Faculty and Clinical Affairs

Series 400 Patient Care

Wright State University Boonshoft School of Medicine
Sponsored Graduate Medical Education Programs
Resident Manual

Item 401 Prescribing Controlled Substances
Item 402 Infection Control
Item 403 Medical Records Completion
Item 404 Death Certificates

Item 401
Prescribing Controlled Substances

Revised September 2003

Each resident is assigned a DEA number. The program's fiscal agent is identified by a letter prefix to designate the specific teaching hospital.

  • C: Children's Medical Center
  • G: Good Samaritan Hospital
  • K: Kettering Medical Center
  • M: Miami Valley Hospital
  • V: Veterans Affairs Medical Center (Dayton)
  • W: Wright-Patterson Medical Center

The number assigned to each resident is specific for that individual. The following example illustrates the system:

AM2789482 M98 001

  • The first 9 characters shall be the hospital's DEA number.
  • The next 3 characters shall be the hospital code and the year the number is issued.
  • The last 3 characters shall be the number of the individual physician participant.

A resident uses the assigned number for writing outpatient prescriptions for controlled substances during educational training. Residents who have a temporary teaching assignment off-site at another teaching hospital should continue to use the assigned "home base" number. However, should residents moonlight for the purpose of generating additional income, the physicians must obtain and use their DEA number and not use the hospital assigned number. Residents must not use the hospital assigned DEA number for the purpose of prescribing controlled substances for themselves or for family members.

Graduate medical education participants shall not use the privilege of training licensure for the prescribing of controlled substances outside of their training institutions, or for individuals who are not patients of the training institutions that are designated to support an accredited, school-sponsored program.

Item 402
Infection Control

Revised June 2006; Employee Health Contact List Updated April 6, 2011

1. Physicians in the State of Ohio who are infected with HIV or HBV and who perform invasive procedures must follow rules set out by the Ohio State Medical Board (Administrative Rules Chapter 4731-19, Licensees Infected with HIV or HVB: Reporting Requirements and Duty of Care Requirements, http://www.state.oh.us/med/rules/4731-19.htm).

2. Wright State University Boonshoft School of Medicine Policy: Management of Residents Having an Occupational Exposure to Bloodborne Pathogens

Since a bloodborne pathogen exposure places an individual at risk for hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infection, it is important that one seeks medical attention as soon as possible after an exposure occurs. Any resident who sustains an exposure to blood or body fluids should be managed according to currently recommended guidelines from the Centers for Disease Control and Prevention (CDC) and according to the policies and procedures of the institution. Proper steps must be taken to ensure that both evaluations and preventive measures are instituted in a timely manner. The steps noted below should be followed when an exposure occurs in a resident participating in a Wright State University Boonshoft School of Medicine (WSU BSOM)-affiliated or -sponsored residency program.

a. The exposure site should be cleansed thoroughly immediately following the exposure. Irrigate eye with water keeping the affected eye lower than the unaffected eye during irrigation.

b. Note the patient's name, the location where the exposure occurred, the date and time of the exposure, the rotation, the names of witnesses, and, in the case of a needlestick, the type (hollow bore or solid).

c. Notify the employee health office in the hospital or the safety officer in a private setting during regular working hours. Report to the emergency department during evenings, nights and on weekends. A list of employee health office contacts is at the end of this policy.

d. The exposed resident should be managed according to the institution's policy on management of an employee following a percutaneous or permucosal occupational bloodborne exposure.

e. All laboratory evaluations should follow the recommended institutional policies.

f. If appropriate, after assessments are performed and based on current guidelines, the resident may be offered antiviral prophylaxis against HIV. After discussion of the risks and benefits of antiviral prophylaxis, any resident not employed by the institution where the exposure occurred should be dispensed a 96-hour supply of the antiviral medications. A resident employed by the institution should be managed according to policy. All exposed individuals must be counseled on the importance of follow-up evaluations. Each must have a follow-up evaluation at the base institution within 96 hours of the exposure. Follow-up of the resident must be ensured. The following should be done.

(1) Notification must be given to the employee health service of the resident's base institution, as soon as possible but not later than 96 hours following the initial evaluation. (Please see list of contact addresses and telephone/FAX numbers at the end of this policy.)

(2) Ensure that copies of all records are confidentially forwarded as soon as possible but not later than 96 hours following the initial evaluation to the employee health service of the institution that serves as the fiscal agent for the resident.

(3) The resident must be instructed on the requirement for follow-up evaluations within the 96-hour period. Appropriate educational and medical support must be provided. This should be coordinated at the base institution of the resident.

g. Financial charges incurred during the evaluation should be forwarded to the employee health service of the exposed resident's base institution.

Resident Post-Exposure Policy
Employee Health Contacts per Hospital
List Updated April 6, 2011

Dayton Children's Hospital
One Children's Plaza
Dayton, OH 45404

Employee Health Manager
Fax: 937-641-3473

Good Samaritan Hospital
2222 Philadelphia Drive
Dayton, OH 45406

Lisa Shores, RN
937-278-2612 x3200
Fax: 937-276-7622
E-mail: lshores@shp-dayton.org

Grandview and Southview Hospitals
405 West Grand Avenue
Dayton,OH 45401

GiGi Dues, RN
Employee Health Coordinator
Fax: 937-723-5016
E-mail: gigi.dues@khnetwork.org

Greene Memorial Hospital
(AKA: Greene Health Partners, Inc.)
1141 North Monroe Drive
Xenia, OH 45385

Shannon Drake, MT (ASCP)
Infection Preventionist
Fax: 937-352-3162
Pager: 220-7218
E-mail: sdrake@greenehealth.org

Ann Biedenharn, RN
Employee Health Nurse
Fax: 937-352-3101
E-mail: abiedenharn@greenehealth.org

Kettering and Sycamore Hospitals
3535 Southern Boulevard
Kettering, OH 45429

Deborah Daniel, Employee Health Coordinator
Fax: 937-395-8894
E-mail: deborah.daniel@khnetwork.org

Miami Valley Hospital
One Wyoming Street
Dayton, OH 45409

Carol Ondercin, RN, MS
Employee Health Manager
Fax: 937-208-4640
E-mail: crondercin@mvh.org

Veterans Affairs Medical Center
4100 West Third Street
Dayton, OH 45428

Hobart Hampton, RN
Employee Health Service
937-268-6511 x2338
Fax: 937-262-5998
E-mail: hobart.hampton@med.va.gov

Wright-Patterson Medical Center
4881 Sugar Maple Drive
Wright-Patterson AFB, OH 45433

Nina Shepherd, RN
Public Health Nurse Consultant
Fax: 937-656-1296
E-mail: nina.shepherd@wpafb.af.mil

Wright State University Boonshoft School of Medicine
Student Affairs/Admissions
190 White Hall
3640 Colonel Glenn Highway
Dayton, OH 45435-0001

Fax: 937-775-3322

Item 403
Medical Records Completion

Revised July 1996

All Boonshoft School of Medicine (BSOM) sponsored residents must observe the following practices when rotating among hospitals or when graduating from the BSOM program. These practices refer to completion of medical records at all teaching hospitals that are listed in accreditation documents as supporting any of the BSOM-sponsored programs. This policy will ensure that medical records are completed in a timely manner by responsible BSOM residents in order to assure the continuity of patient care and billing for hospital services.


  1. When rotating for training among teaching hospitals:
    1. residents and programs must be aware of individual hospital policy on record completion, including any disciplinary procedures,
    2. incomplete or delinquent records remain the individual resident's responsibility,
    3. programs will assure record completion by the resident by implementing appropriate policies that allow the resident or a designee time to complete records.
  2. When graduating from BSOM-sponsored GME programs:
    1. residents must notify the program director or director (department) of medical education of planned departure at least five working days in advance of that departure date,
    2. the "Resident Route Out" procedure will be completed (route out slip completed),
    3. incomplete medical records are the resident's responsibility.
  3. Residents must always ensure record completion in a timely fashion. Completion of records can usually be assured by a visit to the medical records department every two weeks.
  4. Residents should notify program directors/directors of medical education of any circumstance preventing timely completion of records.
  5. Programs must have a policy that is compliant with that of their training that will assure timely completion of resident medical records.
  6. Hospitals must have a policy to keep residents and programs continually informed about incomplete or delinquent medical record status, and must make every effort to assure record availability for completion.

NOTE: A specific time frame has been developed in the office or department of medical education in each training hospital for completion of delinquent medical records. Residents must familiarize themselves and comply with medical records policy at each teaching hospital or institution in which they train and participate in patient care. The medical education department in each hospital should provide monthly lists of residents leaving the training site to the records departments.

Item 404
Death Certificates

Revised July 1996

Under Ohio Administrative Code Rule 4731-14-01, only a licensed medical or osteopathic physician can pronounce a person dead. A physician does not have to personally examine the body of the deceased "if a competent observer has recited the facts of the deceased's present medical condition to the physician and the physician is satisfied that death has occurred." (OAC 4731-14-01)

Competent observers are individuals who by virtue of their training and licensure are able to assist the physician in making the determination of death. A competent observer includes any of the following individuals: a licensed registered nurse or practical nurse, an EMT or paramedic, an intern, a resident or another licensed physician, a clinical fellow, a chiropractor, an embalmer or funeral director who completed coursework in vital signs or patient assessment, a physician's assistant or a licensed podiatrist. Competent observers are not permitted to make a pronouncement of death.

The physician most familiar with the case should sign the death certificate. If that physician is not licensed to practice medicine in Ohio, the ultimate responsibility for death certification will be the program director.

Last edited on 01/28/2015.