Robert R. Cawley, D.O.
Dover, NH 03802
I. The patient shall be treated with consideration, respect, and full recognition of the patient’s dignity and individuality, including privacy in treatment and personal care and including being informed of the name, licensure status, and staff position of all those with whom the patient has contact, pursuant to RSA 151:3−b.
II. The patient shall be fully informed of a patient’s rights and responsibilities and of all procedures governing patient conduct and responsibilities. This information must be provided orally and in writing before or at admission, except for emergency admissions. Receipt of the information must be acknowledged by the patient in writing. When a patient lacks the capacity to make informed judgments, the signing must be by the person legally responsible for the patient.
III. The patient shall be fully informed in writing in language that the patient can understand, before or at the time of admission and as necessary during the patient’s stay, of the facility’s basic per diem rate and of those services included and not included in the basic per diem rate. A statement of services that are not normally covered by Medicare or Medicaid shall also be included in this disclosure.
IV. The patient shall be fully informed by a health care provider of his or her medical condition, health care needs, and diagnostic test results, including the manner by which such results will be provided and the expected time interval between testing and receiving results, unless medically inadvisable and so documented in the medical record, and shall be given the opportunity to participate in the planning of his or her total care and medical treatment, to refuse treatment, and to be involved in experimental research upon the patient’s written consent only. For the purposes of this paragraph "health care providers" means any person, corporation, facility, or institution either licensed by this state or otherwise lawfully providing health care services, including, but not limited to, a physician, hospital or other health care facility, dentist, nurse, optometrist, podiatrist, physical therapist, or psychologist, and any officer, employee, or agent of such provider acting in the course and scope of employment or agency related to or supportive of health care services.
V. The patient shall be transferred or discharged after appropriate discharge planning only for medical reasons, for the patient’s welfare or that of other patients, if the facility ceases to operate, or for nonpayment for the patient’s stay, except as prohibited by Title XVIII or XIX of the Social Security Act. No patient shall be involuntarily discharged from a facility because the patient becomes eligible for Medicaid as a source of payment.
VI. The patient shall be encouraged and assisted throughout the patient’s stay to exercise the patient’s rights as a patient and citizen. The patient may voice grievances and recommend changes in policies and services to facility staff or outside representatives free from restraint, interference, coercion, discrimination, or reprisal.
VII. The patient shall be permitted to manage the patient’s personal financial affairs. If the patient authorizes the facility in writing to assist in this management and the facility so consents, the assistance shall be carried out in accordance with the patient’s rights under this subdivision and in conformance with state law and rules.
VIII. The patient shall be free from emotional, psychological, sexual and physical abuse and from exploitation, neglect, corporal punishment and involuntary seclusion.
IX. The patient shall be free from chemical and physical restraints except when they are authorized in writing by a physician for a specific and limited time necessary to protect the patient or others from injury. In an emergency, restraints may be authorized by the designated professional staff member in order to protect the patient or others from injury. The staff member must promptly report such action to the physician and document the same in the medical records.
X. The patient shall be ensured a confidential treatment of all information contained in the patients personal and clinical record, including that stored in an automatic data bank, and the patients written consent shall be required for the release of information to anyone not otherwise authorized by law to receive it. Medical information contained in the medical records at any facility licensed under this chapter shall be deemed to be the property of the patient. The patient shall be entitled to a copy of such records upon request. The charge for the copying of a patient’s medical records shall not exceed $15 for the first 30 pages or $.50 per page, whichever is greater; provided, that copies of filmed records such as radiograms, x−rays, and sonograms shall be copied at a reasonable cost. The patient may be charged additional fees for copies of medical records to the extent permitted by New Hampshire law.
XI. The patient shall not be required to perform services for the facility. Where appropriate for therapeutic or diversional purposes and agreed to by the patient, such services may be included in a plan of care and treatment.
XII. The patient shall be free to communicate with, associate with, and meet privately with anyone, including family and resident groups, unless to do so would infringe upon the rights of other patients. The patient may send and receive unopened personal mail. The patient has the right to have regular access to the unmonitored use of a telephone.
XIII. The patient shall be free to participate in activities of any social, religious, and community groups, unless to do so would infringe upon the rights of other patients.
XIV. The patient shall be free to retain and use personal clothing and possessions as space permits, provided it does not infringe on the rights of other patients.
XV. The patient shall be entitled to privacy for visits and, if married, to share a room with his or her spouse if both are patients in the same facility and where both patients consent, unless it is medically contraindicated and so documented by a physician. The patient has the right to reside and receive services in the facility with responsible accommodation of individual needs and preferences, including choice of room and roommate, except when the health and safety of the individual or other patients would be endangered.
XVI. The patient shall not be denied appropriate care on the basis of race, religion, color, national origin, sex, age, disability, marital status, or source of payment, nor shall any such care be denied on account of the patient's sexual orientation.
XVII. The patient shall be entitled to be treated by the patient’s physician of choice, subject to reasonable rules and regulations of the facility regarding the facility’s credentialing process.
XVIII. The patient shall be entitled to have the patients parents, if a minor, or spouse, or next of kin, or a personal representative, if an adult, visit the facility, without restriction, if the patient is considered terminally ill by the physician responsible for the patients care.
XIX. The patient shall be entitled to receive representatives of approved organizations as provided in RSA 151:28.
XX. The patient shall not be denied admission to the facility based on Medicaid as a source of payment when there is an available space in the facility.
XXI. Subject to the terms and conditions of the patient’s insurance plan, the patient shall have access to any provider in his or her insurance plan network and referral to a provider or facility within such network shall not be unreasonably withheld pursuant to RSA 420−J:8, XIV.
You may file a grievance with the State of New Hampshire Department of Health & Human Services Office of Legal & Regulatory Services, Bureau of Health Facilities Administration, 129 Pleasant Street, Concord, NH 03301 Phone: (603) 271−9039 or toll free at (800) 852−3345 should you have any concern related to the rights listed above.
I. The patient shall have the right to appropriate assessment and management of pain.
II. The patient shall have the right to reasonable access to care.
III. The patient shall have the right to consideration of psychosocial, spiritual, and cultural variables that influence the perception of illness.
IV. The patient shall have the right to obtain information as to any relationship of the Hospital to other health care and educational institutions insofar as his/her care is concerned. The patient has the right to obtain information as to the existence of any professional relationships among individuals, by name, which are treating him/her. The patient has the right to ask and be informed of the existence of business relationships among the Hospital, educational institutions, other health care providers, or payers that may influence the patient’s treatment and care.
V. The patient shall have the right to have an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decision maker with the expectation that the Hospital will honor the intent of that directive to the extent permitted by law and Hospital policy. Health care institutions must advise patients of their rights under state law and Hospital policy to make informed medical choices, ask if the patient has an advance directive, and include that information about Hospital policy that may limit its ability to implement fully a legally valid advance directive.
VI. The patient shall have the right to examine and receive an explanation of his/her bill regardless of source of payment.
VII. The patient shall be accorded impartial access to treatment or accommodations that are available or medically indicated, regardless of race, age, color, creed, gender, gender identity/expression, national origin, citizenship, physical or mental disability, religion, sexual orientation, socioeconomic status, language, or any other protected status pursuant to Federal and State laws within the limits of ethical practice, the law, and our capabilities.
Patients, parents and guardians have the responsibility to:
If you have any questions concerning your rights or any part of your care, ask any staff member for assistance.
Patient and Family Relations strives to meet the needs and interests of each patient and their family. If you have a concern related to care or service that cannot be resolved with your health care team, or if you have a suggestion for improved services, please reach out to Wentworth-Douglass Hospital’s Patient and Family Relations office. We will work with you and the care team to respond to your grievance. We can also answer questions you may have about hospital policies and procedures, assist with special requests, and provide general information. We appreciate you giving us the opportunity to be of assistance. Patient and Family Relations can be reached by calling 603−740−2823 (Mon − Fri 8:00 a.m. − 4:30 p.m.), or ask to speak to the nursing supervisor after office hours. The grievance process is confidential and you may remain anonymous if you wish. Patient care will not be affected if you file a grievance.
Patients, Family, or Visitors who have concerns about safety or quality of care provided by Wentworth-Douglass may report these concerns to the Joint Commission at 800−994−6610.
If you have a suggestion, comment, compliment, or complaint about Wentworth-Douglass Hospital and wish to share your feedback, please call Patient and Family Relations at (603) 740-2823.
Patient and Family Relations Specialists are available Monday - Friday, 8:00 a.m. – 4:30 p.m.
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