. Patients have the right to limit access for research purposes to their medical record. These
restrictions cannot prevent review by authorized personnel and organizations for the purpose of
assuring the quality of care.
7. The patient has a right to request how and where we will direct all communications to them
outside the clinical or the hospital setting. See UWHC Policy #6.24-Communication with Patients
Outside of the Clinical Setting.
8. The patient has a right to information about Hospital policies and procedures.
9. The patient who has Limited English Proficiency (LEP) or has a disability has the right to
accommodation to ensure equal access to and participation in health care decision-making.
Foreign language and American Sign Language interpreters, in addition to adaptive equipment
aimed at facilitating communication (such as TDDs), are available for patients' use through the
Interpreter Services Department, 262-9000. (See UWHC policy #7.53-Interpreter Services
and/or Linguistic Access for details about how to reach an interpreter between the hours of 5pm
and 7am Monday - Friday or on weekends.)
10. The patient has a right to complete information. This information would include the patient's
condition, treatment plan, and outlook for recovery. The patient also has a right to know the
name of the physician or other practitioner who has primary responsibility for the patient's care.
11. The patient has the right to be informed of his/her health status, to be involved in care planning
(within the AFCH this includes involvement in family medical rounds) and treatment, including
managing pain effectively, to participate in decisions involving his/her health care, and not to be
subjected to procedures without his/her consent. Consent must be given by the patient or the
patient's authorized representative in the case of patients who are unable to consent. The patient
should be given an explanation of the following:
a. Patient's condition
b. Intended procedure or treatment
c. Treatment alternatives
d. Risks and side effects
e. Consequences of failure to treat

f. Probability of success
12. The adult patient with decision-making capacity has the right to formulate an advance directive
(example, Power of Attorney for Health Care or Living Will) and to expect providers who care for
him/her in the hospital to honor his/her wishes to the extent permitted by law.
13. The patient has the right to choose not to be treated if the patient has decisional capacity. On
consent for minors, refer to UWHC Policy #4.17-Informed Consent. The physician must inform
the patient of the consequences of refusal. The patient is responsible for his/her actions if he/she
refuses treatment or does not follow the practitioner's instructions.
14. The patient and, when appropriate, the patient's family has the right to be informed about the
outcomes of care, including unanticipated outcomes.
15. The patient has a right to refuse experimental treatment or participation in research.
16. The patient has a right to participate in the consideration of ethical issues that may arise from
the patient's care. These issues may include resolution of conflict, withholding or withdrawal of
life-sustaining treatment and participation in investigational studies and clinical trials. Contact the
Department of Patient Relations (G7/210, 263-8009) or the Ethics Committee Member on call
(262-2122) for information or assistance with the resolution process for ethical concerns.
17. The patient has the right to request a limit on the number of medical students and residents
involved in their care. Patients who wish to limit the involvement of resident physicians or
medical students with their care should speak with their doctor. To the extent possible, the
request will be honored if doing so would not negatively affect the patient's care, treatment or
18. The patient has the right to prompt notification of his/her hospitalization to a family member or
representative, as well as the patient's personal physician.
19. The patient has the right to decide who may or may not visit them during their hospital stay.
20. The patient has the right to identify a support person to be involved in care, treatment decisions
and services (to the extent authorized by the patient).
21. The patient has a right to care that recognizes the patient's psychosocial, emotional, spiritual and
cultural needs. The patient has a right to exercise his or her cultural and spiritual beliefs that do
not harm others or interfere with the planned course of medical treatment.
22. The patient has a right to access protective services when indicated, such as guardianship.
Patients or their authorized representatives should talk with their case manager or contact the
Coordinated Care/Case Management Department at (608) 263-8669.
23. The patient has a right to receive care in a safe setting.
24. The patient has a right to be free from seclusion or restraints of any form unless clinically or
forensically indicated.
25. The patient has a right to appropriate assessment and management of pain.
26. The patient has a right to examine and obtain copies of his or her medical or billing records within
a reasonable time frame and at a reasonable cost. See UWHC Policy #6.13-Patient Right to
Access Their Medical Records and #2.24-Patient Right to Access Billing Records.
27. The patient has a right to challenge the accuracy of information in their medical or billing records.
If the patient disagrees with a portion of the medical or billing record, he/she may make a written
request to change the information contained in the records. See UWHC Policy #6.14-Amendment
of the Medical Record and #2.25-Patient Right to Amend Billing Records.
28. The patient has a right to receive a copy of his/her bill and to know the charges for each service
he/she received, except that the hospital is not permitted to provide an itemized list of charges to
patients receiving Medical Assistance, so they need to contact the Health Care Financing Bureau
to obtain this information.
29. The patient has the right to request an accounting of disclosures of their health care information.
See UWHC policy #6.23-Accounting of Protected Health Information Disclosures.
30. A patient has the right to receive information about the hospital's Charity Care program that
provides financial assistance to patients who qualify.
31. A guardian or next of kin or other authorized representative may exercise these rights on the
patient's behalf if the patient is a minor or lacks decisional capacity.
C. Resolution of Patient and Family Concerns.
1. Patients and families are encouraged to discuss any concerns regarding their medical care and
treatment experience, or issues regarding the privacy and confidentiality of their information with
members of the medical and nursing staff. Patients and/or families who feel that their concerns
have not been adequately addressed should contact the Department of Patient Relations,
G7/210, 263-8009 or uw.hospital@uwhealth.org. Inquiries will be reviewed in a timely manner
and resolved whenever possible. (See UWHC policy #4.36-Responding to Patient/Family
Complaints and Grievances for complete information).
2. Patients or their authorized representatives may also file a complaint at any time with the
following agencies:
a. The State of Wisconsin, Department of Health Services, Division of Quality Assurance,
Bureau of Health Services, P.O. Box 2926, Madison, WI 53701-2969, (800) 642-6552.

b. The Joint Commission, Office of Quality Monitoring, One Renaissance Boulevard,
Oakbrook Terrace, IL 60181, phone (800) 994-6610, fax (630) 792-5636, or via
email: complaint@jointcommission.org
c. Patients who wish to file a complaint about their laboratory testing may contact either
the Centers for Medicare & Medicaid Services (CMS) Central Office, Division of
Laboratory Services (CLIA), toll free 1-877-267-2323 extension 63531 or the College of
American Pathologists (CAP), toll free 866-236-7212.
d. Patients can file an appeal with KEPRO, the Wisconsin Quality Improvement Organization
at (855) 408-8557 if they are a Medicare patient and have a quality of care complaint or
believe they are being discharged from the hospital too soon.
e. Patients who feel that the privacy and confidentiality of their information has been
breached may also file a complaint with the Secretary of the Federal Department of
Health and Human Services. The U.S. Department of Health and Human Services 200
Independence Avenue, S.W. Washington, D.C. 20201. Toll Free: 1-877-696-6775.
f. Patients who wish to file a formal service delivery discrimination complaint may contact:
--Wisconsin Department of Health Services, Division of Enterprise Services, Office of
Civil Rights Compliance, 1 W. Wilson, Room 561, P.O. Box 7850, Madison, WI 53707,
voice (608) 266-9372, TTY/TDD 1-888-701-1251.
--U.S. Department of Health & Human Services, Director, Office for Civil Rights Room
509F HHH Bldg, 200 Independence Avenue, S.W., Washington, D.C. 20201, voice (202)
619-0403, TTY/TDD (202) 619-3257.
--U.S. Department of Health & Human Services, Office for Civil Rights, Region V, 233
Michigan Ave., Chicago, IL 60601, voice (312) 886-2359, TTY/TDD (312) 353-5693.
D. Additional Rights of Pediatric Patients and Their Parents or Guardians.
1. Consent to treatment for persons under age 18 is usually given by a parent or
guardian. Exceptions may be made in certain circumstances, i.e., when emergency treatment is
needed or if a minor is mature or emancipated. For further information about informed consent,
refer to UWHC Policy #4.17-Informed Consent.
2. Children in the Hospital shall have the right to have parents (or a parent substitute) with them
except in some situations defined by the caregivers, such as the operating room, intensive care
unit, burn unit or during procedures.
3. Children shall have the opportunity for play, recreation, and education suited to their age,
developmental level, and condition and shall be in an environment designed, furnished, staffed
and equipped to meet their needs.
4. Children shall be cared for by staff that is able to respond to the physical, emotional, and
developmental needs of children and families.
E. Patient Responsibilities.
1. The patient has a responsibility to follow Hospital rules and regulations.
2. The patient has a responsibility to respect the rights of other patients, families, visitors, and
Hospital personnel.
3. The patient has a responsibility to provide accurate and complete information about matters
pertaining to his or her health.
4. The patient has a responsibility to ask their health care provider for more information if the
patient does not understand his/her illness or treatment plan.
5. The patient has a responsibility to cooperate with caregivers to implement the treatment plan.
6. The patient has a responsibility to report any changes in condition after discharge.
7. The patient has a responsibility to provide the Hospital with accurate health insurance information
and/or to make other appropriate arrangements for reimbursement of the services rendered.
8. The patient has a responsibility to keep appointments or give proper notice if unable to do so.
9. The above statements of patient responsibility also pertain to children and their parent(s) or
This statement is intended as a summary to assist patients and staff in understanding patient rights. It does not
detail the special circumstances when exceptions and alternatives can be authorized.

UWHC policy #6.24, Communication with Patients Outside of the Clinical Setting
UWHC policy #7.53, Interpreter Services and/or Linguistic Access
UWHC policy #4.17, Informed Consent
UWHC policy #6.13, Patient Right to Access Their Medical Records
UWHC policy #2.24, Patient Right to Access Billing Records
UWHC policy #6.14, Amendment of the Medical Record
UWHC policy #2.25, Patient Right to Amend Billing Records
UWHC policy #6.23, Accounting of Protected Health Information Disclosures
UWHC policy #4.46, Responding to Patient/Family Complaints and Grievances


Sr. Management Sponsor: VP, Quality and Patient Safety
Author: Director, Patient Relations and Patient/Family Partnerships
Reviewer(s): Director, Pediatric Nursing; General Counsel; Director, Compliance

Approval Committee(s): UW Health Clinical Policy Committee; Medical Board


Christopher Green, MD
SVP Medical Affairs and CMO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee