Your Care - Patient Rights and Responsibilities Policy

All patients seeking treatment or care at Washington Health System Washington Hospital have rights which are described below. Information on these rights is available to all patients upon request and will be given to all inpatients upon admission.  If patients have been judged to be incompetent in accordance with law, are found by their physicians to be incapable of understanding their rights, are unable to communicate, or are un-emancipated minors, these rights may be exercised by guardians, next-of-kin, or legally authorized persons on behalf of the patients.  It is the hospital’s duty to protect and promote each patient’s rights.



1.  A patient, or when appropriate, the patient’s representative, has the right to be informed of their rights and responsibilities in advance of receiving or discontinuing patient care whenever possible and to know what hospital rules and regulations apply to his or her conduct.  A patient has the right to expect good management techniques to be implemented within the hospital to effectively utilize his or her time and to avoid personal discomfort.  A list of patient responsibilities is included at the end of this document.


2.  Each patient has the right to consent to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member or a friend.  The patient also has the right to withdraw ordering such consent at any time.  The Hospital will not restrict, limit or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability.  All visitors will enjoy full and equal visitation privileges consistent with patient preferences.  The Hospital allows a family member, friend or other individual to be present for emotional support during the course of the stay.  Each patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission, and to involve them in decisions about care, treatment or services.  Each patient has the right to request religious and other spiritual services.


3.  A patient has the right to high quality, considerate, dignified and respectful care given by competent personnel and to expect that high professional standards are continually maintained and reviewed.  A patient has a right to medical and nursing services without discrimination as noted above.  A patient has the right to participate in the development and implementation of his or her plan of care.  A patient has the right to personal privacy and to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation.  The Hospital respects the patient’s cultural and personal values, beliefs and preferences.


4.  A patient has the right to every consideration of his or her privacy, safety and security concerning his or her own medical care program.  Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly, making every attempt to maintain the patient’s verbal and visual privacy.  A patient has the right to be free from all forms of abuse and harassment and to have his/her care provided in a safe environment.


5.  A patient has the right to freedom from restraints in acute medical and surgical care and/or freedom from seclusion and restraints in behavior management, unless clinically necessary or in an emergency situation to protect the patient or others from harm.


6.  A patient has the right to expect emergency procedures to be implemented without unnecessary delay.

7.  A patient has the right of access to protective services or advocacy groups or to an individual whom, or an agency which, is authorized to act on behalf of the patient to assert or protect the rights set out in this policy.


8.  All patients have the right to all necessary measures as clinically appropriate to assure comfort by the provision of treatment of symptoms, pain management and the acknowledgment of the psychological, social, emotional, cultural and spiritual concerns of the patient and family.


9.  The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, payment source, sex, sexual orientation, and gender identity or expression.


10.  A patient has the right to review and acknowledge The Notice of Privacy Practices of Washington Health System Washington Hospital.  This Notice describes how medical information about the patient may be used and disclosed and how the patient can get access or request amendment to this information.  The patient has the right to refuse to acknowledge the Notice of Privacy Practices of Washington Health System Washington Hospital without denial of treatment.


11.  A patient has the right to have all records pertaining to his or her medical care treated as confidential except as otherwise provided by law or third-party contractual arrangements.  The hospital shall provide the patient, upon request, access to all information contained in his or her medical records in accordance with applicable regulations (unless access is specifically restricted by the attending physician for medical reasons or is prohibited by law).


12.  A patient has the right to effective communication and full information in layman's terms concerning diagnosis, treatment and prognosis including information about advantages/disadvantages, alternative treatments and possible complications of proposed treatments.  When it is not medically advisable to give such information to the patient, the information shall be given to the patient's next of kin or other appropriate persons.  Except in emergencies, a patient has the right to expect that his or her physician will obtain the necessary informed consent prior to the start of any procedure or treatment. 


13.  Patients also have the right to full access to his or her clinical records and information regarding their health status and the outcomes of treatment whether such outcomes are positive or negative.  In accordance with Pennsylvania law, the hospital informs the patient or surrogate decision maker about unanticipated outcomes of care that are considered to be sentinel events.


14.  A patient has the right to communicate complaints regarding his or her care without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care, treatment, and services.  A patient can voice complaints to his or her physician, case manager, nurse team member, or hospital management or administration.  Complaints may also be communicated to the Pennsylvania Department of Health, Acute & Ambulatory Care Services, PO Box 90, Harrisburg, PA. 17108-0090, Telephone 1-800-254-5164 or the Joint Commission’s Office of Quality Monitoring by either calling 1-800-994-6610 or e-mailing


15.  Medicare patients/families with concerns regarding the quality of care or premature discharge shall be advised that they may contact Quality Insights of Pennsylvania, 2601 Market Place Street, Suite 320, Harrisburg, PA 17110.


16.  A patient who cannot communicate with hospital staff because he or she does not speak English or because of hearing, vision, cognitive or speech impairment shall have access, where possible, to an interpreter and/or technology that will facilitate communication and meet the patient’s needs.


17.  A patient, next-of-kin, or legally responsible representative has the right to participate in the consideration of ethical issues.  For more information about the hospital's Ethics Committee, contact Administration at 724-223-3007 Monday through Friday, 8 AM - 5 PM, or an Administrative Nursing Supervisor at 724-223-3242. Patients or families may seek spiritual counsel from Pastoral Care by calling the operator at 724-225-7000 24 hours a day, 7 days a week.


18.  A patient has the right to formulate an Advance Directive (Living Will or Durable Power of Attorney for Healthcare). Provision of care is not conditioned upon whether or not the patient has an Advance Directive.  The patient also has the right to receive information about the hospital's policies and procedures relating to Advance Directives.


19.  A patient has the right to expect that the hospital will provide a mechanism whereby he or she is informed upon discharge of his or her continuing healthcare requirements, and the means for meeting them.


20.  A patient has the right to refuse any drug, treatment, or procedure offered by the hospital to the extent permitted by law.  A physician shall inform the patient of the medical consequences of his or her refusal of any drug, treatment, or procedure.


21.   When medically permissible a patient may be transferred to another facility, only after the patient or next-of-kin or other legally responsible representative has received complete information and an explanation concerning the needs for and alternatives to such a transfer.  The institution to which the patient is to be transferred must accept the patient for transfer in advance.  The necessary medical information will be sent to the transfer facility.


22.   A patient has the right to designate a surrogate decision maker when the patient is unable to make decisions regarding health care.  Alternatively, the patient has the right to include or exclude family members from participating in his or her health care decisions.  A surrogate decision maker may refuse care, treatment or services.


23.   A patient has the right to expect that his or her consent will be obtained for recording or filming made for purposes other than the identification, diagnosis or treatment of patients.  A patient also has the right to request that recording or filming cease and to rescind consent at a later date.  Any person participating in such filming or recording who is not a hospital employee shall sign a confidentiality agreement in accordance with hospital policy.


24.  A patient (or in the event the patient is unable to give informed consent, a legally responsible party) has the right to be advised when a physician is considering him or her as part of a medical care research program or donor program. The patient, or legally responsible party, must give informed consent prior to participation in such a program.  The patient or legally responsible party may at any time refuse to continue in any such program to which he or she has previously given informed consent.  Such refusal will not compromise access to services.  Informed consent will consist of expected benefits, potential discomforts and risks, a description of alternative services that might also prove advantageous and a full explanation of procedures to be followed.


25.   A patient has the right, upon request, to be given the name of his or her attending physician, the names of all other physicians directly participating in his or her care, and the names and functions of other healthcare personnel having direct contact with him or her.


26.  A patient has the right to assistance in obtaining consultation with a physician other than the attending physician at the patient’s request and own expense.


27.  A patient has the right to examine and receive a detailed explanation of hospital bills.  He or she has a right to full information and counseling on the availability of financial resources for healthcare.




1.  A patient must provide, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalization, medications, pain and other matters relating to his or her health that facilitates care, treatment and services.  Unexpected changes in condition are also to be reported to the appropriate individual.


2.  A patient must ask questions and acknowledge whether or not he or she clearly understands a contemplated course of action and what is expected.


3.  A patient must follow the treatment plan recommended by the practitioner primarily responsible for his or her care.  This may include following the instructions of nurses and allied health personnel as they carry out the coordinated plan of care and implement the responsible practitioner’s orders, and as they enforce the applicable rules and regulations.  The patient is responsible for resulting outcomes if he or she refuses treatment or does not follow the practitioner’s instructions.


4.  A patient must assure either personally or through a legally responsible party that the financial obligations of his or her stay are fulfilled as promptly as possible.


5.  A patient must be considerate of the rights of other patients and personnel and is responsible for assisting in the control of noise and number of visitors.  This includes being respectful of the property of other patients, staff and the hospital and maintaining civil language and conduct in all interactions with staff, physicians and other patients and their families.


6.  A patient and their family must follow the hospital’s rules and regulations.




Specific patient rights have also been developed for Hospice and Behavioral Health patients.


APPROVED BY THE MEDICAL STAFF EXECUTIVE COMMITTEE:  3/10/92; 2/11/97; 5/12/98; 11/9/99; 7/11/00; 11/11/03; 12/9/05; 1/9/07; 5/12/09; 2/15/10; 9/14/10; 01/11/11; 03/13/12; 11/13/12


APPROVED BY THE BOARD OF TRUSTEES:  3/24/92; 2/12/97; 5/26/98; 11/23/99; 6/27/00; 9/24/02; 11/25/03; 12/14/05; 8/9/06; 1/23/07; 5/26/09; 3/10/10 (Bd Exec); 3/23/10; 9/28/10; 01/12/11 (Bd Exec); 03/27/12; 11/27/12



Date of Origin:  9/28/82

REVISED:  11/91; 3/24/92;2/97; 5/98; 12/99; 6/00; 5/02; 7/03; 12/05; 2/06; 6/06; 1/07, 4/09; 1/10; 8/10; 1/11; 1/12; 10/12

REVIEWED:  3/83; 6/84; 6/85; 5/86; 6/87; 6/88; 6/89; 6/90; 6/91; 11/92; 5/93; 5/94; 4/95; 8/96; 6/05; 9/06