409-772-1011
SPEAK UP!
Ask Questions and Voice Concerns Page 13
KNOW YOUR RIGHTS
Page 19
ALL ABOUT ADVANCE DIRECTIVES
Page 26
2016
Patient Information & Visitor’s Guide
In This Guide Welcome to UTMB Health League City Campus About Us Telephone Directory Rapid Response Team Be Prepared During Your Stay
3 4 5 6 7-8 9-12 Visitor Guidelines 9 Personal Belongings 9 Valuables 10 Pre-Certification 10 Inpatient Registration 10 Confidentiality 10 10 Patient Safety Wireless Internet Access 11 Medications from Home 11 TV 11 Mail and Flowers 11 Retail Food Options 11 Smoking 11 Fire Safety 11 Meditation Room 12 12 Patient Meal Service Gift Shop - Lori’s Gifts 12
13 Speak Up Take charge of your care.
14 Stay Safe You can contribute to health care safety.
OUR ADDRESS
2240 Gulf Freeway South League City, TX 77573 The editorial content displayed here is the responsibility of PatientPoint. This material is for your educational use only. It does not contain, nor should it be construed as containing, medical advice. Talk to your doctor before making any lifestyle or treatment changes. Sponsors are responsible for the material provided, and your healthcare provider’s participation in the program does not represent an explicit or implied endorsement of any material presented. The people shown are models and are not known to have any health condition. Images are for illustrative purposes only. Image credits: Getty Images, iStockphoto. ©2016 PatientPoint ®
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In This Guide continued Speak Up
13
Stay Safe
14-17
Do You Have Pain?
18 Do You Have Pain? Make your stay as comfortable as possible.
28 Don’t Leave Until... 6 things you should know before you walk out the door.
35 Charitable Giving Opportunities Help us help others. 2
18
Patient’s Rights & Responsibilities
19-21
Derehos y Responsabilidades del Paciente
22-25
Advance Directives
26
Patient Privacy & Security
27
Don’t Leave Until…
28-29
Preparing to Leave the Hospital
30-32
Discharge Planning
30
When You Are Discharged
30
Coordination of Benefits (COB)
30
Financial Arrangements
31
If You Have Health Insurance
32
If You Are a Member of an HMO or PPO
32
If You Are Covered by Medicare or Medicaid
32
If You Have No Insurance
32
Your Hospital Bill
32
Financial Assistance
33
Discharge Planning
33
Hospital Services
34
Charitable Giving Opportunities
35
Sudoku 36
Welcome to UTMB Health League City Campus Dear Patients and Families, Welcome to UTMB Health. We are pleased that you have selected us to provide your medical care. During your hospital stay, we will do everything possible to make you comfortable. If you have any questions or concerns, please do not hesitate to ask your physician or nurse. In addition, if you have any concerns regarding the quality or safety of your care or feel that you are not being treated in a fair and compassionate manner, please call the Patient Services Department at 409-772-4772 to register your concern. If UTMB Health cannot resolve your concerns to your satisfaction, you are encouraged to contact The Joint Commission by fax at 630-792-5636 or email at patientsafetyreport@jointcommission.org. For more information, visit its website at www.jointcommission.org. We know you have choices for your health care provider, and we are honored you have chosen UTMB Health. Sincerely, EVP & Chief Executive Officer UTMB Health System
Donna K. Sollenberger Executive Vice President and Chief Executive Officer, UTMB Health
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About Us Our Address 2240 Gulf Freeway South League City, TX 77573
Services We Provide nA CR-Accredited
Mammography Services n Cardiac Rehabilitation n Comprehensive Imaging Services B one Density Scanning CT Scan MRI–Outpatient Imaging Center nL aboratory Services– Inpatient & Outpatient nO bstetrics and Gynecological Services n Occupational Therapy n Physical Therapy nS urgical and Cardiac Care n2 4-Hour Emergency Department Services
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Patient Satisfaction Survey
After your discharge, you will receive a patient survey that will be emailed or mailed to your home. It is important to remember when completing the survey to rate the services you received during your hospital stay. We value your honest opinion. Please tell us what we did right and also where improvements are needed. Your opinion matters most to us because it is the best way we can learn how to give you and other patients the best possible care. Please let us know before your discharge if there are any issues we can resolve before you leave. Mission, Vision & Values At the University of Texas Medical Branch, we are dedicated to a long-standing mission of improving health for the people of Texas and around the world. We are a collaborative community that works together to define the future of health care and strives to be the best in everything we do for those we serve. We uphold our core values by demonstrating compassion for all, always acting with integrity, showing respect to everyone we meet, embracing diversity to best serve a global community, and promoting excellence and innovation through lifelong learning. Our mission and values are at the heart of the care that we provide to you and your family.
Telephone Directory Access Center 409-772-2222 Billing Inquiries - Patient Financial Customer Service Office 409-771-8811 409-772-1541 Care Management Cashier’s Office 409-772-5379 Emergency Room 409-772-1479 Food Services - Patient Food 409-747-FOOD (3663) Gift Shop - Lori’s Gifts League 832-505-1236 City Campus Hospital Operator (inside hospital) 0 Hospital Operator (outside hospital) 409-772-1011 Information Desk League City Hospital 832-505-3190 Information Desk Jennie Sealy Hospital 409-266-9974 Information Desk 409-772-6265 John Sealy Hospital Language Assistance 409-747-2121 409-747-3260 Mail Services Medical Records - Information Release 409-772-1965 Parking 409-266-PARK (7275) Pastoral Care 409-772-3909 Patient Information 409-772-1191 Patient Services 409-772-4772 Transportation 409-772-1512 UTMB Clinics - Clinic Appointments 409-772-2222 University Police 409-772-2691 Volunteer Services 409-772-2549
MAIN NUMBER 409-772-1011
Information Desk 832-505-3190
Billing 409-771-8811
Gift Shop 832-505-1236
Medical Records Information Release 409-772-1965
The League City Campus has 10-digit dialing. Please dial the area code and the number.
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Rapid Response Team You will be asked: n Caller identification n Room number n Patient’s name n Patient concern (what
issues are they having?) A Rapid Response Team will be activated.
To promote rapid identification and treatment of urgent patient care needs, UTMB Health League City Campus has implemented a Rapid Response Team (RRT). The Rapid Response Team is a group of highly trained nurses and respiratory therapists who help when there are signs that a patient is developing serious medical problems. The purpose of the Rapid Response Team is to check the condition of the patient quickly and provide help before there is a medical emergency, such as a heart attack. The Rapid Response Team usually is summoned by any clinical staff member who is concerned in a change in condition of a patient. At UTMB Health, we feel that it is important for the patient or patient’s family to have access to this service. Should you or your family feel that there has been a significant worsening in your condition, first please make sure your nurse and/or physician knows this concern immediately. If you feel that additional help is needed or you are not satisfied with the response of the patient care staff, please dial 0 and ask for the Rapid Response Team. You will need to tell the operator the patient’s name and location.
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FRAN DRESCHER 1957-PRESENT
Surgery is half the race, but you have to go for the follow-up or do yourself a major disservice.
Be Prepared How you can make your surgical procedure and follow-up care as safe as possible. Mistakes can happen during surgery.
As an active member of your health care team, you can make your surgical procedure and follow-up care as safe as possible. Here’s what you need to know.
Before Your Surgery
nA rrange for transportation to and
from the hospital or surgical center.
nA sk a relative or friend to go to the
hospital or surgical center with you, stay during your procedure and accompany you home afterward.
nB ring a list of any questions you have
about your surgery to your pre-surgical doctor’s visit. Also bring a list of all the prescription, over-the-counter and herbal medications that you are currently taking or that you took until very recently. Review the list with your surgeon and ask if there are any you should stop taking prior to your procedure. nB e sure your surgeon knows about any allergies you have to medications and foods. nA sk your surgeon whether you can eat or drink before your procedure and if so, what kinds of food or drink, and within how many hours of your surgery. nA sk your surgeon whether you should remove nail polish or temporary dental appliances (such as a bridge), if you can wear deodorant or body lotion and if there are other preparations you need to make prior to surgery. nF ind out if you will need therapy after your surgery, who will arrange for it and whether you can have therapy at home.
It’s hard to remember everything yourself. When you meet with your doctor, bring your questions and a friend. Your friend can help listen, take notes and ask questions, too!
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BE PREPARED continued
A Team Effort
Here’s how to work with your surgical team to get the best outcome: n Know the preparations you must make before your surgery. n Get to the hospital or surgical center early on the day of your surgery. n Review paperwork carefully before signing. n Make sure the proper part of your body is marked for surgery. n Get your post-surgical care instructions in writing before you leave.
On the Day of Your Surgery
nS hower or bathe and wash your hair.
Don’t wear makeup or perfume. Be sure to follow any other pre-surgery instructions you were given. nL eave your jewelry, money, credit cards and other valuables at home. nA llow yourself plenty of time for travel. nO nce you arrive at the hospital or surgical center, you will be given an Informed Consent form to sign. Read it carefully. Make sure everything on the form is correct. If you don’t understand something, ask questions before you sign the form.
Before Your Procedure Begins n Staff at the hospital or surgical
center should ask you the following questions more than once before your surgery: Your name What kind of surgery you’re having The part of your body that is being operated on nA health care professional will mark
the spot on your body that is going to be operated on. Make sure he or she marks only the correct part. If he or she makes a mistake and has to make a new mark, be sure the old mark is completely cleaned off. 8
n I f you won’t be awake for the
marking, be sure your relative or friend watches the marking. nA sk your surgeon if the team will take a “time out” just before your procedure. This is done to make sure the team is doing the correct surgery on the correct body part of the correct person.
After Your Surgery
nS peak up about any pain you are
having and ask for relief. Be specific about the intensity and location. n I f you are given medications right after surgery, ask what they are and what they are for. Ask about side effects. If you are given a prescription for medications you must take while recovering, be sure you understand the instructions for the dosage, how frequently you need to take the medications and for how long. n I f you are given IV (intravenous) fluids right after surgery, ask what they are and what they are for. Be sure someone monitors the fluid level. nA sk your surgeon if your activities need to be limited, and if so, for how long. Ask when you will be able to resume work, exercise and travel. nB e sure to get instructions for post-surgical care in writing before you leave.
During Your Stay We have policies and procedures in place to help you and your family work with our doctors, nurses and staff to get the most from your hospital stay. Please take a few minutes to review these guidelines with your loved ones.
Visitor Guidelines
Family and Friends Visitors can play an important role in the healing process for our patients. UTMB Health allows the patient to choose family members, friends or other individuals to be present for support during the course of his or her hospital stay. The patient also has the right to withdraw or deny such consent at any time. Patients may usually have two visitors at a time however, exceptions may be made at the discretion of the unit charge nurse, who has the authority to determine the number of visitors and length of visitation, based on patient needs and other unit activities. No exceptions will be based on race, color, national origin, religion, sex, gender identity, sexual orientation or disability. Because visiting hours or the number of visitors may be restricted depending on the patient’s condition or type of patient care unit, visitors are encouraged to inquire about area-specific visitation standards. For visitors entering the hospital between 9:00 p.m. and 5:00 a.m., staff at the reception desk will issue a visitor pass. The visitor’s name and destination will be recorded. Women, Infant and children units have specific policies to protect newborn babies and ensure a familycentered birthing experience. Ask your nurse about these policies.
Personal Belongings Most of what you need for your hospital stay will be provided. You should plan to bring a toothbrush and toothpaste, hairbrush and/or comb, slippers and personal care items. You also should bring your driver’s license, insurance information and any item requested by your physician.
Visitor Conduct Visitors are expected to conduct themselves in an appropriate manner considered consistent with community standards within a hospital environment. Visitors should be considerate of all patients by refraining from loud conversations or any other behavior that may disturb a patient, and abiding by other restrictions that are either described in this document or posted throughout the hospital.
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During Your Stay Leave Your Valuables At Home If you have valuables, such as jewelry, credit cards and cash, please give them to a relative or friend to take care of during your stay. Store your contact lenses, eyeglasses, hearing aids and dentures in containers labeled with your name and place them in a drawer in your bedside table when not in use. Please don’t put them on your bed or food tray— they may be damaged or lost. The hospital cannot be responsible for replacement of personal belongings.
Pre-Certification
Most insurance plans now require pre-certification for hospital stays and certain tests and procedures in order for you to be eligible for full policy benefits. This information can be found on your insurance card. If you are unsure of your pre-certification requirements, we recommend that you contact your insurance company as soon as possible.
Inpatient Registration
Our Patient Financial Services representative will request medical and insurance information. To expedite the registration process, please have your photo ID, insurance identification, Social Security card, Medicare/ Medicaid card and any other medical insurance information. You will be asked to pay any deductibles, co-payment or non-covered services. If you have an advance directive or medical power of attorney, please bring a copy with you or request a copy of our information brochure.
Confidentiality
Information regarding your condition is confidential and UTMB Health League City Campus will honor that confidentiality.
Patient Safety
The safety of patients, visitors, employees, medical staff and auxiliary is of critical importance at UTMB Health. We encourage patients and families to participate actively in their care and to voice questions regarding care and any concerns regarding accuracy of treatment. We have implemented many patient safety initiatives within our facility including, but not limited to, the accuracy of patient identification, medication safety practices, correct site surgery protocol and infection prevention strategies. If you have questions or concerns regarding your care or safety, please tell your nurse, other clinical staff or physician.
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Wireless Internet Access
Smoking
Wi-Fi access is available in each patient room at no charge.
UTMB Health, as a provider of health care in this community, wishes Medications from Home All medications you take while a patient at UTMB Health to establish and maintain the most effective have been prescribed by your physician, are dispensed environment possible by the hospital pharmacy and administered by a trained professional. Patients are not permitted to administer their in which to deliver our health services. own medications or to keep personal medications, unless As such, we are a approved by their physician. smoke-free and tobaccofree campus. This TV Cable televisions are provided in each patient room. Please includes vaping and be considerate of others by keeping the TV volume down electronic cigarettes.
and turning off your TV at bedtime.
Mail and Flowers
Your mail and flowers will be delivered to you Monday through Saturday. Any mail received after your discharge will be forwarded to your home address.
Retail Food Options
Fire Safety We periodically conduct fire drills. If you hear an alarm, stay where you are. In the event of an actual emergency, hospital staff will notify you.
Einstein Bagels Scheduled to open August 1, 2016. Once open, Einstein Bagels will offer a full menu of bagels, sandwiches, wraps, salads, drinks, snacks, chips, desserts and specialty coffees. Hours are 6:30 a.m. to 2:00 p.m., seven days a week. Vending Machines Vending machines are on the first floor of League City Campus and are available 24/7. They offer snacks, drinks and food items while on the go.
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During Your Stay Meditation Room Located on the first floor, our mediation room is available 24 hours a day for patients and their families.
Patient Meal Service
Proper nutrition plays an important part in your recovery and continued good health. Food and Nutrition Services is dedicated to ensuring that your nutritional requirements are met in accordance with your physician’s orders. Even patients who are on a restricted diet have a variety of selections from which to choose. At UTMB League City, we offer a room service program called “Dining on Call.” After reviewing your menu, which your nurse will provide, you can call 7-FOOD (7-3663) between 6:30 a.m. and 6:30 p.m. One of our call center operators will assist you with your selections. After your order is placed, we will deliver your food in 45 minutes or less. Guest trays also are available for $10. Please ask your call center operators for more details.
Gift Shop – Lori’s Gifts
The hospital’s gift shop is located in the main lobby of the hospital. Cash, check and credit cards accepted. Hours: Monday through Friday: 9:00 a.m. to 8:00 p.m. Weekends and holidays: 11:00 a.m. to 6:00 p.m. Phone number: 832-505-1236
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FRANCIS BACON 1561–1626
Who questions much, shall learn much, and retain much.
Speak Up! Take charge of your care. During your stay, the doctors, nurses and staff of
your hospital will treat you and your family as partners in your own care. One important way that you can be involved is to speak up. Ask questions, voice your concerns and don’t be afraid to raise any issues relating not only to your care and treatment, but also to overall hospital services. In the pages that follow, you’ll find a step-by-step guide to making the most of your hospital stay—how to stay safe, get the information you need, ask the right questions and interact effectively with your doctors, nurses and hospital staff.
STEP UP & SPEAK UP SPEAK UP: Ask questions and voice concerns. It’s your body and you have a right to know. PAY ATTENTION: Make sure you’re getting the right treatments and medicines. EDUCATE YOURSELF: Learn about the medical tests you get and your treatment plan.
FIND AN ADVOCATE: Pick a trusted family member or friend to be your advocate or support person.
WHAT MEDS & WHY: Know what medicines
Remember: rite down any questions W you have n Choose a support person to communicate with the doctors and staff n K eep a list of doctors you see and the meds they prescribe n
Don’t Get Overwhelmed, Write It Down!
you take and why you take them.
CHECK BEFORE YOU GO: Use a hospital, clinic, surgery center or other type of health care organization that meets The Joint Commission’s quality standards. PARTICIPATE IN YOUR CARE: You are the center of the health care team.
Courtesy of The Joint Commission.
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HENRY H. TWEEDY 1868-1953
Fear is the father of courage and the mother of safety.
Stay Safe You can contribute to health care safety. While you are in the hospital, many people will enter your room, from doctors and nurses to aides and orderlies. The following information will help make your hospital stay safe and comfortable.
Employee ID All hospital employees wear identification badges. Feel free to ask any staff member for his or her name and job classification. If you do not see an ID badge on an employee, please call your nurse immediately.
Don’t Be Afraid to Ask… A number of people may enter your hospital room. Be sure to: n Ask for the ID of everyone who comes into your room. n Speak up if hospital staff doesn’t ask to check your ID. nA sk if the person has washed his or her hands before he or she touches you. n I f you are told you need certain tests or procedures, ask why you need them, when they will happen and how long it will be before you get the results. 14
PATIENT IDENTIFICATION Any time staff members enter your room to administer medications, transport you or perform procedures and treatments, they must check your birth date and name before they proceed. At times, you may be asked the same questions repeatedly. We are aware that this may be annoying. Please understand, however, that this verification process is a critical component in our patient safety program in order to guarantee that all of our patients receive the correct medications and treatments.
Check ID
STAY SAFE
Fighting Infections While you’re in the hospital to get well, there is the possibility of developing an infection. The single most important thing you can do to help prevent infections is to wash your hands and make sure that everyone who touches you—including your doctors and nurses—washes his or her hands, too.
You, your family and friends should wash hands:
1. after touching objects or surfaces in the hospital room 2. before eating 3. after using the restroom
Happy Birthday to You! Wash your hands with soap and warm water for 15 to 20 seconds. That’s about the same amount of time that it takes to sing the “Happy Birthday” song twice.
It also is important that your health care providers wash their hands with either soap and water or an alcohol-based hand cleaner every time, before and after they touch you. Health care providers know to practice hand hygiene, but sometimes they forget. You and your family should not be afraid or embarrassed to speak up and ask them to wash their hands.
It’s Always Wise to Sanitize Alcohol-based hand cleaners are as effective as soap and water in killing germs. To use, apply the cleaner to the palm of your hand and rub your hands together. Keep rubbing over all the surfaces of your fingers and hands until they are dry.
Doctors, nurses and other health care providers come into contact with a lot of bacteria and viruses. So before they treat you, ask them if they’ve cleaned their hands.
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STAY SAFE
Preventing Falls Hospital patients often fall because they are weak or unsteady due to illness or medical procedures, their medications make them dizzy, or they’ve been sitting or lying down for too long. UTMB Health League City Campus cares about our patients’ safety. Please help us keep you safe by following these guidelines during your hospital stay: n Do not get out of bed by yourself. Your hospital bed is probably higher and narrower than your bed at home, and you can easily fall while trying to get in or out of it. Please use your nurse call button and ask for assistance. n Keep often-used items—call button, tissues, water, eyeglasses, telephone, TV remote—within easy reach. n Do not walk in bare feet. Wear nonskid socks or slippers. n Make sure your robe or pajamas don’t drag on the floor; they can cause you to trip. n Use the handrails in your bathroom and throughout the hospital at all times. n Ask your nurse to show you how to properly walk with your IV pole, drainage bags or any other equipment. n Be sure your wheelchair is locked when getting in or out of it. Never step on the footrest. n If you see a spill on the floor, report it at once.
DVT: Lower Your Risk Deep-vein thrombosis (DVT) occurs when blood clots form in the legs and block circulation. The clots can lodge in your brain, heart or lungs, causing damage or even death. When you’re hospitalized and in bed with limited physical activity, your risk of DVT increases. Ask your doctor about using compression boots or stockings and/or blood thinners to prevent DVT during your stay. And be sure to tell your doctor or nurse if you have any of the following warning signs: A leg cramp or charley horse that gets worse Swelling and discoloration in your leg, upper arm or neck Unexplained shortness of breath Chest discomfort that gets worse when you breathe deeply or cough Lightheadedness or blacking out
PATIENTS OF ALL AGES ARE AT RISK OF FALLS BECAUSE OF MEDICATIONS THAT MAY MAKE THEM DIZZY, WEAK OR UNSTEADY 16
STAY SAFE
Know Your Meds While you are hospitalized, your doctor may prescribe medications for you. Be sure that you understand exactly what they are and why they are being prescribed. Use this checklist to help you get the information you need from your doctor: What is the name of the medicine? What is its generic name? Why am I taking this medicine? What dose will I be taking? How often, and for how long? When will the medicine begin to work? What are the possible side effects? Can I take this medicine while taking my other medications or dietary supplements? Are there any foods, drinks or activities that I should avoid while taking this medicine? Should I take my medicine at meals or between meals? Do I need to take the medicine on an empty stomach or with food or a whole glass of water? What should I do if I forget to take the medicine and miss a dose?
KEEP A WALLET-SIZED NOTEBOOK OF ALL MEDICATIONS YOU ARE TAKING.
Preventing Medication Errors By taking part in your own care, you can help the members of your health care team avoid medication errors. Here’s how: Be sure that all of your doctors know what medications you have been taking, including prescription drugs, over-thecounter medications, herbal and vitamin supplements, natural remedies and recreational drugs. Be sure that all of your doctors know of any allergies you may have— to medications, anesthesia, foods, latex products, etc. When you are brought medications or IV fluids, ask the person to check to be sure you are the patient who is supposed to receive the medications. Show that person your ID bracelet to double-check. Remember—you play an important role in helping to reduce medication errors.
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TORI AMOS 1963-PRESENT
Healing takes courage, and we all have courage, even if we have to dig a little to find it.
Do You Have Pain? Manage your pain so your hospital stay is as comfortable as possible.
You are the expert about how you are feeling. Be sure to tell your doctor or nurse when you have any kind of pain.
To help describe your pain, be sure to report: n When the pain began. n Where you feel pain. nH ow the pain feels—sharp, dull, throbbing, burning, tingling. n If the pain is constant, or if it comes and goes. n What, if anything, makes the pain feel better. n What, if anything, makes the pain feel worse. nH ow much pain, if any, your medicine is taking away. n I f your medicine helps with the pain, how many hours of relief do you get? nF or most patients, a nurse will ask to rate your pain on a scale of 0-10 or may use the Wong-Baker Scale below.
USE THE PAIN RATING SCALE BELOW TO TELL YOUR DOCTOR OR NURSE HOW YOUR PAIN IS AFFECTING YOU.
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Patient’s Rights & Responsibilities Welcome to UTMB Health. As a patient of this hospital, or as a family member or surrogate decision-maker of a patient at this hospital, we want you to know you have choices, rights and responsibilities. We are committed to honoring your rights and want you to know that by taking an active role in your health care, you can help your hospital caregivers meet your needs as a patient or family member. That is why we ask you and your family share with us certain responsibilities.
n Be informed about the outcomes
of care, including unanticipated outcomes. n Refuse care, treatment and services. n Make choices about your care based on your spiritual and personal values, and receive access to pastoral counseling and other spiritual services. n Designate a decision-maker who may act on your behalf in case you become unable or incapable of communicating your wishes regarding care.
Visitation n Receive and designate visitors, Patient Rights Patients (and, as applicable, family including family, loved ones, friends and others. You also have the right to members or surrogate decision-makers) have the right to: change or deny this decision at any Communication time. The hospital may need to limit n Have access to effective visitors to better care for you or other communication. patients. No visitor will be denied n Receive information in a way that based upon race, religion, beliefs, you understand. This includes cultural values, gender identity or interpretation and translation, free expression, age, sexual orientation, of charge, in the language you prefer disability, veteran or financial status. n Have a family member, friend or for talking about your health care. This also includes providing you with individual present with you for emotional support. In some instances, needed help if you have vision, speech or cognitive impairments. the hospital may restrict a patient’s n Designate a surrogate decision-maker visitors, mail, telephone calls or other in case the patient is incapable of forms of communication. In these understanding a proposed treatment or instances, the restrictions are evaluated procedure or is unable to communicate for their therapeutic effectiveness. n Access protective services (such as his or her wishes regarding care. child or adult protective services, Informed Decisions guardianship, or the state survey and n Be informed about and participate in certification agency). decisions regarding care, treatment and n Designate a support person who may services, including the right to have his determine who can visit you if you or her physician notified of admission become incapacitated. to hospital.
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Patient’s Rights & Responsibilities Advance Directives risks, alternative services that might n Create advance directives regarding be advantageous to them, and a full care and have staff and practitioners explanation of the procedures to be who provide care comply with these followed, especially those that are directives. experimental in nature. Access to n Participate in ethical questions services will not be compromised for that arise in the course of care, those patients who refuse to participate including issues of conflict resolution, in a research project. withholding of resuscitative services, forgoing or withdrawal of lifePrivacy and Confidentiality sustaining treatment, and participation n Security, personal privacy and in investigational studies or clinical confidentiality of information. n Review and request copies of your trials. n Receive end-of-life care that is medical record unless restricted for respectful and responsive and that medical or legal reasons. demonstrates concern for a patient’s comfort and dignity. Complaints, Concerns and Questions n Tell hospital staff about your concerns Care Delivery or complaints regarding your care. This n Receive care in a manner that is will not affect your future care. n Seek review of quality of care concerns, considerate, respectful of personal values and beliefs and in an coverage decisions and concerns about environment that preserves the dignity discharge. n Expect a timely response to your of the patient without regard to race, religion, beliefs, cultural values, gender complaint or grievance from the identity or expression, age, sexual hospital. Complaints or grievances orientation, disability, veteran or may be made by contacting UTMB’s financial status. Patient Services Department. n Know the names of doctors and nurses providing care to you and the names Patient Responsibilities and roles of other health care staff that As a patient, family member or surrogate is caring for you. decision-maker, you have the right to n Receive proper assessment and know all hospital rules and what we management of pain. expect of you during your hospital stay. n Reasonable access to treatment or service. Provide Information n Certain information about any research n Provide accurate and complete project that the patient is asked to information about current health participate in, including expected care problems, past illnesses, benefits, potential discomforts and hospitalizations, medications and other 20
matters relating to the patient’s health.
n Provide other names by which the
patient has been known and any changes in address or telephone number(s). n Report unexpected changes in the patient’ condition to their responsible practitioner.
there are obstacles that would preclude the execution of the treatment plan, including discharge instructions. n If you or the patient refuse treatment or refuse to follow instructions (to the extent permitted under applicable law), the patient is responsible for his or her actions and any outcomes from such actions.
Respect and Consideration n Recognize and respect the rights Charges n You are responsible for paying for of other patients, families and staff. Please assist in the control of noise and the health care that you received as promptly as possible. number of visitors. Be respectful of the property of others and of the hospital. n Comply with the hospital’s no smoking Cooperation n You are expected to follow the care policy. n Refrain from conducting illegal activity plans suggested by the health care professionals caring for you while in on the hospital property. If such activity occurs, the hospital will report the hospital. You should work with your health care professionals to it to the police. develop a plan that you will be able to Safety follow while in the hospital and after n Promote your own safety by becoming you leave the hospital. n You are expected to follow hospital an active, involved and informed member of your health care team. rules and regulations affecting patient n Ask questions if you are concerned care and conduct. about your health or safety. n Be informed about which medications Please contact the department of Patient you are taking and why you are taking Services at 409-772-4772 if you feel you them. are not being afforded these rights or if n Report whether the patient clearly you have concerns or issues you would understands a contemplated course of like addressed. action and what is expected of them. Refusing Care n Follow the treatment plan recommended by the practitioner primarily responsible for the patient’s care and inform the physician whether 21
Derechos y Responsabilidades del Paciente Bienvenido a UTMB Health. Como paciente de este hospital, o como miembro de la familia o un tomador de decisiones sustituto de un paciente, deseamos informarle que tiene opciones, derechos y responsabilidades. Nosotros nos comprometemos a respetar sus derechos, y queremos notificarle que al tomar usted un papel activo en el cuidado de su salud, puede ayudar a que sus proveedores de salud satisfagan sus necesidades como paciente, o como miembro de su familia. Es por eso que pedimos que usted y su familia compartan con nosotros ciertas responsabilidades.
procedimiento propuestos o que no pueda comunicar sus deseos con respecto a su cuidado de salud.
Decisiones Informadas n Ser informado de y participar en las decisiones acerca de la atención médica, tratamientos y servicios, incluyendo el derecho de que se le notifique a su doctor de su admisión al hospital. n Ser informado acerca de los resultados del cuidado médico, incluyendo los resultados imprevistos. n Rechazar la atención médica, el tratamiento y los servicios. n Elegir su atención médica basado en sus valores espirituales y personales, y tener Derechos del Paciente acceso a la consejería pastoral y a otros servicios espirituales. El paciente (miembros de su familia o n Designar a un tomador de decisiones tomador de decisiones sustituto que sustituto que pueda actuar en su decida sobre la salud del paciente) tienen nombre en caso de que usted no pueda el derecho de: Comunicación o no esté capacitado para comunicar n Tener acceso a una comunicación sus deseos con respecto a su atención efectiva. médica. n Recibir información de manera que usted pueda entenderla. Esto incluye Visitas n Recibir y designar visitantes, interpretación y traducción de forma gratuita y en el idioma que que usted incluyendo miembros de su familia, prefiera para hablar sobre la atención seres queridos, amigos y otras personas. médica. Esto también incluye que se le Usted también tiene el derecho de proporcione la ayuda necesaria si usted cambiar o negar esta decisión en (el paciente) tiene deficiencias con cualquier momento. El hospital la visión, el habla o con las funciones posiblemente necesite limitar las visitas cognitivas. para brindarles una mejor atención n Designar a un tomador de decisiones médica a usted o a otros pacientes. No sustituto que actúe en caso de se rechazará a ningún paciente debido que el paciente no esté capacitado a su raza, creencias religiosas, valores para entender un tratamiento o culturales, identidad o expresión de 22
género, edad, orientación sexual, discapacidad, condición de veterano o posición económica. n Tener a un familiar, amigo u otro individuo que le acompañe y le brinde apoyo emocional. En algunos casos el hospital puede restringir las visitas del paciente, el correo, las llamadas telefónicas u otras formas de comunicación. En estos casos, las restricciones serán evaluadas por su eficacia terapéutica. n Tener acceso a servicios de protección (tales como servicios de protección para menores y adultos, servicios tutelares, o de la agencia estatal de inspección y certificación). n Designar a una persona que pueda determinar quién puede visitarle si usted queda incapacitado.
y sensible y que demuestren preocupación por la comodidad y la dignidad del paciente.
Prestación de Atención Médica n Recibir atención considerada, respetuosa de los valores y las creencias personales, en un entorno que asegura la dignidad del paciente, sin importar la raza, las creencias religiosas, los valores culturales, la identidad o expresión de género, la edad, la orientación sexual, la discapacidad, la condición de veterano o la posición económica. n Saber el nombre de los doctores y enfermeras que le proporcionen el cuidado médico a usted y los nombres y las funciones que desempeñen otros proveedores de atención médica o personal médico que tomen parte en el cuidado de su salud. n Recibir evaluación y manejo del dolor Directivas Médicas Anticipadas n Elaborar una Directiva Médica apropiados. n Acceso razonable a tratamiento o Anticipada con respecto a la atención médica y hacer que el personal y servicios. n Cierta información acerca de algún los médicos que le proporcionen la atención médica den cumplimiento a lo proyecto de investigación en el que dispuesto en dichas directivas. se le pida al paciente participar, n Participar en preguntas éticas que incluyendo los beneficios que se surjan en el curso del cuidado de salud, esperan, incomodidades y riesgos incluyendo cuestiones de resolución potenciales, servicios alternativos que de conflictos, suspensión de servicios podrían ser provechosos para ellos, de resucitación, rechazo o retiro de y una explcación completa de los tratamiento para mantener al paciente procedimientos a seguir, especialmente con vida (artificial), y la participación los que son experimentales. El acceso a servicios del cuidado de salud no se en estudios de investigación o ensayos clínicos. verá comprometido para los pacientes n Recibir cuidados paliativos (para que se rehúsen a participar en un personas con enfermedades en fase proyecto de investigación. terminal) de manera respetuosa
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Derechos y Responsabilidades del Paciente Privacidad y Confidencialidad n Que toda información sea tratada con seguridad, privacidad personal, y confidencialidad. n Revisar y solicitar copias de su expediente médico, a menos que dicha información sea restringida por razones médicas o legales. Quejas, Preocupaciones y Preguntas n Expresarle al personal del hospital sus preocupaciones o quejas relacionadas con su cuidado de salud. Esto de ninguna manera afectará su atención médica en el futuro. n Pedir una revisión de sus preocupaciones por la calidad del servicio, decisiones de la cobertura y preocupaciones acerca del alta hospitalaria. n Esperar que el hospital le dé una respuesta oportuna a su queja o reclamo. Las quejas o reclamos se pueden hacer comunicándose con el Departamento de Servicios al Paciente de UTMB (Patient Services Department).
hospitalizaciones, medicamentos y otros asuntos relacionados a la salud del paciente. n Provea otros nombres por los cuales se conozca al paciente y cualquier cambio en la dirección o en los números telefónicos. n Reporte cambios inesperados en la condición del paciente al proveedor de salud responsable.
Respeto y Consideración n Reconozca y respete los derechos de otros pacientes, familiares y los del personal. Por favor ayude en el control del ruido y del número de visitantes. n Sea respetuoso de la propiedad de otros y del hospital. n Cumpla con el reglamento de no fumar del hospital. n Se abstenga de mantener alguna actividad ilegal en las propiedades del hospital. Si estas actividades ocurrieran, el hospital las reportaría a la policía.
Seguridad n Promueva su propia seguridad, siendo Responsabilidades del Paciente un miembro activo, participante e Como paciente, miembro de la familia informado de su equipo de atención de o tomador de decisiones sustituto, usted salud. n Haga preguntas si usted está tiene el derecho de conocer todas las reglas del hospital y lo que se espera de preocupado por su salud o seguridad. n usted durante su estancia en el hospital. Se informe acerca de qué medicinas está tomando y por qué las está Información del Paciente tomando. n Provea una información completa y n Reporte si el paciente entiende precisa acerca de sus problemas actuales claramente el curso de acción de salud, enfermedades en el pasado, contemplado y lo que se espera de él. 24
Rechazo de Atención Médica Cooperación n Siga el plan de tratamiento n Se espera que usted siga el plan de recomendado por el proveedor de salud atención sugerido por los profesionales primario responsable de la atención de atención de salud que le atendieron del paciente e informe al doctor si hay durante el tiempo que estuvo en el algún obstáculo que pudiera impedir hospital. Usted debe trabajar con los la ejecución del plan de tratamiento, profesionales de atención de salud para incluso las instrucciones para darle de desarrollar un plan que usted pueda alta. seguir mientras esté en el hospital y n Si usted o el paciente rechazan el después que sea dado de alta. n Se espera que usted siga las reglas y tratamiento o no aceptan seguir las instrucciones (en la extensión regulaciones que afecten la atención del paciente y su conducta. permitida bajo la ley aplicable), el paciente es responsable por sus acciones Por favor comuníquese con el y por los resultados de sus acciones. Departamento de Servicios al Paciente Facturación al 409-772-4772 si usted siente que n Usted es responsable del pago por el no goza de estos derechos o si tiene cuidado de salud que usted recibió, tan preocupaciones o asuntos que quisiera pronto como sea posible. discutir.
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Advance Directives Advance Directives
Texas law provides three means of making decisions about medical care. They are called advance directives because they allow you to make your wishes known to your family and doctors concerning medical treatment before you actually need such care. Help is available in making your advance directives and a lawyer is not needed. Your physician or the hospital can provide the forms and assist in filling them out. Please remember an advance directive will be used only when you cannot speak for yourself and can be changed at any time. nA directive to physicians (formerly known as a living will) allows you to specify treatments you would want/ not want in the event of a terminal or irreversible illness.
n Th e medical power of attorney allows
you to appoint someone to make decisions about medical care should you become unable to make them yourself. n Th e out-of-hospital do-not-resuscitate order allows a patient and/or family members to make end-of-life decisions regarding resuscitation in an out-ofhospital setting. Discuss the different advance directives with people you trust. Talking about illness and death isn’t easy for anyone; it’s important to be open with your feelings. Don’t put this important decision off until later; your family and friends need to know what your wishes are. Provide copies to your doctor, family and agent. Bring a copy with you anytime you come to the medical center.
For more information about advance directives or to obtain forms, please speak with your nurse.
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Patient Privacy & Security Medical Records
To protect the confidentiality of your medical records, we must have written authorization before information regarding your medical treatment can be released. If you or your physician need this information, please send a signed and dated letter outlining the specific information you need from your medical record. Be sure to include your complete name, date of birth and UTMB Health patient identification number. Also, include the name and address of the physician to whom the record should be sent. The letter requesting your medical record should be addressed to: The University of Texas Medical Branch Health Information Management Department Release of Information 301 University Blvd. Galveston, TX 77555-0782
Privacy and Security of Health Information
UTMB Health is committed to protecting the privacy of our patients and keeping their health information secure. According to the federal law named the Health Insurance Portability and Accountability Act (HIPAA), you have rights concerning the use of individually identifiable health information. The primary purpose of this law is to provide standards to facilitate the electronic exchange of health information, provide individuals with better access to their health information and standardize this access among states, decrease health care fraud and abuse and, most importantly, protect your personal health information. If you feel your health information has been misused in any way, please call the UTMB Health Privacy Office at 409-747-8700. You also may call our anonymous Fraud, Abuse and Privacy hotline at 800-898-7679.
For more information regarding the process for obtaining a copy of your medical record or to request a copy of your medical record prior to discharge, contact the Health Information Management Department at 409-772-1965.
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LOUIS PASTEUR 1822-1895
In the field of observation, chance favors only the prepared mind.
Don’t Leave Until… 6 things to know before you walk out that hospital door.
Be sure to meet with the hospital’s discharge planner early in your stay to ensure a smooth discharge process later on.
When it’s time to be released from the
hospital, your physician will authorize a hospital discharge. This doesn’t necessarily mean that you are completely well—it only means that you no longer need hospital services. If you disagree, you or your caregiver can appeal the decision (see If You Disagree, at right). On the other hand, you may be pleased to learn that your doctor has approved your discharge. But before you can leave the hospital, there are several things that you or your caregiver must attend to. The first step is to know who will be involved in your discharge process. This starts with the hospital’s discharge planner, who may be a nurse, social worker or administrator, or may have 28
some other title. You and your caregiver should meet this person relatively early in your hospital stay; if not, find out who this person is and be sure to meet with him or her well before your expected discharge date. If You Disagree You or your support person can appeal your doctor’s discharge decision. If you are a Medicare patient, be sure you are given “An Important Message from Medicare” from the hospital’s discharge planner or caseworker. This details your rights to remain in the hospital for care and provides information on who to contact to appeal a discharge decision.
Don’t Leave Until... Make sure you have the following information before you leave the hospital: 1. Discharge instructions.
You will be given a copy of your discharge instructions. This is important information to guide you in the management of your care after discharge.
2. Medications list. This is a listing of what medications you are taking, why, in what dosage and who prescribed them. Having a list prepared by the hospital is a good way to double-check the information you should already have been keeping track of. 3. Rx. A prescription for any
medications you need. Be sure to fill your prescriptions promptly, so you don’t run out of needed medications.
Be sure to ask what foods to stay away from while on your medications.
4. Follow-up care instructions.
Make sure you have paperwork that tells you: n What, if any, dietary restrictions you need to follow and for how long n What kinds of activities you can and can’t do, and for how long n How to properly care for any injury or incisions you may have n What follow-up tests you may need and when you need to schedule them n What medicines you must take, why and for how long n When you need to see your physician nA ny other home-care instructions for your caregiver, such as how to get you in and out of bed, how to use and monitor any equipment, and what signs and symptoms to watch out for n Telephone numbers to call if you or your caregiver has any questions pertaining to your after-hospital care
5. Other services. When you leave the hospital, you may need to spend time in a rehabilitation facility, nursing home or other institution. Or you may need to schedule tests at an imaging center, have treatments at a cancer center or have in-home therapy. Be sure to speak with your nurse or physician to get all the details you need before you leave. 6. Community resources. You and your caregiver may feel unprepared for what will happen after your discharge. Make sure your discharge planner provides you with information about local resources, such as agencies that can provide services like transportation, equipment, home care and respite care.
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Preparing to Leave the Hospital When your doctor feels that you are ready to leave the hospital, he or she will authorize a hospital discharge. Please speak with your nurse about our discharge procedures. Here are a few tips to make the discharge process run smoothly: nB e sure you and/or your caregiver have spoken with a discharge planner and that you understand what services you may need after leaving the hospital. (See “Don’t Leave Until…” on page 28 for more discharge advice.) nV erify your discharge date and time with your nurse or doctor. nH ave someone available to pick you up. A member of the hospital staff or a volunteer will escort you to the front of the hospital and help you into your car. nC heck your room, bathroom, closet and bedside table carefully for any personal items. n Retrieve any valuables you have stored in the hospital safe. nM ake sure you or your caregiver has all necessary paperwork for billing, referrals, prescriptions, etc. n I f you had bloodwork or other tests done, be sure you know the results before you are discharged.
Discharge Planning
As soon as you are admitted to the hospital, we begin making plans to help you prepare for discharge. When your physician or case manager discusses your discharge plans with you, you should begin making arrangements for your trip home. Please notify your nurse if you 30
think there may be difficulties or delays in making these arrangements. Before discharge, you will receive instructions about post-hospital care from your nurse, including what symptoms or health problems to look out for after you leave the hospital. You should have your prescriptions filled at your local pharmacy. It is very important that you understand your physician’s instructions and recommendations for your follow-up care. If you have any unanswered patient care questions or concerns during the discharge process, please ask your nurse of your social worker. We will work to resolve those issues before you leave UTMB. Please also check your room carefully before leaving to be sure you have all of your personal belongings.
When You Are Discharged
Your physician determines when you are ready to be discharged. Your physician and nurse will give you discharge instructions and answer any questions you have about managing your treatment and medications once you are home. If you are confused or unsure about what you need to do, what medications you must take or if you have to restrict your diet or activities, don’t be afraid to ask and take notes. Be sure you understand any instructions you have been given before you leave the hospital.
Coordination of Benefits (COB)
Coordination of Benefits, referred to as COB, is a term used by insurance companies when you are covered under
two or more insurance policies. This usually happens when spouses or partners are listed on each other’s insurance policies, when both parents carry their children on their individual policies, or when there is eligibility under two federal programs. This also can occur when you are involved in a motor vehicle accident and have medical insurance and automobile insurance. Most insurance companies have COB provisions that determine who is the primary payer when medical expenses are incurred. This prevents duplicate payments. COB priority must be identified at admission in order to comply with insurance guidelines. Your insurance may request a completed COB form before paying a claim and every attempt will be made to notify you if this
occurs. The hospital cannot provide this information to your insurance company. You must resolve this issue with your insurance carrier in order for the claim to be paid.
Financial Arrangements
All patients should familiarize themselves with the terms of their insurance coverage. This will help you understand the hospital’s billing procedures and charges. If there is a question about your insurance coverage, a member of the Inpatient Registration Office will contact you or a member of your family while you are here. We will gather all the information needed to bill your insurance company for your hospital stay and collect the payment for your portion of the hospital bill.
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Preparing to Leave the Hospital If You Have Health Insurance
We will need a copy of your driver’s license or other identification card as well as your insurance card to verify eligibility and process your insurance claim. We will ask your permission to directly bill and receive payment from your insurance provider. If you are in need of financial assistance, please call the Office of Financial Counseling at 409-772-6464.
If You Are a Member of an HMO or PPO Your plan may have special requirements, such as a second surgical opinion or pre-certification for certain tests of procedures. It is your responsibility to make sure the requirements of your plan have been met. If the requirements of your plan are not followed, you may be financially responsible for all or parts of the services rendered in the hospital. In addition, some physician specialists may not participate in your health care plan and their services may not be covered.
If You Are Covered by Medicare or Medicaid
We will need a copy of your Medicare card or Medicaid form to verify eligibility and process your Medicare claim. You should be aware that Medicare specifically excludes payment for certain items and services, such as cosmetic surgery, some oral surgery procedures, personal comfort items, hearing evaluations and other costs. Deductibles and coinsurance are also the responsibility of the patient. Medicaid also has payment limitations on a number of services and items. 32
If You Have No Insurance
A representative from the Inpatient Registration Office will discuss financial arrangements with you. This representative is also available to assist you in applying for Medicaid or other government assistance programs.
Your Hospital Bill
The hospital is responsible for submitting bills to your insurance company based on the insurance information that was provided and verified. Please remember that your policy is a contract between you and your insurance company; you have the final responsibility for payment of your hospital bill. We have several payment options available to assist you in paying your bill. Your bill reflects all the services you receive during your stay. Charges fall into two categories: a basic daily rate, which includes your room, meals, nursing care, housekeeping, telephone and television; and charges for special services, which include items your physician orders for you, such as X-rays or laboratory tests. If you have a question about your hospital bill, contact UTMB Health Business Office at 409-771-8811 or 800-994-0363. Physicians are required to submit separate bills, so their charges will not be included on your hospital bill. If you have certain tests or treatments in the hospital, you may receive bills from physicians you did not see in person. These bills are for professional services rendered by these doctors in diagnosing and interpreting tests results while you were a patient. Pathologists, radiologists,
cardiologists, anesthesiologists and other specialists perform these services. If you have a question about these bills, please call the number printed on the statement you receive from them.
Financial Assistance
UTMB Health has a financial assistance program for qualified uninsured patients. To apply for financial assistance, contact the Office of Financial Counseling at 409-772-6464.
Discharge Planning
n We begin making plans to help you prepare for discharge as soon as you are
admitted to the hospital.
n When your doctor or case manager talks about your discharge plans with you,
you should start making arrangements for your trip home. Please notify your nurse if you think you may have trouble with making these arrangements. n Before discharge, your nurse will give you instructions about post-hospital care, including what symptoms or health problems to look out for after you leave the hospital. n Remember to fill your prescriptions at your local pharmacy. n Also remember to check your room carefully before leaving to be sure you have all of your personal belongings. n It is very important that you understand your doctor’s instructions and recommendations for follow-up care. n If you have any unanswered questions or concerns during the discharge process, please ask your nurse to speak with the case manager or social worker assigned to your unit. We will work together to resolve those issues before you leave UTMB.
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Hospital Services Pastoral Care
UTMB believes in providing care to the spiritual, as well as the physical and emotional, needs of each patient. Members of the Pastoral Care staff are available to assist you, whatever your faith tradition. You may contact our office at 409-772-3909. The meditation room is open around the clock for prayer and mediation. Also, your faith leader/ spiritual guide always is welcome to visit you while you are in our hospital.
Volunteer Services
409-772-2549
There are many ways you can volunteer at UTMB Health, depending on your interests and availability. Volunteering is a great way to contribute to your community and participate in helping patients and guests have the best experience they possibly can. If you are interested in volunteering your time and talent to serve others, contact Volunteer Services at 409-772-2549.
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Services We Provide
nM ammography Services Accredited by
the American College of Radiology Breast Imaging (ACR) MRI (ACR) CT (ACR) Ultrasound (ACR) Nuclear Medicine (ACR) Bone Density Screening nC omprehensive Imaging Services Bone Density Scanning CT Scan MRI–Outpatient Imaging Center nL aboratory Services Inpatient & Outpatient nO bstetrics and Gynecological Services nO ccupational Therapy nP hysical Therapy nS urgical and Cardiac Care nS ports Medicine and Rehabilitation nC ardiac Rehabilitation Clinic n2 4-Hour Emergency Department Services n Endoscopy n I npatient Medical Services nL abor & Delivery
Charitable Giving Opportunities To speak to someone about making a gift to UTMB Health, please contact the UTMB Health Development Office at 409-772-1991 or visit us at workingwonders. utmb.edu.
Help us help others
UTMB Health is fortunate that many of our patients make generous gifts in honor of the care they’ve received. They give to say thanks. But they also give to make sure other patients have the same opportunities they did: to be tended to by some of the best and most compassionate caregivers in all of academic medicine. Your gift can enhance the patient care experience at UTMB Health. It can help purchase state-of-the-art equipment to diagnose and treat illness and injury. It can help construct the next generation of hospital facilities. Or it can help support the training of tomorrow’s medical pioneers. Your generosity also can light the spark of innovation, supporting the kind of groundbreaking research that gives hope to millions, whether it’s the family struggling with Alzheimer’s, the victim of severe burns undergoing a long rehabilitation process, or the brain injury victim working to rebuild his life.
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WOODY ALLEN 1935-PRESENT
It is impossible to travel faster than the speed of light, and certainly not desirable, as one’s hat keeps blowing off.
Sudoku
Fill in the blank squares so that each row, each column and each 3-by-3 block contain all of the digits 1 through 9.
ANSWER KEY
How did you do? Check your answers here. Source: www.sudoku-puzzles.net
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