Patient Rights & Responsibilities

Patient's Rights

BHS respects the rights, dignity and choices of the patient. Every patient receiving care, treatment, and/or services in the BHS has the following rights. Texas law requires that your legal representative or surrogate decision maker, next of kin, family member(s), parent(s), guardian(s), or other legally authorized representative may exercise those rights on your behalf:

  • The hospital respects, protects, and promotes patient rights, to include:
  • Privacy of health information
  • Freedom from restraints and seclusion unless specific clinical justification criteria is met and your doctor writes an order
  • The hospital respects the patient’s right to receive information in a manner he or she understands.
  • The hospital respects the patient’s right to participate in decisions, development, and implementation of his or her care, treatment, and services.
  • The hospital honors the patient’s right to give or withhold informed consent.
  • The hospital honors the patient’s right to give or withhold informed consent to produce or use recording, films, or other images of the patient for purposes other than his or her care.
  • The hospital protects the patient and respects his or her rights during research, investigation, and clinical trials.
  • The hospital respects the patient’s right to receive information about the individual(s) responsible for, as well as, those providing, his or her care, treatment, and services.
  • The hospital addresses patient decisions about care, treatment, and services received at the end of life.
  • The patient has the right to be free from neglect, exploitation, and verbal, mental, physical, and sexual abuse.
  • The patient has the right to an environment that preserves dignity and contributes to a positive selfimage.
  • The patient and his or her family have the right to have complaints reviewed by hospital.
  • The patient has the right to access protective and advocacy services.
  • The hospital informs the patient about his or her responsibilities related to his or her care, treatment, and services.
  • The hospitalsupports the right of a patient to request and have a chaperone present during certain sensitive physical examinations and treatments. Sensitive physical examinations and treatments are typically those that involve the reproductive and sexual organs, those that may be perceived as potentially threatening to a patient’s sense of privacy or modesty, or those that may induce feelings of vulnerability or embarrassment.
  • Service Animals – the hospital has a written policy based on (ADA) Americans with Disabilities regulations that define the patient’s rights and responsibilities regarding service animals.

Patient's Responsibilities

In order to promote quality care, the BHS affirms the following patient responsibilities, while receiving care, treatment, and services, as an integral part of the healing process. The patient is responsible for:

  • Providing accurate and complete information about present health, past illnesses, hospitalizations, medications, allergies, and other health matters to the best of your knowledge;
  • Reporting to your physician and/or nurse any changes in your condition;
  • Participating in developing and for following the treatment plan recommended to you. This includes instructions of nurses and allied health personnel as they carry out the coordinated plan of care, implement the physician’s orders, and enforce applicable hospital rules and regulations. You are also responsible for reporting to your physician and/or nurse whether you clearly comprehend a contemplated course of action and what is expected of you;
  • Accept the consequences for outcomes related to your actions if you refuse treatment or do not follow instructions given to you;
  • Providing the hospital with a copy of your written Advance Directive(s), if one has been executed. Also, reporting any changes in your Advance Directive(s);
  • Assuring financial obligations are fulfilled promptly by providing the necessary information to ensure processing of hospital bills;
  • Following hospital rules and regulations affecting patient care and conduct;
  • Protect your own valuables. You are also responsible for being respectful of the property of other patients and of the hospital;
  • Consideration of the rights of other patients, volunteers, visitors, and hospital personnel;
  • Ask questions if directions and/or procedures are not understood;
  • Ask your physician or nurse what you should expect in relation to pain and pain management; discuss pain relief options with your physician and/or nurse; work with your physician and/or nurse to develop a pain management plan; ask for pain relief when pain first begins; help your physician and/or nurse to measure your pain; and tell your physician and/or nurse if your pain is not relieved;
  • Notify hospital personnel if you and/ or your surrogate decision maker are concerned about any patient safety related issues.

You Right To Make a Complaint

Complaints and Grievances

Our mission is to provide our patients with the highest quality health care that we can by meeting your needs, keeping you safe, and making your stay with us as comfortable as possible. We depend on our patients and their families to keep us informed of any incident that does not meet the highest level of satisfaction.

Should we fail to meet your needs or you are dissatisfied with any aspect of your care, the BHS has adopted procedures to help you let us know about your concerns and take action to help resolve them.

Patients or their representative may file a verbal or written complaint or grievance at any time. For a prompt response, you may speak to a member of your health care team or call the hospital operator and request Administration by dialing “0” (from inside the hospital). From outside the hospital, you may dial the facility where you received care at:

Baptist Medical Center
(210) 297-7000

Mission Trail Baptist Hospital
(210) 297-3000

Northeast Baptist Hospital
(210) 297-2000

North Central Baptist Hospital
(210) 297-4000

Resolute Baptist Hospital
(830) 500-6000

St. Luke’s Baptist Hospital
(210) 297-5000

Westover Hills Baptist Hospital
(726) 266-8100

Notices Regarding Patient Care or Safety

In addition, you may also choose to report a complaint/grievance to one of the following agencies:

The Joint Commission (TJC)
Online at https://www.jointcommission.org/report_a_complaint.aspx
by Fax (630-792-5636) or by mail to the following address:
Office of Quality and Patient Safety
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181

Texas Health and Human Services
Phone Number: 1-888-973-0022
Fax Number: (512) 834-6653
Mailing Address:
P. O. Box 149347 Mail Code 1979
Austin, Texas 78714-9347
Website Address: www.dshs.state.tx.us

Centers for Medicare & Medicaid Services
Phone Number: 1-800-985-3059
Website Address: www.cms.gov/medical-bill-rights/help/submit-a-complaint

Certain Federal and State laws give you specific rights with regard to filing grievances and complaints concerning care and services.

Duty To Report Abuse and Neglect or Illegal, Unprofessional, or Unethical Conduct

A person, including an employee, volunteer, or other person associated with the BHS, has a duty to report to the appropriate state health care regulatory agency any abuse or neglect of a patient as required by law.

All employees, health care professionals, or other persons associated with the Baptist Health System have a duty to report to the appropriate state health care regulatory agency, any illegal, unprofessional, or unethical conduct as required by law

Report immediately any abuse, neglect, or illegal, unethical, or unprofessional conduct in accordance with Texas Health and Safety Code §162.132 to the Texas Department of State Health & Human Services Licensing and Complaint Line:

Texas Department of State Health Services (TDSHS)
Patient Quality Care Unit / Health Facility Compliance
Licensing and Complaint Line
Phone Number: 1-888-973-0022
Fax Number: (512) 834-6653
Office Hours: Monday – Friday, 8:00 a.m. – 5:00 p.m. Central Standard Time
Mailing Address:
P. O. Box 149347, Mail Code 1979
Austin, Texas 78714-9347
Website Address: www.dshs.state.tx.us

Reports of suspected abuse or neglect may be made to any of the following entities:

Texas Department of State Health Services Health Facility Compliance Division
Complaint Hotline: 1-888-973-0022

Texas Department of Family and Protective Services
Abuse/Neglect Reports Hotline: 1-800-252-5400

Texas Department of State Health Services
Substance Abuse Consumer/Family with Complaint: 1-800-832-9623

Texas Department of State Health Services
Consumer Rights for Mental Health Services: 1-800-252-8154

Texas Department of Aging and Disability Services (DADS)
Phone Number: 1-800-458-9858

Complaints About Physicians and Other Licensees and Registrants of The State of Texas

Complaints against physicians, physician assistants, acupuncturists, surgical assistants, respiratory care practitioners, medical radiologic technologists, medical physicists and perfusionists may be reported for investigation at the following address:

Texas Medical Board
Attention: Investigations
333 Guadalupe, Tower 3, Suite 610
P.O. Box 2018, MC-263
Austin, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number:
1-800-201-9353
For more information please visit our website at www.tmb.state.tx.us.

Prohibition Against Retaliation

As outlined in the Texas Health and Safety Code 571.135, a hospital, mental health facility, or treatment facility may not retaliate against a person who is not an employee for reporting a violation of a law or any rule adopted by the Texas Board of Mental Health and Mental Retardation, the Texas Board of Health, or the Texas Commission on Alcohol and Drug Abuse.

Non-Discrimination Notice and Language Assistance Services

BHS complies with applicable Federal civil rights laws and does not discriminate on the basis of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity, or expression. BHS does not exclude people or treat them differently because of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity, or expression.

Baptist Health System Provides

Free auxiliary aids and services to people with disabilities to communicate effectively with us, such as:

  • Qualified interpreter
  • A language line
  • Information written in other languages

If you need these services, please contact your nurse or House Officer.

If you believe BHS has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, BHS’s ADA Coordinator is available to help you.

ADA Coordinator
Regional Quality Department
730 N. Main Avenue, Suite 424
San Antonio, TX 78205
Phone: 1-210-297-8262
Fax: 1-210-297-0926
Email: [email protected]

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html

Continue