Patient Rights & Responsibilities


Baylor Scott & White Medical Center – Uptown will inform each patient, or when appropriate, the patient’s representative, of the patient’s rights, in advance of furnishing or discontinuing patient care whenever posible in a language or method of communication that the patient understands. The hospital involves the patient and/or family in decisions regarding the provision of ongoing care, treatment, services, or discharge based on the care, treatment and services required by the patient.

1. The hospital respects the rights of patients to respectful and considerate care. The patient has the right to the hospital’s reasonable response to his/her requests and needs for care, treatment or service, within the hospital’s capacity, stated mission and applicable law and regulation. The patient has the right to have his or her cultural, psychosocial, spiritual and personal values, beliefs, and preferences respected. The hospital supports a patient’s right to personal dignity. The hospital accommodates the right to pastoral and other spiritual services services.

2. Each patient has the right to receive, upon or prior to admission, information about the hospital’s Patient Rights. Upon admission, the patient has the right to know the extent the hospital is able, unable or unwilling to honor advanced directives, if the patient has an advanced directive. The patient has the right to access, request amendment to, and receive an accounting of disclosures regarding his or her health information as permitted under HIPAA and all applicable laws.

3. Patients are involved in decisions about care, treatment and services provided at the hospital, and are involved in resolving dilemmas about care, treatment and services. When a patient is unable to make decisions about his or her care, treatment and services, the patient has a right to a surrogate decision maker as allowed by law. The legally responsible representative of the patient approves care, treatment and services decisions. The family, as appropriate and allowed by law, and with permission of the patient or surrogate decision maker is involved in care, treatment and services decisions. Each patient will receive the SPEAK-UP pamphlet. The patient has the right to expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care options when hospital care is no longer appropriate.

4. Informed consent is obtained and documented in accordance with hospital policy. The process includes a discussion of the nature of the proposed care, treatment, services, medications, interventions, or procedures; potential benefits, risks, or side effects including potential problems during recuperation; the likelihood of achieving goals; reasonable alternatives; the relevant risks, benefits and side effects related to alternatives, including the possible results of not receiving care, treatment and services; and when indicated, any limitations on the confidentiality of information learned from the patient.

5. Consent is obtained for recording or filming made for purposes other than the identification, diagnosis or treatment of patients. Patients have the right to request cessation of recording or filming, and to rescind consent for use. Anyone engaged in recording or filming signs a confidentiality statement. All patients will sign a separate consent for filming and recording prior to filming or recording.

6. Each patient has the right to information about the physician or other practitioner responsible for, or actually providing, care, treatment and services. The information will include the name of the physician or other practitioner. Patients also have the right to know the immediate and long-term financial implications of treatment choices, in so far as they are known.

7. Patients have the right to refuse care, treatment and services as allowed by law and regulations. If the patient is not legally responsible, the surrogate decision maker has the right to refuse on behalf of the patient.

8. Patients have the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives. Adults have the right to accept or refuse medical or surgical treatment including forgoing or withdrawing life-sustaining treatment or withholding resuscitative services. The hospital will document whether or not a patient has a signed advanced directive, and will give the patient the option to review and revise advanced directives. Hospital will be informed whether a patient has an advanced directive. Baylor Medical Center at Uptown does honor advanced directives, and can help patients formulate advanced directives. Your advanced directive will be included in your patient record.

9. When medically appropriate and legally permissible, or when a patient has so requested, a patient may be transferred to another facility. The institution to which the patient is to be transferred must first have accepted the patient for transfer. The patient must also have the benefit of complete information and explanation concerning the need for, risks, benefits, and alternatives to such a transfer.

10. Patients have 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 to the hospital.

11. The patient has the right to ask and be informed of the existence of business relationships among the hospital, educational institutions, and other health care providers, or payers that may influence the patient’s treatment and care.

12. Patients, and their families if appropriate, have the right to be informed about outcomes of care, treatment and services that affect current and future decisions, and unanticipated outcomes related to care, treatment and services.

14. Patients have the right to effective communication, and to receive information and all communication in a manner the patient understands, appropriate to age, understanding and language of the patient. The hospital has access to interpreters, to provide verbal information in the language the patient requests. The needs of the hearing, vision, speech, language and cognitive impaired are addressed. If you have special needs that are not being addressed, please let any staff member know.

15. Patients have the right to make a complaint or file a grievance. See the back of this page for further information about the hospital’s grievance policy. The hospital receives, reviews and, when possible, resolves complaints from patients and visitors. The hospital responds to individuals making a significant or recurring complaint. Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or unreasonable interruptions of care, treatment or services. See SPEAK-UP pamphlet.

16. Patients have the right to confidentiality, privacy and security. The hospital protects confidentiality of information, respects patient privacy, provides for private telephone conversations, and provides for the safety and security of patients and their property. This includes confidentiality of all health information. Patients have the right to request that no information regarding their presence, diagnosis or treatment be released. Release of any information requires prior consent from the patient. The patient has the right to consent to, or decline to participate in, proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent. A patient who declines to participate in research or experimentation is entitled to the most effective care that the hospital can otherwise provide.

17. Patients have the right to an environment that preserves dignity and contributes to a positive self-image.

18. Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. All allegations, observations or suspected cases of abuse, neglect or exploitation will be explored and, based on the type of event, referred to the proper authorities for investigation. Baylor Scott & White Medical Center – Uptown does not use physical restraints.

19. Patients have the right to pain management. See Pain Management pamphlet.

20. Patients have a right to access protective and advocacy services. A list of community advocacy groups is available upon request. Any patient may also request to speak to a social worker provided by the hospital.

21. Children/Adolescents and their parents/guardians have the additional following rights:

a. To have parents/guardians with children/adolescents as much as possible

b. To have the child/adolescent be considered a unique individual separate from the parents

c. To be cared for by staff that is knowledgeable in age-specific care

d. To be in a supportive, secure, non-threatening environment that promotes growth and development

e. To cry, make noise or object to anything that hurts

f. To appropriate treatment in the least restrictive setting available.

In addition, the hospital will meet the requirements of the Federal Rehabilitation Act of 1973 and the Americans with Disabilities Act, which requires program and facility accessibility.


1. The patient, guardian or legally authorized representative has the responsibility to provide the best of his/her knowledge, accurate and complete information about present complaints, past illnesses, hospitalization, medication and other matter related to health. He/she has the responsibility to report unexpected changes in his/her (the patient’s) condition to the responsible practitioner.

2. The patient’s guardian or legally authorized representative has the responsibility to participate in and follow the treatment plan that was developed in cooperation with his/her desires, the physician and health care team. This may include following the instructions of nurses, and allied health personnel as they carry out a coordinated plan of care, implement the responsible practitioners order and enforce the applicable hospital rules and regulations.

3. The patient, guardian or legally authorized representative has the responsibility for his actions, and accepting consequences, if he refuses treatment or does not follow the practitioner’s instructions.

4. The patient and family are responsible for asking questions when they do not understand what they have been told about the patient’s care or what they are expected to do.

5. The patient has the responsibility for respecting and showing consideration of the rights of other patients and personnel of the Hospital, and assisting in the control of noise, smoking and the number of visitors. Patient and visitors must follow hospital rules and regulations.

6. The patient has the responsibility to participate in those education and discharge planning activities necessary to ensure he/she has the adequate knowledge and support services necessary to provide him/her with a safe environment upon discharge from the hospital

7. The patient, guardian or legally authorized representative will be responsible for fulfilling the financial obligation of his/her health care.


  • The hospital provides for, and welcomes the expression of grievances/complaints and suggestions by the patient, patient’s family and designated representatives at all times. This feedback allows the hospital to understand and improve the patient’s care and environment.
  • Every patient has the right to file a grievance with any staff member or the facility’s CEO. In the absence of the CEO, senior management will address the grievance/complaint.
  • The grievance process begins with the facility CEO. If the patient is still not satisfied, the process is given to the Patient Care Committee. In the event the problem is still not resolved, a complaint can be registered by phone or in writing to:

Texas Department of State Health Services, Health Facility Licensing and Compliance Division, 1100 West 49th St., Austin, TX 78756 or call (888) 973-0022

A complainant may also contact the state directly, bypassing any internal process.

  • A complainant may provide his/her name, address, and phone number to the department. Anonymous complaints may be registered. All complaints are confidential.
  • A complainant may also contact the Joint Commission to register a complaint, which will be confidential and can be done anonymously: E-Mail: [email protected]; Fax: Office of Quality Management (630) 792-5636; Mail: Office of Quality Management, The Joint Commission One Renaissance Boulevard, Oakbrook Terrace, IL 60181
  • The main goal of the hospital is to provide excellent care to every patient. Every patient is encouraged to SPEAK-UP and ask questions.
  • All Medicare beneficiaries may also file a complaint or grievance with the Medicare Beneficiary Ombudsman. Visit the
  • Ombudsman’s webpage on the web at:


All patients have the right to chose who may visit during an inpatient stay. The facility will not restrict an approved visitor except in medically appropriate circumstances. The approved visitor(s) will enjoy full and equal visitation privileges consistent with the wishes of the patient. This applies to all patients regardless of payor source. The patient has the right to withdraw such consent to visitation at any time.

The definition of a patient-designated visitor shall be anyone the patient approves regardless of whether or not that visitor is legally related by marriage or blood to the patient.

The medical staff and caregivers are not to restrict any approved visitor expect in medically appropriate circumstances. Please limit visitors to two at a time. Please limit visiting hours from 7 am to 11 pm so the patient might rest. Children under twelve should visit only during normal visiting hours.


In the State of Texas, all patients have the right to participate in their own health care decisions and to make Advance Directives or to execute Powers of Attorney that authorize others to make decisions on their behalf based on the patient’s expressed wishes when the patient is unable to make decisions or unable to make decisions or unable to communicate decisions. The Baylor Scott & White Medical Center – Uptown respects and upholds those rights. However, unlike in an acute care hospital setting, Mary Shiels does not routinely perform “high risk” procedures. While no surgery is without risk, most procedures performed in this facility are considered to be of minimal risk. You will discuss the specifics of your procedure with your physician who can answer your questions as to its risks, your expected recovery, and care after your surgery.

Therefore, it is our policy, regardless of the contents of any Advance Directive or instructions from a health care surrogate or attorney-in-fact, that if an adverse event occurs during the your treatment at this facility, we will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation. At the acute care hospital, further treatments or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, Advance Directive, or health care Power of Attorney. Your agreement with this facility’s policy will not revoke or invalidate any current health care directive or health care power of attorney. If you wish to complete an Advance Directive, copies of the official State forms are available at our facility. If you do not agree with this facility’s policy, we will be pleased to assist you in rescheduling your procedure.


Baylor Scott & White Medical Center – Uptown is proud to have a number of quality physicians invested in our facility. Their investment enables them to have a voice in the administration of policies of our facility. This involvement helps to ensure the highest quality of surgical care for our patients. Your physician may have a financial interest in this facility. A list of physician owners is available upon request.

A copy of the Patient Bill of Rights and Responsibilities has been placed in the MSH packet or given to the patient by the personnel in the Admitting Department. References: A Patient’s Bill of Rights approved by AHA Board of Trustees, October, 1992. JCAHO 2008 Hospital Accreditation Standards and 2008 updates.