THIS FILE CONTAINS A COMPLETE LISTING OF THE TABLE OF CONTENTS
FOR EACH OF GATOR SOFTWARE'S POLICY & PROCEDURE MANUALS.  IN
ADDITION IT GIVES A DESCRIPTION OF SOME OF OUR OTHER HOSPITAL
RELATED SOFTWARE THAT IS AVAILABLE.  PLEASE FEEL FREE TO SHARE
ALL OR PART OF IT WITH OTHER DEPARTMENT DIRECTORS IN YOUR
HOSPITAL.  REMEMBER, ORDERS FOR MORE THAN $175 QUALIFY FOR A 25%
DISCOUNT.  SEE THE ORDER FORM THAT CAME WITH YOUR ORDER OR USE
THE ONE THAT FOLLOWS:


*************
INTRODUCTION:
*************

DEPARTMENT DIRECTORS:
Do You Need An Updated . . .

	POLICY AND PROCEDURE MANUAL

But You're Short On Manpower to get the job done??? 

We have the solution to your problems!!!  

Purchase our Policy and Procedure Manual ON A COMPUTER DISK which
you can easily customize for your own hospital.  Our manuals have
been utilized in over 2,000 JCAHO accredited hospitals for years. 
Although our manuals are inexpensive, costing no more than one of
your reference books, don't let the price fool you.  Each
complete manual is writen by experts in your respective field and
contains all of the most common policies and procedures utilized
by hospitals.  Unlike other companies who send you copyrighted
printed manuals for a lot more money, we send you licensed
manuals ready to print out on your computer's printer.  It
appears as if you have spent weeks at your typewriter (only your
hairdresser will know for sure).  If you wish, you can add or
delete information with your computer's word processor to
customize the manuals for your hospital or if you're in a hurry
you can use them "as is".  Think of how impressed your
administrator will be when you show him/her your newly revised
and professionally typed manual.  With 1 out of 4 hospitals using
our software, you're assured of flying though that JCAHO
inspection with flying colors.  With so many JCAHO inspectors
accustomed to looking at our manuals, you may actually be at a
disadvantage if you're not using our manual.  If you already have
a good policy and procedure manual, chances are there may be some
policies and procedures in our manuals that you may have
overlooked.  In that case you can just print the portions that
you need.  Even if you only use one or two of the procedures, you
probably would save time and money over what it would have cost
for you to write and type them.  The manuals are formatted for
use with WordPerfect Version 4.1, 4.2, 5.0 and 5.1 (WordPerfect
program not included), and are compatible with most other word
processing programs.  WordPerfect is the most popular word
processing program in the world so if you are not using it, check
around the hospital, chances are someone else probably is.  If
you have a different word processor that happens to be your
personal favorite, don't despair.  Almost all high quality word
processing programs have the ability to import WordPerfect files. 
If you can't use WordPerfect files, we will supply the files in
ASCII format which is generic to all word processors.  So what
are you waiting for??  Don't forget to use the enclosed order
form and send your check or purchase order today.  The manuals
are only $99, some as low as $49 and are available on 3.5 or 5.25
inch disks.  For even faster service, fax us your order and it
will usually be shipped the same day.  As if all of this isn't
enough, look below for our special offers on how you get FREE
software and a 25% Discount on your order.

FREE SOFTWARE OFFER #1:
	Enclose your payment with your order and receive a FREE copy
of our HOSPITAL BUDGET TEMPLATES.  Your order must be prepaid to
get this free disk!


"ALMOST" FREE SOFTWARE OFFER #2:
	Buy 2 or more manuals or other programs that total $175 or
more and SAVE 25% off the total cost of your order.  This offer
is valid only when all manuals are ordered at the same time. 
Check with some of your other department heads.  Many hospitals
order manuals for several departments.

"INCREDIBLE" FREE SOFTWARE OFFER #3:
        Now you can standardize all of your hospital's manuals at
one time by purchasing a complete set of all of our programs and procedure
manuals listed on the order form for only $1299.  Plus you can apply
your 25% discount to bring the total price down to only $974.25 (That's
less than $35 per P&P manual or program).  This is the perfect solution
if you have an upcoming JCAHO inspection.


A WORD ABOUT HOSPITAL COMPUTER PROGRAMS FROM GATOR SOFTWARE: 

POLICY AND PROCEDURE MANUALS -- Our manuals are text files on a
computer disk containing generic policies and procedures that are
common to most hospitals and are similar to printed versions that
are available elsewhere.  These manuals are unique in that
everything is on a computer disk which allows you to easily alter
or add information to make it specific for your hospital.  Once
you complete your changes, you just print it out on your
computer's printer.  No need to have your secretary (if you're
lucky enough to have one) re-type the whole manual.  Our
competition charges anywhere from $200 to $1500 for simlar
manuals in un-editable hard copy format.  Although our text files
are in WordPerfect 4.1 format, they are directly compatible with
versions 4.2, 5.0 and 5.1.  They will be converted automatically
when you load them into the WordPerfect program.  If you're using
another word processing program, read your program's manual to
determine the procedure for converting WordPerfect files for use
with your word processor.  If you have lost your program's
manual, you can obtain replacements at your local bookstore (i.e.
B.Dalton's or Waldenbooks).  Almost all of the major word
processing programs have the capability of importing WordPerfect
files.  Sometimes there is a conversion program on your word
processor's utility disk for this purpose.  If you encounter
difficulty, we will send you the files in ASCII format which is
generic to all wordprocessors.

MEDICATION FORMULARY PROGRAM -- A complete self-contained program
which allows you to easily create and maintain your hospital's
medication formulary and print it out in ready-to-xerox format.
Don't be duped into paying someone to print your formulary only
to have it be out-of-date by the time you receive it.  The
program includes a base-line formulary of over 600 frequently
used drugs which are common to most hospital formularies. You can
easily add or delete items to customize the formulary or you can
use it as is. The program will list your formulary by AHFS
therapeutic class to help you identify generically or
therapeutically equivalent drugs in your hospital. You can also
print out your formulary alphabetically by generic name if you
prefer this format.  Other printouts include a Table of Contents
listing all of the therapeutic categories contained in your
formulary and an Index listing all generic names and the
therapeutic categories they are contained in.  It also produces a
generic-brand equivalency chart of all the drugs in your
hospital, which your nurses will find very handy. The files
produced are DBase III compatible and can be manipulated without
the program if you have a copy of DBase III or a clone. A hard
drive is strongly recommended and DOS 3.0 or higher is required.

BUDGET TEMPLATES -- These files are designed to be used with
Lotus-123 or a compatible program to help you plan your hospital
budget. You enter the last year's expense or revenue figures and
the program will calculate the next year's projected figures from
projected patient-days. Another template calculates the projected
FTE's and salary expense by month for each employee.  These are a
big time-saver for preparing your department's hospital budget.

WHY DO 1 OUT OF 4 HOSPITALS USE OUR SOFTWARE??
Because we save you hours & hours of time (and that means
money!!!)

IMPRESS YOUR ADMINISTRATOR!	
Don't re-invent the wheel . . . CALL GATOR
ALL ORDERS SHIPPED PROMPTLY
****************
*  ORDER FORM  *
****************

GATOR SOFTWARE, INC
Suite 719
3400 Peachtree Road
Atlanta, GA  30326-1107

(404) 262-3572 -- Customer Service
(404) 231-0595 -- FAX



SHIP TO:

NAME: _________________________________________________

TITLE/DEPT: ___________________________________________

HOSPITAL:______________________________________________

ADDRESS:_______________________________________________

CITY,STATE,ZIP:________________________________________

PHONE:_________________________________________________


BILL TO:   (If Different Than Above)

NAME:__________________________________________________

DEPT:__________________________________________________

HOSPITAL:______________________________________________

ADDRESS:_______________________________________________

CITY,STATE,ZIP:________________________________________

DISK SIZE:    (Check One)
[  ]	3.5 Inch (720Kb)           (If You Do Not Specify, The 3.5
[  ]	5.25 Inch (360Kb)           Inch Size Will Be Sent)

PAYMENT METHOD:     (Check One)
[  ]	CHECK/MO ENCLOSED
[  ]	BILL ME (Enclose PO and FAX or  MAIL)
		Terms: Net 30, 1.5% Per Month Late Fee 
		Do Not Mail Confirming PO
		All Discounts Disallowed If Invoice Not Paid In 30 Days

SPECIAL OFFER:        (Help Us Keep Our Costs Low!!)
ALL PREPAID ORDERS WILL RECEIVE A FREE COPY OF OUR HOSPITAL BUDGET TEMPLATES. 
You must enclose payment with your order to get this free disk 

IMPORTANT PLEASE NOTE:
1.  All P&P Manuals require WordPerfect 4.1, 4.2, 5.0 or 5.1 or another word
processor compatible with the WordPerfect file format. Check your program's
manual to determine the file compatibility before ordering.  ASCII Format is
also availble.
2.  Our disks are not copy protected, therefore, DISKS MAY NOT BE RETURNED FOR CREDIT OR REFUND.  Defective disks will be replaced at no additional charge.
3.  Orders must be mailed or faxed. To keep our prices low, we do not accept
phone orders.  Your order will be received via Priority Mail in 7-10 days.
4.  If you have difficulty please call our Customer Service Representatives. 
However, teaching you how to use your word processor is beyond the scope of our customer service.
5.  If you fax your order, DO NOT MAIL CONFIRMING PURCHASE ORDER to avoid
duplication.


Check One or More Disk Selections:

POLICY & PROCEDURE MANUALS: 
(NOTE: All are IBM/WordPerfect 4.1 Format)

[  ] Administrative Policy Manual  - - - - - - - - - - - -$99.00 
[  ] Anesthesia Dept- - - - - - - - - - - - - - - - - - - $99.00
[  ] BioMedical Dept - - - - - - - - - - - - - - - - - - -$49.00
[  ] Customer Relations Manual - - - - - - - - - - - - - -$49.00
[  ] Disaster Plan (Emergency Action)  - - - - - - - - -  $99.00
[  ] Dietary Dept  - - - - - - - - - - - - - - - - - - - -$99.00
[  ] Engineering Dept - - - - - - - - - - - - - - - - - - $99.00
[  ] Environmental Services Dept - - - - - - - - - - - - -$99.00
[  ] Hazardous Materials Manual     - - - - - - - - - - - $99.00
[  ] Home IV Therapy Manual  - - - - - - - - - - - - - -  $99.00
[  ] Institutional Review Board (IRB) - - - - - - - - - - $49.00
[  ] Invasive Cardiology (CATH LAB)- - - - - - - - - - -  $99.00
[  ] Laboratory Dept - - - - - - - - - - - - - - - - - - -$99.00
[  ] Materials Management Dept  - - - - - - - - - - - - - $99.00
[  ] Medical Records Dept - - - - - - - - - - - - - - - - $99.00
[  ] Medical Staff Bylaws - - - - - - - - - - - - - - - - $99.00
[  ] Neurology Dept (EEG)- - - - - - - - - - - - - - - - -$99.00
[  ] Non-Invasive Cardiology (EKG)    - - - - - - - - - - $49.00
[  ] Nursing Dept - - - - - - - - - - - - - - - - - - - - $99.00
[  ] Operating Room - - - - - - - - - - - - - - - - - - - $99.00
[  ] Pain Clinic - - - - - - - - - - - - - - - - - - - - -$99.00
[  ] Pharmacy Dept - - - - - - - - - - - - - - - - - - - -$99.00
[  ] Physical Therapy Dept - - - - - - - - - - - - - - - -$99.00
[  ] Radiology/Nuclear Medicine Dept   - - - - - - - - -  $99.00
[  ] Respiratory Care Dept - - - - - - - - - - - - - - - -$99.00
[  ] Risk Management/Safety Manual   - - - - - - - - - -  $99.00
[  ] Sleep Lab - - - - - - - - - - - - - - - - - - - - - -$49.00
[  ] Total Quality Management (TQM)- - - - - - - - - - - -$99.00
MISCELLANEOUS PROGRAMS

[  ] Department Supervisor Training
		       Manual (WordPerfect 4.1)   - - - - - - - $99.00
[  ] Hospital Budget Templates
		       (Lotus 123 Format) - - - - - - - - - - - $49.00
[  ] Medication Formulary Ver 2.0
		       (Hard Disk Required)  - - - - - - - - -  $99.00
        
[  ] SPECIAL OFFER: ONE COPY OF EVERY PROGRAM AND POLICY &
           PROCEDURE MANUAL LISTED ABOVE - - - - - - - - - - -$1299.00		     

SUBTOTAL  - - - - - - - - - - - - - - - - - - - - - - - -  $__________ 

DISCOUNT (Subtract 25% If Subtotal Is $175
		    Or More For This Order) - - - - - - -  $__________


SHIPPING & HANDLING - - - - - - - - - - - - - - - - - - -    $ 4.00


FLA. HOSPITALS ENCLOSE 6% TAX OR EXEMPTION - - - - - - - - $__________
	(Florida Hospitals Only)

TOTAL AMOUNT - - - - - - - - - - - - - - - - - - - - - - - $__________




ADMINISTRATION
POLICY & PROCEDURE MANUAL

TABLE OF CONTENTS


GENERAL POLICIES:

Adult Neglect & Abuse
Admitting Policies
Audiovisual Services
Child Neglect & Abuse
Conflict of Interest
Continuing Education Programs
Contracts & Agreements
Department Policy Manuals
Dress Code
Discharge Planning
Education Program Approval
Emergency Department Treatment
Equipment Disposal
Establishing Policy
Flag Display
Gifts
Hold Orders
Hospital Policy
Hospital Property
Informed Consent
Lease, Contract & Agreement Authorization
Living Will
Lost & Found
Medical Records, Examination, Copying & Release
News Media, Release of Information
Ordering Food & Beverages
Organ Donation, Routine Inquiry
Patient Fraud
Patient Information, Release to Media
Patient Possession of Illegal Controlled Substances
Patient Rights & Responsibilities
Patient Transportation
Patient Valuables
Purpose & Objectives
Speakers Bureau
Student Clinical Experience
Transport of the Deceased Patient

ADMINISTRATION

POLICY & PROCEDURE MANUAL

TABLE OF CONTENTS


ENVIRONMENT:

Key Control
Personal Protective Equipment
Property Pass
Renovation Authorization
Telephone Equipment
Work Orders


FISCAL:

Business Trips
Capital Equipment Requests
Check Cashing, Employees
Check Requests
Employee Payroll Deduction
Personal Business Expenses
Petty Cash
Travel Advances & Expenses
Travel Reimbursement
Tuition Reimbursement
Valuables of Deceased Patients
Volunteer Meals


SAFETY:
Bomb Threat
Communication System Failure
Electronic Equipment Evaluation
Employee Safety
Equipment Maintenance From Outside Sources
Evacuation & Fire Plan
Medical Gas Systems
Hazardous Materials/Waste Management
Hospital Lockers
Mercury
Personal Electric Equipment
Risk Management/Safety
Safety Committee Authorization
Signage
Smoking Policy

ANESTHESIA DEPARTMENT
POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS


Annual Review
Blood & Component Transfusion
Clinical Privileges
Continuing Education Requirements
Anesthesia Department Organization
Equipment Maintenance
I.V. Fluids & Medication
Medication Orders
Anesthesia Record Monitor
Nitronex Guidelines
Withholding Anesthesia Services
Perioperative Patient Safety
Post Anesthesia Care
Position Responsibilities
Privilege Roster
Patient Care Review
Quality Assurance
Safety Program
Scope of Services
Smoking Restrictions
Staffing Policy
Standards of Care

BIOMEDICAL DEPARTMENT
POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS

Mission Statement
Patient Rights
Official Hospital Abbreviations
Procedure for Testing Biomedical Equipment
Biomedical Maintenance Requisition System
Biomedicalawechnician Rounds Procedure
Designation of Electrical Susceptible Patient Locations (ESPL)  
Dress and Grooming Codes
New Biomedical Equipment Purchase Evaluations
Use of Extension Cords and Adapters
Your Duty When You Hear The Fire Alarm
Your Duty if You Discover a Fire
Handwashing Policy
Handwashing Procedure
Hospital Organization
Incoming Biomedical Equipment Inspection
JOB DESCRIPTIONS:
	POSITION TITLE:   Biomedical Equipment Technician
	POSITION TITLE:   Junior Biomedical Equipment Technician
	POSITION TITLE:   Senior Biomedical Equipment Technician
	POSITION TITLE:   Supervisor, Biomedical Engineering
Material Safety Data Sheets 
Biomedical Engineering Work Hours and On-Call System
Control of Sending Biomedical Equipment
     For Outside Repair and/or Calibration
Biomedical Equipment Spare Parts Purchasing Procedure
Biomedical Trouble Call Procedure
Procedure for Testing Non-Hospital-Owned Biomedical Equipment
Unusual Occurrence
Visitor Incident Report
Break Periods

HOSPITAL CUSTOMER RELATIONS MANUAL

TABLE OF CONTENTS


WHO IS A CUSTOMER?
MOST COMPLAINTS FALL INTO ONE OF THREE MAIN CATEGORIES
HOW WELL DO YOU RATE AS A CUSTOMER KEEPER?
THE OVERENTHUSIASTIC COMMUNICATOR
THE INSECURE COMMUNICATOR
THE UNPERSUASIVE COMMUNICATOR
THE PASSIVE COMMUNICATOR
THE FRANTIC COMMUNICATOR
AUTOMATIC ADJUSTMENT OF LOW DOLLAR COMPLAINTS
THREE WAYS TO MONITOR YOUR OWN COMPLAINT HANDLING PERFORMANCE
SAMPLE CUSTOMER FEEDBACK QUESTIONNAIRE
FOLLOW THESE 10 TIPS FOR EFFECTIVE TELEPHONE PROCEDURE
"ACTION" WORDS AND STATEMENTS FOR SUCCESSFUL CUSTOMER RELATIONS
ARE YOU REALLY LISTENING?
BASIC RULES FOR FILLING OUT COMPLAINT FORMS
BASIC RULES OF GOOD LETTER WRITING
YOU, YOU, YOU AND YOU !!!
BEFORE YOU COMMIT TO TAKE ANY REMEDIAL ACTION, ANSWER THESE QUESTIONS TO YOUR
	SATISFACTION
BASIC RULES FOR PREVENTING AND AVOIDING FUTURE COMPLAINTS
HOW WILL YOU SPEND THE NEXT 667 HOURS?


DISASTER MANUAL

TABLE OF CONTENTS

GENERAL POLICIES:

	Bomb Threat
	Community Disaster Preparedness Plan
	Disaster Plan
	Evacuation Plan
	Fire Plan
	Internal Disaster Plan
	Radiation Accident
	Radiation Internal Accident
	Sever Wind, Hurricane, Tornado Plan

DEPARTMENTAL PLANS:

	Administration	
	Ambulance Service
	Cardiology
	Critical Care
	Emergency Department
	Enviromental Services
	Fincancial Services
	Food & Nurtrion Services
	General Accounting
	Human Resources
	Laboratory
	Maintenance
	Materials Management
	Mechanical Information Systems
	Medical Records
	Nursing Service
	Patient Accounting
	Personnel
	Pharmacy
	Planning/Public Relations
	Radiology
	Rehabilitation Services
	Respiratory Care
	Safety
	Security
	Social Services
	Speech & Hearing
	Surgical Services
	Volunteer Services

RADIATION EMERGENCIES:

	Emergency Department
	Environmental Services
	Radiology/Nuclear Medicine Department

ENGINEERING DEPARTMENT

TABLE OF CONTENTS

SECTION I.   INTRODUCTION
	Maintenance Department Description                           
	Organizational Chart                                          
	Job Description Policy                                        
	Job Descriptions                                              

SECTION II.   SAFETY MANAGEMENT
	Life Safety System
	Fire Protection                                              
	Safety Policies and Procedures                               
	Smoking, Patient Safety, Visitor Safety, Employee Safety     
	Extension Cords, Flammable Materials, Compressed Gas 
	Hazardous Materials
	Testing/Inspection/Monitoring
	Incident Reporting, General Caution                          
	Department Policies                                          
	On-call, Maintenance Contracts                               		
	In-service Education                                         
	Infection Control, ETO                                       
	Work Orders, Quality Assurance                               
	Project Management                                           
	Dress Policy, Breaks                                         
	Helicopter Landings                                          

SECTION III.   UTILITIES MANAGEMENT
	General Procedures                                           
	Plumbing System                                        		
	Electrical Distribution System                               
	HVAC Systems                                                 
	Medical Gas Delivery Systems                                 
	Elevators                                                    			Communications Systems                                       
	Waste Disposal/Handling Systems                              
	
SECTION IV.    EQUIPMENT MANAGEMENT
	System Description                                           
	Equipment Inclusion Criteria                                 
	Equipment Record Keeping                                     
	
SECTION V.   EMERGENCY PREPAREDNESS
	External Disaster-Maintenance Role                           
	Internal Disaster-Maintenance Role                           

ENGINEERING DEPARTMENT

TABLE OF CONTENTS



APPENDICES:
	A. Plumbing Charts
	B. Electric Risers
	C. HVAC Charts
	D. Fire Alarm Zones
	E. Utilities Management Equipment List
	F. Equipment Management Master List
	G. General Safety and Other Inspection Checklists


ENVIRONMENTAL SERVICES DEPARTMENT

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS

POLICIES:

	Areas of Responsibility
	Customer Relations
	Dress & Grooming
	General Policies
	Incentive Program
	Introduction
	Keys
	Organization
	Parking
	Department Purpose
	Smoking Policy
	Housekeeper of the Year

PROCEDURES:
	Cleaning Ambulance Equipment
	Bait Stations
	Blackboard Cleaning
	Blood/Body Fluid Spill Clean-up
	Body Parts Incineration
	Carpet Care
	Housekeeping Closets
	Commode Cleaning
	Crack & Crevice Pesticide Treatment
	Damp Mopping
	Defrosting Refrigerators
	Disinfecting/Cleaning Ice Machines
	Disinfecting Refrigerators/Freezers
	Discharge/Transfer Cleaning
	Drager Gas/Vapor Detector
	Drager Gas/Vapor Detector Tubes
	Dry (Dust) Mopping
	Fertilizing
	Fire Extinguishers
	Pesticide Fogging
	Biohazardous Waste - Incinerator Operation
	Laundry Chute Cleaning/Disinfecting
	Linen Distribution
	Medication Room Cleaning Procedures
	Mercury Spill Procedure
	Nursing Station Cleaning Procedures
	Office Cleaning Procedure
	Trash Compactor Operation
	Cleaning Overhead Pipes
	Pediculosis and Scabies


ENVIRONMENTAL SERVICES DEPARTMENT

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS


PROCEDURES (CONT'D)

	Personal Protective Equipment
	Pest Control
	Pest Control - Kitchen/Cafeteria/Serving Line
	Product Studies & Usage
	Reject Linen
	Respirator Use and Care
	Scrubs
	Soiled Linen Pick-up
	Hazardous Waste Spill Kit/Cart
	Emergency Spill Response


JOB DESCRIPTION

	Director
	Shift Supervisor
	Housekeeping Supervisor - Training and Quality Control
	Secretary
	Groundsman
	Housekeeping Aide - Carpets
	Housekeeping Aide I  - Floor Maintenance
                          - General
                          - Linen
	                     - Trash & Linen
     Housekeeping Aide II - Floor Maintenance
                          - General
                          - Trash & Linen
                          - Supply Aide
                          - Lead Person


QUALITY

	Quality Assurance Plan
	Quality Assurance Thresholds
	Quality Control Program
	Quality Control Score Breakdown





ENVIRONMENTAL SERVICES DEPARTMENT

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS


SAFETY

	Chemicals
	Employee Safety
	Environment
	Equipment
	Fire Plan & Evacuation Policy
	Fire Plan
	Fire Prevention & Protection
	Housekeeping Role in Safety
	Infectious Hazards
	Employee Injuries
	Lifting and Body Mechanics
	Patient Valuables and Clothing
	Departmental Safety Statement


INFECTION CONTROL

	Isolation Anteroom
	Cleaning Bassinets
	Blood/Body Fluid Precautions
	Blood/Body Fluid Isolation
	Carpet Cleaning - Isolation Room
	Critical Care Cleaning Procedures
	Central Supply Cleaning Procedures
	Isolation Room Daily Cleaning
	Donning Isolation Gowns
	Drainage/Secretion Precautions
	Emergency Department Cleaning Procedures
	Enteric Isolation
	Handwashing
	Infection Control
	Isolation
	Isolation & Precautions - Definition
	Cleaning Isolettes
	Labor & Delivery Cleaning Procedures
	Infection Control - Linen
	Nursery Cleaning Procedures
	Precaution Category - Oral
	OR (After C-Section) Cleaning Procedures
	Pharmacy Cleaning Procedures
	Precaution Categories
	Removing Contaminated Gowns
	Respiratory Isolation
	Reverse Isolation

ENVIRONMENTAL SERVICES DEPARTMENT

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS



INFECTION CONTROL (CONT'D)

	Soiled Linen Pick-up
	Statement of Blood/Body Fluid Precautions in the
 			Healthcare Setting
	Precaution Category - Stool
	Strict Isolation
	Isolation Cleaning Supplies
	Isolation Supply Cart
	Isolation Room Terminal Cleaning
	Universal Blood/Body Fluid Precautions
	Skin & Wound Isolation



MISCELLANEOUS

	Inspection Criteria
	Low Census Staffing
	My Own Inspection of My Work
	Room Check List Priorities
	Staffing
	Housekeeper of the Quarter Award




HAZARDOUS MATERIALS

MANAGEMENT PLAN

Table of Contents



ANTINEOPLASTIC WASTE MANAGEMENT PLAN

BIO-HAZARDOUS WASTE MANAGEMENT PLAN

HAZARDOUS CHEMICAL WASTE MANAGEMENT PLAN

WASTE GASES MANAGEMENT PLAN

HAZARD COMMUNICATION PROGRAM

GENERAL INFORMATION

USED OIL\PETROLEUM PRODUCTS MANAGEMENT PLAN

RADIOACTIVE WASTE MANAGEMENT PLAN


HOME INTRAVENOUS THERAPY MANUAL


TABLE OF CONTENTS




A.SITE CARE AND MAINTENANCE OF CENTRAL LINE CATHETERS

1.PROCEDURE: DRESSING CHANGE OF THE BROVIAC/HICKMAN CENTRAL VENOUS
             CATHETER

2.PROCEDURE: HEPARINIZATION AND CAP CHANGE OF THE CAPPED CENTRAL VENOUS
             LINE

3.PROCEDURE: CARE AND MAINTENANCE OF SUBCLAVIAN CATHETER CENTRAL VENOUS
             LINE

4.PROCEDURE: CARE AND MAINTENANCE OF THE SILICONE ELASTOMER CENTRAL
             VENOUS CATHETER FOR LONG-TERM

5.HEPARINIZATION OF SILICONE ELASTOMER CENTRAL VENOUS CATHETER

6.CAP CHANGE OF SILICONE ELASTOMER CENTRAL VENOUS CATHETER

7.WITHDRAWAL OF BLOOD SAMPLES FROM SILICONE ELASTOMER CENTRAL VENOUS
             CATHETER

8.COMPLICATIONS RELATED TO SILICONE ELASTOMER CENTRAL VENOUS CATHETER

9.PROCEDURE: ADMINISTRATION OF IN MEDICATION THROUGH A PORT-A-CATH
             SUBCUTANEOUS INJECTION PORT

10.CARE AND MAINTENANCE OF THE GROSHONG CENTRAL VENOUS CATHETER

11.PROCEDURE: CARE AND MAINTENANCE OF THE QUINTON DUAL-LUMEN SUBCLAVIAN
             CATHETER

HOME INTRAVENOUS THERAPY MANUAL


TABLE OF CONTENTS (CONTINUED)



B.IV PUMPS FOR HOME-CARE USE

	1.PROCEDURE: ADMINISTRATION OF MEDICATION VIA AN AUTO-SYRINGE--AS-2F

	2.PROCEDURE: INITIATION OF IV THERAPY VIA AN IVAC 560 PUMP

	3.PROCEDURE: USE OF TRAVENOL INFUSOR

	4.PROCEDURE: INITIATION OF TPN THERAPY THROUGH A CENTRAL VENOUS LINE                        VIA A SIMPLICITY PLUS INFUSION PUMP


C.STANDARDIZED PROCEDURE FOR VENIPUNCTURE

	1.VENIPUNCTURE PROTOCOL

	2.VENIPUNCTURE POLICY

	3.VENIPUNCTURE PROCEDURE


D.STANDARIZED PROCEDURE FOR INTRAVENOUS ADMINISTRATION OF MEDICATIONS AND
          SOLUTIONS

	1.IV ADMINISTRATION OF MEDICATIONS PROTOCOL

	2.PROCEDURE: ADMINISTRATION OF MEDICATIONS BY IV PUSH THROUGH A
                     BUTTERFLY NEEDLE

	3.MEDICATIONS APPROVED FOR IV ADMINISTRATION
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TABLE OF CONTENTS (CONTINUED)


	4.PROCEDURE: INFUSION OF SECOND MEDICATION THROUGH IV CANNULA

	5.IV ADMINISTRATION OF CHEMOTHERAPY POLICY

	6.PROCEDURE: REMOVING CANNULA FROM PATIENT'S VEIN

	7.ANAPHYLAXIS PROTOCOL

	8.PROCEDURE: HEPARINIZATION OF IV CANNULA

	9.PROCEDURE: INFUSION OF A SECOND MEDICATION THROUGH BROVIAC/HICKMAN
                     CATHETER

	10.PROCEDURE: DRAWING BLOOD FROM BROVIAC/HICKMAN CATHETER

	11.PROCEDURE: IV INFUSION THROUGH BROVIAC/HICKMAN CATHETER

	12.INTRAVENOUS ADMINISTRATION OF MEDICATIONS AND SOLUTIONS POLICY

	13.PROBLEMS THAT MAY DEVELOP WITH IV CANNULA DURING IV THERAPY


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TABLE OF CONTENTS (CONTINUED)



	14.PROCEDURE: IV INFUSION THROUGH CANNULA

	15.PROCEDURE: HEPARINIZATION OF BROVIAC/HICKMAN CATHETER

	16.PROCEDURE: VENIPUNCTURE FOR IV CANNULA INSERTION


E.HOME TRANSFUSION THERAPY PROCEDURES

	1.HOME TRANSFUSION THERAPY PROTOCOL

	2.HOME TRANSFUSION THERAPY PROCEDURE

	3.PROCEDURE: INTRAVENOUS ADMINISTRATION OF HUMAN SERUM ALBUMIN

	4.PROCEDURE: TRANSFUSION OF PLATELETS/PLATELETPHERSIS

	5.PROCEDURE: ORDERING BLOOD PRODUCTS

	6.PROCEDURE: TRANSFUSION OF FACTOR VIII CONCENTRATE

	7.TRANSFUSION OF PACKED RED BLOOD CELLS AND SALINE WASHED RED BLOOD
                    CELLS

	8.NON-ACUTE SYSTEMIC ALLERGIC REACTION

	9.ACUTE SYSTEMIC ALLERGIC REACTION
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TABLE OF CONTENTS (CONTINUED)


	10.ACUTE HEMOLYTIC TRANSFUSION REACTION (LIFE-THREATENING)

	11.ANAPHYLAXIS PROTOCOL

	12.PROCEDURE: DISPOSAL OF HOME TRANSFUSION THERAPY HAZARDOUS WASTE


F.PROCEDURES FOR THE INTRAVENOUS ADMINISTRATION OF CHEMOTHERAPY

	1.IV ADMINISTRATION OF CHEMOTHERAPY PROTOCOL

	2.IV ADMINISTRATION OF CHEMOTHERAPY POLICY

	3.PROCEDURE: IV ADMINISTRATION OF CHEMOTHERAPEUTIC DRUGS THROUGH A
                BUTTERFLY NEEDLE

	4.IV CHEMOTHERAPY RECOMMENDED SAFETY GUIDELINES

	5.PROCEDURE: DISPOSAL OF WASTE MATERIAL

	6.ANTINEOPLASTIC MEDICATIONS APPROVED FOR IV ADMINISTRATION

	7.PROCEDURE: ADMINISTRATION OF CHEMOTHERAPY DRUGS THROUGH A SIDE-ARM                   OF A RUNNING IV

	8.PROCEDURE: CONTINUOUS IV INFUSION OF CHEMOTHERAPEUTIC DRUGS THROUGH                  A CENTRAL VENOUS LINE

	9.EXTRAVASATION PROTOCOL
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TABLE OF CONTENTS (CONTINUED)


G. CONTINUOUS SUBCUTANEOUS ADMINISTRATION OF OPIATES AND NARCAN

	1.ADMINISTRATION OF OPIATES

	2.PROCEDURE: ADMINSTRATION OF OPIATE VIA IV PUSH

	3.PROCEDURE: ADMINISTRATION OF OPIATE VIA CONTINUOUS IV DRIP

	4.PROCEDURE: ADMINISTRATION OF CONTINUOUS SUBCUTANEOUS OPIATE INFUSION
	5.PROCEDURE: ADMINISTRATION OF SUBCUTANEOUS NARCAN

	6.PROCEDURE: ADMINISTRATION OF IV NARCAN


H.HOME TOTAL PARENTERAL NUTRITION

	1.HOME TOTAL PARENTERAL NUTRITION PROGRAM: CRITERIA FOR ADMISSION

	2.PROCEDURE: ADDING MULTIVITAMINS TO TPN SOLUTION

	3.PROCEDURE: BEGINNING TPN WITH IMED 922, 927, OR 928

	4.PROCEDURE: DISCONTINUING TPN

	5.PROCEDURE: INFUSION OF INTRALIPIDS THROUGH A CENTRAL VENOUS LINE

	6.PROCEDURE: DISCONTINUING INTRALIPIDS INFUSION (PIGGYBACK METHOD)


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TABLE OF CONTENTS (CONTINUED)



	7.PROCEDURE: INFUSION OF INTRALIPIDS THROUGH INFUSION PUMP FOLLOWING                        TPN INFUSION

	8.PROCEDURE: DISCONTINUING INTRALIPIDS INFUSION (PUMP METHOD)

	9.PROCEDURE: SELF-MIXING OF TPN SOLUTION


I.PATIENT EDUCATION

	1.PATIENT GUIDE: SELF-MIXING OF TPN SOLUTION


INSTITUTIONAL REVIEW BOARD




TABLE OF CONTENTS


INTRODUCTION...................................................3

PURPOSE........................................................5

DEFINITIONS....................................................5

STATEMENT OF COMPLIANCE........................................8

IMPLEMENTING GUIDELINES:

   A.  CODES AND STATEMENTS OF PRINCIPLES.....................10

   B.  INSTITUTIONAL REVIEW BOARD MEMBERSHIP..................11

   C.  THE GENERAL FUNCTIONS AND OPERATION OF THE IRB.........12

   D.  REQUIREMENTS FOR IRB REVIEW AND RESEARCH APPROVAL......14

   E.  CATEGORIES OF RESEARCH EXEMPTED FROM IRB REVIEW........16

   F.  REGULATIONS FOR EXPEDITED REVIEW.......................17

   G.  EXPEDITED APPROVAL PROCESS.............................19

   H.  PRINCIPAL INVESTIGATOR REQUIREMENTS....................22

   I.  RIGHT OF DISAPPROVAL BY THE EXECUTIVE COMMITTEE........23

   J.  RIGHT OF APPEAL OF SUBJECTS............................23

   K.  MAINTENANCE OF AN ACTIVE AND EFFECTIVE BOARD AND
       IMPLEMENTATION OF THE BOARD'S RECOMMENDATIONS..........24

   L.  RECORD KEEPING RESPONSIBILITIES OF THE IRB.............24

   M.  PROMULGATING POLICY AND CONTINUING INDOCTRINATION
       OF PERSONNEL...........................................25

REGULATORY GUIDELINES FOR THE CLINICAL USE OF
INVESTIGATIONAL DRUGS.........................................26

PHARMACY & THERAPEUTICS COMMITTEE POLICIES & 
PROCEDURES FOR THE USE OF INVESTIGATIONAL DRUGS...............33
INVASIVE CARDIOLOGY

POLICY & PROCEDURE MANUAL

TABLE OF CONTENTS

POLICIES:

24 Hour Follow-up
Abnormal Test Results
Cardiac Catheter Criteria
Confidentiality of Medical Records
Appointment Scheduling
Staff Call-In Policy
Cardiac Catheter Philosophy
Charge Form
Closing the Lab
Physically Impaired Patients
Counting Narcotics
Notifying Patients
Position Control
Cardiac Catheter Procedures
Cardiac Catheter Protocol
Pre-Catheter/PTCA Protocol
Radiation Safety Policy
Personnel-Radiation Safety
IV Sedation Standard
Narcotic Key Storage


PROCEDURES:

IV Therapy Abbocath
IV Therapy Butterfly
	Blood Transfusion
Calibration of Physiologic Pressure Amplifiers
Cardiac Arrest
Defibrillation
Cine Film Processing - Q.C.
Heparin Lock to IV Conversion
Crash Cart Check List
Opening & Closing Darkroom
Discharging & Transporting Patients
Draping Patients
ECG Electrode Placement
EPS Checklist
EPS Pacing Cable Connection
EPS Recording
Ergonovine Maleate Administration
Exercise During Cardiac Catheterization
Female Urinary Catheterization
Mailing Catheterization Films to Other Facilities
Open Gloving
Donning a Sterile Gown
INVASIVE CARDIOLOGY
TABLE OF CONTENTS
PAGE 2


PROCEDURES: (CONT'D)

Heparin Flush Preparation
IAP Preparation & Insertion
IAPB Set-up
Loading Cine Film Magazine
Loading Injector
Midchest Measurement
NTG Preparation
Opening Lab
Cardiac Catheter Room Preparation
Observation Room Preparation
Catheterization Record
R2 Pad Placement
Recording
Room Cleaning & Restocking
Scrubbing Patients
Surgical Scrubbing
Setting ECG Amplifier for EPS
Thermodilution Cardiac Output Determination
Transfer Patient To/From Table
Sterile Tray Set-up
X-ray Processor Q.C. Program


JOB DESCRIPTIONS:

Clerk Typist
Medical Secretary
Cardiovascular Specialist I
Cardiovascular Specialist II
Cardiovascular Technologist


MISCELLANEOUS:
Approved Abbreviations
Patient Care Model-Local Infiltration
Connection of Electrical Equipment
A I C D
Hazards of Electrical Equipment
Fire Alarm - Your Duty
Fire - You Discover
General Safety Program
Handwashing
MSDS Policy
New Electrical Equipment
Red-Tagging Electrical Equipment
Unusual Occurrence
Visitor Incident Report
LABORATORY DEPARTMENT
POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS

POLICIES:

		Fire Plan
		Infection Control
		Centrifuge Tachometer Verification
		Safety Equipment Testing
		Staff Meetings
		Critical Values
		Turn-around-times
		Pipette Calibrations
		Preventive Maintenance
		Delivery of Results
		Communication
		Specimen Requirements
		Stopwatch/Timer Verification
		Safety
		Thermometer Verification
		Workload Reporting
		Code Blue
		Blood Bank Alarm Verification
		Charge Verification
		SKBL Requisition
		Histopathology Referral

SEROCOAGULATION:

		Infectious Mononucleosis Tests
		Stopwatch Test
		Coagulation Quality Assurance

HEMATOLOGY:

		Platelet Count
		Reticulocyte Count
		S550 Routine Operation
		Hematology Quality Assurance

MICROBIOLOGY:

		Stool Exam for Parasites
		Pediatric Blood Culture Collection
		Modified Acid Fast Stain
		Ocular Micrometer
		Formalin Concentration
		Parasitology Reports
		Pin Worm Examination
		Standard Blood Culture Collection
		Direct Plating Blood Culture
		Direct Examination
LABORATORY DEPARTMENT
POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS (CONT'D)

MICROBIOLOGY: (CONT'D)

		Trichrome Stain
		Microbiology Quality Assurance
		Buffy Coat Smear

CHEMISTRY:

		Alanine Amino Transferase
		Amylase
		Aspartate Amine Transferase
		Urea Nitrogen
		Calcium
		Chemistry Quality Assurance
		Cholesterol
		Creatine Kinase Isoenzyme
		Creatine Kinase
		Creatinine
		Glucose
		Lactate Dehydrogenase Isoenzyme 1
		Lactate Dehydrogenase
		Linearity Evaluation
		Magnesium
		Critical Values
		Phosphorus
		Reference Ranges
		Reagent Preparation
		Total Bilirubin
		Total Protein
		Triglycerides
		Uric Acid
		Alkaline Phosphatase
		Albumin

BLOOD BANK:

		ABO Grouping
		Alloantibodies
		Blood Bank Refrigerator Alarm
		Blood Bank Refrigerator Quality Assurance
		Quality Assurance
		Orders
		Cell Suspension
		Blood Chart
		Cord Blood Testing
		Direct Antiglobulin Testing
		Serologic Centrifuge
		Blood Unit Inspection
		Blood Component Return
LABORATORY DEPARTMENT
POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS (CONT'D)

BLOOD BANK: (CONT'D)

		Specimen Collection
		Specimen Transport
		Temperature Check
		Transfusion Reaction
		Compatibility Testing

JOB DESCRIPTIONS:

		Laboratory Manager
		Chief Medical Technologist
		Shift Supervisor
		Bench Chief
		Medical Technologist
		Phlebotomist
		Histotechnologist / Cytotechnologist
		Phlebotomist Check List
		Laboratory Orientation Check List

FORMS:

		Chemistry Reagent Cost Comparison
		Patient Result Release Form
		Corrective Action Report
		Microbiology Daily Quality Control
		Blood Bank Alarm Check
		Receptor Assay Requisition
		Centrifuge Tachometer Verification
		HIV Specimen Disposition Log
		Linearity Limits
		Workload Summary
		Microbiology Quality Assurance
		Microbiology Infection Control Worksheet
		Parallel Study
		Histopathology Referral Log
		Histopathology Transport Log
		Misbilled Patient Transaction
		Profiles
		Quality Assurance Monitor
		Quality Assurance Review
		Lab Requisition
		Safety Equipment Testing
		Standing Order Form
		Infection Control Corrective Action Form
		Additional Charge - Laboratory

MATERIAL MANAGEMENT DEPARTMENT

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS



GENERAL:

	APPROVED ABBREVIATIONS
	SERVICE ON ALL BIOMEDICAL EQUIPMENT
	EMPTY CARDBOARD BOXES
	STOREROOM DISASTER CHECKLIST
	CONFIDENTIALITY
	ELECTRICAL CONNECTION OF EQUIPMENT
	IN-HOUSE DELIVERIES
	HAZARDS FROM ELECTRICAL EQUIPMENT
	EQUIPMENT
	YOUR DUTY WHEN YOU HEAR A FIRE ALARM
	YOUR DUTY WHEN YOU DISCOVER A FIRE
	FORKLIFT OPERATION
	GIFTS AND GRATUITIES
	HOSPITAL ORGANIZATION	
	HOURS OF OPERATION
	INVENTORY CONTROL
	PRODUCT INFORMATION REQUESTS
	ACQUISITION OF LOANER/EVALUATION EQUIPMENT
	MISSION STATEMENT
	MSDS
	ARRIVAL OF NEW ELECTRICAL EQUIPMENT
	DEPARTMENT ORIENTATION
	PERSONAL VISITORS
	MEDICAL DEVICE HAZARD AND PRODUCT RECALL
	POLICY AND PROCEDURE MANUAL PURPOSE
	QUALITY ASSURANCE PLAN
	PRODUCT WARNINGS, DEFECTS AND RECALL NOTIFICATION
	RED TAGGING MALFUNCTIONING EQUIPMENT
	SAFETY
	CUSTOMER SATISFACTION
	SMOKING POLICY
	STANDING ORDERS
	UNUSUAL OCCURRENCES
	PRODUCT AND EQUIPMENT EVALUATION AND STANDARDIZATION
	VENDOR GENERAL POLICIES
	VISITOR INCIDENT REPORT
	BREAK PERIODS
	ITEMS FOR NEGOTIATION
	VENDOR BIDDING
	IDENTIFICATION OF SALES REPRESENTATIVES
	PURCHASING CONTROL
	CODE OF ETHICS
MATERIAL MANAGEMENT DEPARTMENT

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS

(CONT'D)


PURCHASING:

	CONTRACT FORMATION
	DEPARTMENT APPROVAL FOR REQUISITIONING SUPPLIES
	CAPITAL PURCHASES
	PURCHASING CATALOGS AND PRICE LISTS
	CAPITAL EQUIPMENT COMPETITIVE PURCHASING
	PURCHASE ORDER DISCREPANCIES
	EMERGENCY ITEM PURCHASES
	PURCHASE ORDER EXPEDITING
	PURCHASES WITH PETTY CASH
	PURCHASE ORDER PROCESSING
	PURCHASE REQUISITION REVIEW
	PURCHASE REQUISITIONS
	PURCHASING CONTROL
	PURCHASING OF NONSTOCK ITEMS
	PRICING QUOTES AND NEGOTIATION
	VENDOR BIDDING
	INITIAL SERVICE CONTRACT
	SERVICE CONTRACT RENEWAL
	REQUEST FOR PURCHASING SERVICES
	IDENTIFICATION OF SALES REPRESENTATIVES

RECEIVING:

	RECEIPT OF CAPITAL EQUIPMENT
	COMMON CARRIER FREIGHT
	DAMAGED GOODS
	DISCREPANCIES IN PROCESSING FREIGHT
	EMERGENCY ORDERS
	HANDLING FREIGHT
	LOST PURCHASE ORDERS
	MISSING PACKING TICKETS
	RECEIVING OVERVIEW
	PROCESSING FREIGHT
	RECEIVING ALL ITEMS
	VENDOR RETURN NOTICES
	RECEIVING REFRIGERATED MATERIAL
	UNITED PARCEL DELIVERIES
	FILING SYSTEM
	PURGING RECEIVING FILES

MATERIAL MANAGEMENT DEPARTMENT

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS
	
(CONT'D)


SHIPPING:

	SHIPPING OVERVIEW
	RETURN OF REPAIRS AND REPLACEMENTS
	PROCESSING FREIGHT FOR SHIPPING
	


STOREROOM:

	INVENTORY CONTROL
	PURCHASE OF NON-STOCK ITEMS
	SPECIAL PICK-UPS AND DELIVERIES
	STOREROOM RETURNS AND CREDITS
	FILLING SUPPLY REQUISITIONS
	STOREROOM MAINTENANCE
	INVENTORY RETURNS FOR CREDIT
	JOB DESCRIPTION - STOREROOM SUPERVISOR
	STOREROOM OVERVIEW
	STOCK OUTS
	PURCHASE OF INVENTORY STOCK ITEMS
	PRODUCT SUBSTITUTIONS
	TRANSPORTING SUPPLIES
	BACK-ORDER NOTIFICATION


JOB DESCRIPTIONS:
	BUYER
	CUSTOMER SERVICE ASSOCIATE
	MATERIAL MANAGEMENT DIRECTOR
	SECRETARY
	INVENTORY CONTROL
	PURCHASING AGENT
	SURGICAL BUYER
	STOREROOM SUPERVISOR
	MATERIAL TECHNICIAN - DISTRIBUTION/COURIER
	MATERIAL TECHNICIAN - RECEIVING
	MATERIAL TECHNICIAN - DISTRIBUTION
	INVENTORY COORDINATOR
MEDICAL RECORDS DEPARTMENT

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS



APPROVED ABBREVIATIONS
ACCREDITING REQUIREMENTS
ADMINISTRATIVE PROCESS
DATA NEEDS, ANNUAL REVIEW
POLICY MANUAL APPROVAL PROCESS
IN CASE OF FIRE
COMPREHENSIVE AND CENTRALIZED SYSTEM
CENTRALIZED SYSTEM PURPOSE
CHART ORGANIZATION
CLASSIFICATION SYSTEM
CRITERIA FOR CHART COMPLETENESS
COMPLIANCE WITH REGULATIONS AND STANDARDS
STAGES OF REVIEW FOR COMPLETENESS
CONFIDENTIALITY, PRIVACY, AND DATA SECURITY
COMPREHENSIVE AND COORDINATED SYSTEM
ACCESS AND DISTRIBUTION OF DATA
SCOPE OF DATA COLLECTION
CENTRALIZED AND COMPREHENSIVE DATA SYSTEM
DISCHARGE PURPOSES
MEDICAL RECORD DEFINITION AND CREATION
HOURS OF OPERATION AND STAFFING
DICTATION AUTHORIZED USERS AND ACCESS
DICTATION PURPOSE
DICTATION SCOPE OF SERVICES
DISASTER PLAN
HOSPITAL DRESS CODE
EMPLOYEE RESPONSIBILITY
GUIDELINES FOR MEDICAL RECORD ENTRIES
ETHICAL CONSIDERATIONS
REPORTS TO EXTERNAL AGENCIES
FORMS COMMITTEE
GENERAL SAFETY PRECAUTIONS FOR ALL DEVICES
GUEST RELATIONS
INCOMPLETE RECORD ACCESS
INCOMPLETE RECORD EXCEPTIONS
RELEASE OF INFORMATION
INFORMATION RELEASE
LEGAL AND REGULATORY COMPLIANCE
MAINTENANCE REQUESTS
PERIODIC MANUAL UPDATE
ARRIVAL OF NEW ELECTRICAL EQUIPMENT
NOMENCLATURE
MONITORING AND NOTIFICATION SYSTEM
OWNERSHIP OF THE MEDICAL RECORD
PATIENT RIGHTS
INCOMPLETE RECORD TIME FRAME AND PENALTIES
MEDICAL RECORDS DEPARTMENT

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS (CONT'D)


PROPER AUTHORIZATION
RESPONSIBILITY FOR PATIENT/CLIENT IDENTIFICATION
MEDICAL RECORD PURPOSE
QUALITY CONTROLS
RECORD DESTRUCTION
RECORDS STORAGE AND SECURITY
ORGANIZATIONAL COORDINATION
CHART REVIEW RESPONSIBILITY
SCOPE OF SERVICES
SCREENING SERVICES
SPECIAL STATISTICAL REPORTS
STATISTICAL PROFILES
STATISTICAL COMPILATIONS AND REPORTS
COMPREHENSIVE AND CENTRALIZED STORAGE SYSTEM
STORAGE AND RETRIEVAL OF INCOMPLETE RECORDS
UNIT NUMBER
CONTROL REGISTER/UNIT NUMBER INVENTORY
UNUSUAL OCCURRENCE
VISITOR INCIDENT REPORT



MEDICAL STAFF BYLAWS 
TABLE OF CONTENTS

PREFACE 
PREAMBLE 
DEFINITIONS 

ARTTICLES
NAME 
PURPOSES 
MEDICAL STAFF MEMBERSHIP 
Nature of Medical Staff Membership                  
Qualifications for Membership                       
Condition and Duration of Appointment 
Leave of Absence                                    
Medical Directors 
CATEGORIES OF THE MEDICAL STAFF 
The Medical Staff                                   
The Emeritus Medical Staff  
The Active Medical Staff
The Provisional Medical Staff                       
The Consulting Medical Staff 
The Courtesy Medical Staff                           
PROCEDURE FOR APPOINTMENT AND REAPPOINTMENT 
Application for Appointment and/or Clinical Privileges
Appointment Process                                  
Reappointment Process  
CLINICAL PRIVILEGES 
Clinical Privileges                                  
Temporary Privileges  
Emergency Privileges                                 
Specified Professional Personnel  
CORRECTIVE ACTION 
Procedures                                    
Summary Suspension  
Automatic Suspension                                 
HEARING AND APPELLATE REVIEW PROCEDURES
Right to Hearing and to Appellate Review             
Request for Hearing  
Notice of Hearing                                    
Composition of Hearing Committee  
Conduct of Hearing                                   
Appeal to the Governing Body  
Final Decision by Governing Body                     
OFFICERS 
Officers of the Medical Staff                        
Qualifications of Officers  
Election of Officers                                 
Term of Office  
Vacancies in Office                                  
Duties of Officers  
Removal of an Officer                                
MEDICAL STAFF BYLAWS 
TABLE OF CONTENTS


CLINICAL DEPARTMENTS
Organization of Clinical Department 
Qualifications, Selection and Tenure of 
	Department Chiefs 
Functions of the Department Chiefs                   
Functions of Departments 
Assignment to Departments                            
Department of Family Practice  
COMMITTEES 
Executive Committee                                  
Credentials Committee  
Medical Records/Utilization                          
Pharmacy and Therapeutics Committee 
Infection Control Committee 
 Multi-Disciplinary Hospital Committee                
Surgical Case/Blood Utilization Review Committee 
Committees for Special Services and/or Functions     
Radiation Safety Committee  
Quality Assessment Committee                       
MEDICAL STAFF MEETINGS 
Regular Meetings                                     
Special Meetings  
Quorum                                               
Attendance Requirements 
Agenda                                               
COMMITTEE AND DEPARTMENT MEETINGS 
Regular Meetings                                     
Special Meetings  
Notice of Meetings                                   
Quorum  
Manner of Action                                     
Rawhts of Ex Officio Members
Minutes                                              
Attendance Requirements  
IMMUNITY FROM LIABILITY 
RULES AND REGULATIONS
AMENDMENTS 
ADOPTION 

MEDICAL STAFF BYLAWS 
TABLE OF CONTENTS
RULES AND REGULATIONS

ADMISSIONS AND DISCHARGE OF PATIENTS 
Patients Accepted                                          
Admission by Staff Members Only 
Provisional Diagnosis Required                            
Available Bed 
Justification for Emergency Admissions                     
Patients with no Attending Physician 
Physician Must Name Relief                                
Patient Transfers  
Protection of Patient and Others                          
Protection of Potential Suicide Patients and 
	Patients suffering from Intentional Chemical Overdose  
Potential Suicide Patients and Patients Suffering
	from Intentional Chemical Overdose Must be Seen by a
	Psychiatrist 
Admissions to Intensive Care and Cardiac Care Units       
Documented Need for Stay 
Practitioners Order for Discharge Required                
Discharge Hour 
Death Pronounced by Attending Practitioner                 
Autopsies 
Transfer of Patient to Another Staff Member                
MEDICAL RECORDS 
	Practitioner Responsible for Complete Record               
	History and Physicals 
	Progress Notes                                            
	Consultations 
	Special Treatment Procedures - Psychiatric Care           
	Entries Must be Dated 
	Symbols and Abbreviations                                 
	Final Diagnosis at Time of Discharge 
	Discharge Summary      aw                                 
	Written Consent for Release of Information 
	Records are Hospital Property                             
	Free Access of Records for Bona Fide Study 
	Filing the Record 
	Routine Orders                                             
	Incomplete Records
	Delinquent Records                                        
	Unacceptable Records 
GENERAL CONDUCT OF CARE 
	Consent Must be Obtained                                  
	Written Orders are Required 
	Orders Must be Clearly Written                            
	Cancellation of Orders 
	Standing Orders                                           
	Pharmacopoeia Drugs Only 
	Automatic Stop-Order on Drugs                              
	Daily Visits of Patients by Attending Practitioners 
	Consultation by Qualified Practitioner 
	Consultation Required                     
	Consultation Responsibility of Attending Practitioner     
	Questionable Need for Consultation  
MEDICAL STAFF BYLAWS 
TABLE OF CONTENTS


GENERAL RULES REGARDING SURGICAL CARE 
	Preoperative Diagnosis and Laboratory Tests                
	Dental Patients 
	Podiatric Patients                                        
	Written Consent Required 
	Operative Reports Requirements                             
	Anesthesia Record 
	Surgical Assistants                                       
	All Tissues to Pathology  
	Transfer of Patient to Surgeon                             
	Surgeon Must be on Time  
	Laboratory Examinations Required                          
LABORATORY 
	Required laboratory Examinations                           
	Reports from Other Laboratories 
	Short Stay Admission                            
	Out-Patient Surgery          
EMERGENCY SERVICES 
	Plan for Emergency Services                               
	Procedure Manual Required  
	Medical Records                                 
	Records Must be Signed            
	Quarterly Review of Emergency Records                     
	Responsibility for Patient Admissions 
GENERAL
	Plans for Mass Casualties 
	Blood Starting by Nurses                                  
	Arterial Blood Gases 
	Report of Disciplinary Action                                   NEUROLOGY 
 
                          POLICIES AND PROCEDURES  
 
                              TABLE OF CONTENTS 
 

       DEPARTMENTAL PROCEDURES 
 
                Department Capabilities and General Patient Instructions 
                Call Schedule and Daytime Coverage 
                Electroencephalographic Procedure 
                Portable Electroencephalographic Procedure 
 

       GENERAL POLICIES AND PROCEDURES 
 
                Cardio-Pulmonary Resuscitation Certification Policy 
                Emergency Box and Oxygen Supply Policy 
                Unattended Patient Policy 
                Medication Policies and Procedures 
                Sedation Policy and Procedure (Out-Patient) 
                Infection Control  
                Designation of Interpreting Physician 
                Physician Interpretation of Neurology Procedures 
                STAT Procedures 


       JOB DESCRIPTIONS 
 
                Medical Director
                Department Director                 
                Secretary                 
                Neurological Technologist                  

NON - INVASIVE CARDIOLOGY DEPARTMENT

TABLE OF CONTENTS



Job Descriptions:

  Department Director
  Cardiopulmonary Technician
  Electrodiagnostic Technician


Policies:

  Scheduling Exercise Stress Test
  Scheduling Holter Monitors
  Exercise Stress Test Record Distribution


Procedures:

  Electrocardiograms
  Use of Skin Pencils
  Exercise Stress Test
  Echocardiograms
  Holter Monitor
  Pacemaker Analysis



NURSING DEPARTMENT
TABLE OF CONTENTS

POLICIES:

STATEMENT OF NURSING PHILOSOPHY
STATEMENT OF NURSING RESPONSIBILITY
ORGANIZATION OF THE NURSING DEPARTMENT
GENERAL NURSING POLICIES
"ACCIDENT" VICTIMS ADMISSIONS
CLINICAL LADDERS
DRESS CODE
PROFESSIONAL LIBRARY SERVICES
MEDICATIONS
NURSING CARE PLAN
PATIENT EDUCATION
QUALITY ASSURANCE PLAN
SAFETY GUIDELINES
VISITATION POLICIES
BODY MECHANICS
CODE DEFINITIONS
CUT HAIR POLICY
DISASTER PLAN
IV THERAPY
PHYSICIAN ORDERS
MERCURY THERMOMETERS


JOB DESCRIPTIONS:
DIRECTOR OF NURSING
ASSISTANT DIRECTOR OF NURSING
DIRECTOR OF CRITICAL CARE
DIRECTOR OF MEDICAL/SURGICAL NURSING
DIRECTOR OF MATERNAL CHILD HEALTH SERVICES
HEAD NURSE
ASSISTANT HEAD NURSE
CLINICAL III
CLINICAL IV
STAFF NURSE
COORDINATOR OF MIDWIFERY SERVICES
COORDINATOR OF MATERNAL CHILD HEALTH
COORDINATOR OF GI LABORATORY
COORDINATOR OF SHORT STAY SURGERY
MANAGER OF STAFF DEVELOPMENT
NURSING ADMINSITRATIVE MANAGER
NURSING TECHNICIAN - CRITICAL CARE
                     OBSTETRICS
                     SHORT STAY SURGERY
                     NEWBORN NURSERY
                     GI LABORATORY
                     PEDIATRICS
NURSE ASSISTANT
UNIT SECRETARY
MONITOR TECHNICIAN
NURSING DEPARTMENT
TABLE OF CONTENTS
                          (cont'd)

PROCEDURES:
ABDOMINAL BINDERS
ACCU CHEK CALIBRATION
ACCU CHEK II
ACE BANDAGE
PATIENT ADMISSION
ANTI-EMBOLISM STOCKINGS
ADULT APNEA MONITOR
BUCKS TRACTION
CERVICAL TONG CARE
CIRCO-ELECTRIC BED
CARDIOPULMONARY ARREST
CARE OF CUFFED TRACHEOSTOMY
DRESSINGS - STERILE MOIST TO DRY
MAINTENANCE ENTERIC FEEDING SYSTEM
FOLEY CATHETER CARE
HEMOCCULT SLIDE
HEPARIN LOC
IM INJECTION
IN ROOM SHARPS CONTAINER
ISOLATION
NASO-GASTRIC TUBES
NASO-PHARYNGEAL SUCTIONING
ORAL HYGIENE
PULSE OXIMETRY
SKELETAL TRACTION PIN SITES
STRYKER WEDGE FRAME
SUBCUTANEOUS INJECTIONS
TELEMETRY MONITORING
TUBE FEEDINGT
UNIT DOSE MEDICATIONS
Z-TRACT INJECTIONS
MEDICATION REACTIONS
AIR MATTRESS
BLIND ENDOTRACHEAL SUCTIONING
BUTTERFLY IV THERAPY
CATHERATERIZATION
CIRCULATION CHECKS
ADVERSE DRUG REACTIONS
CLINITEST
COMPLAINTS
C V P
ENDOTRACHEAL SUCTIONING
ENTERIC FEEDING TUBE INSERTION
GLUCOSCAN MONITOR
HEPAPIN FLUSH
PARENTERAL HYPERALIMANTATION
NURSING DEPARTMENT
TABLE OF CONTENTS
(cont'd)

INCONTINENT CARE
INTRADERMAL INJECTIONS
IV PUSH INJECTIONS
MEDICAL LIBRARY
NURSING KARDEX
PELVIC TRACTION
PATIENT TRANSFERS
SIEZURE PRECAUTIONS
ORAL HYGIENE
SVO2 MONITOR
THROAT CULTURE
TYMPANIC THERMOMETERS
URINE CULTURES


CRITICAL CARE:

AUTOMATIC IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR
APICAL PULSE
ARTERIAL LINE MONITORING
ARTERIAL PRESSURE MONITORING - RIGHT, LEFT
ASSIGNMENTS
BLOOD & BLOOD COMPONENT ADMINISTRATION
BLOOD & BLOOD COMPONENT ADMINISTRATION LEUKOCYTE REMOVAL
     FILTER WITH Y-TYPE ADMINISTRATION SET
BLOOD TRANSFUSION
BLOOD TRANSFUSION REACTION
USE OF BLOOD PUMP
RETURN OF UNUSED BLOOD/BLOOD COMPONENT
SCHEDULED TIME POLICY
IV THERAPY:
     STANDARD
     ABBOCATH
     PUSH
     BUTTERFLY
HEPARIN FLUSH VIA HEPARIN LOCK
CHEMSTRIP bG
CARDIOVERSION
URINARY CATHETERIZATION
FOLEY CATHETER CARE & MAINTENANCE
FOLEY CATHETER URINE COLLECTION
UNDERWATER SEAL / PLEURA-EVAC
CARDIOPULMONARY ARREST


OPERATING ROOM


POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS


POLICIES:

	Patient Abuse and Neglect
	Access to the Surgical Suites
	Anesthesia
	O.R. Apparel
	Patient's Rights
	Care & Cleaning of the O.R.
	Care of the O.R. After a Septic Case
	Cleaning Equipment Record
	Cold Sterilization
	Contaminated Case in Surgery
	Disposal of Trash and Laundry
	Drains
	Draping
	Dress Code
	Dressing the Surgeon by the Surgical Assistant
	Equipment Taken Into the O.R.
	Expiration Dates & Shelf Life
	Flash Autoclaving
	General O.R. Policies
	Gloves
	Gowning & Gloving Techniques
	Hemostasis
	Hours of Operation
	General Instrument Policies
	Instrument Sterilization
	Caring for O.R. Metal Supplies
	Misc. Supplies
	Normal Saline	
	Patients Entering O.R.
	Positioning Patients
	Routine Pre-Op Preparation
	Preparation of Sterile Supplies
	Preparing the O.R. For Surgery
	Cleaning the O.R. After a Contaminated Case
	Cleaning the O.R. After a Routine Case
	O.R. Purpose
	Record Maintenance
	Cleaning the Recovery Room
	O.R. Records
	Surgical Schedules
	Scrubbing Hands and Arms
	Scrub Nurse Duties
	Patient Skin Preparation
	Care of Specimens
OPERATING ROOM
POLICIES: (Cont'd)

	Sterilization & Disinfection
	Basic Instrument Set-up
	Transporting Patients to the O.R.
	O.R. Administration/Organization
	CardioPulmonary Resuscitation Requirements
	Draping Materials
	Counts: Instruments, Sharps & Sponges
	Staffing Plan
	Governing Rules For the O.R.
	Pre-Operative Nursing Assessment


PROCEDURES:
	Aneurysm Excision
	Abdomino-Perineal Resection
	Appendectomy
	Arthrodesis Knee, Ankle
	Arthroplasty Hip
	Assisting With Gastroscopy
	Basic Instruments
	Basic Major Instruments
	Basic Minor Instruments
	Basic Plastic Instruments
	Basic Supplies
	Breast Biopsy
	Bronchoscopy
	Burr Holes
	Caldwell Luc (Antrostomy)
	Capsulorraphy, Open Shoulder Reduction
	Cesarean Section
	Cheiloplasty, Palatoplasty
	Choledochostomy, Cholecystectomy
	Cicatrix
	Circumcision
	Colostomy
	Cornea Transplant
	Craniotomy & Cranioplasty
	Cyclodiathermy for Retinal Detachment
	Cystectomy & Prostatectomy
	Diaphragmatic Hernioplasty
	D & C
	Enucleation of the Eyeball
	Excision of Pterygium
	Operation of Extraocular Muscles
	Eye Operations
	Femoral & Popliteal Aneurysm Excision
	Open Femur Reduction	
	Gastrectomy, Enterectomy
	Hemorrhoidectomy, Anal Fistula Excision
	Open Hip Reduction
	Hydrocelectomy, Vasectomy, Orchiectomy
OPERATING ROOM
PROCEDURES (CONT'D):

	Inguinal Hernioplasty
	Crutchfield Tong Insertion
	Laminectomy
	Laryngectomy
	Carotid Artery Ligation
	Cataract Extraction
	Mammoplasty
	Mastoidectomy
	Nasal Polypectomy
	G. Moss Tube Nursing Care
	Open Reduction Radius, Ulna, Tibia, Humerus
	Open Reduction Hand and Foot Fractures
	Otoplasty
	Abdominal-Pan Hysterectomy
	Parotidectomy
	Partial Excision of Cervix
	Patellectomy & Arthrotomy of Knee
	Peripheral Nerve Operations
	Radical Mastectomy
	Removal Intramedullary Nail
	Removal Smith-Petersen, Jewett Nail
	Repair of Ptosis of Eyelid
	Rhinoplasty
	Simple Mastectomy
	Skin Graft - Full Thickness
	Skin Graft - Pedicle Stage I & II
	Skin Graft - Split Thickness
	Skin Graft - Pedicle Stage III
	Supracervical Hysterectomy, Oophorectomy, Ovarian
		Cystectomy, Salpingectomy, Removal of Ectopic
		Pregnancy
	Tendon Operations
	Thoracotomy, Pneumonectomy, Lobectomy
	Thyroidectomy
	Tonsillectomy
	Vaginal Hysterectomy, Colpoperineoplasty & Colpoplasty
	Ventral Hernioplasty


SAFETY:

	Disaster Plan
	Emergency Use of P.A.C.I.
O.R. Fire Prevention
	General Safety Precautions
	Toxic Substance Exposure

OPERATING ROOM


Q A PLAN:

	Approval
	Authority
	Communication
	Goals
	Objectives
	Organization
	Philosophy
	Purpose
	Responsibilities
	Scope
Summary of QA Program



LASER:

Care & Preventive Maintenance of Lasers
Laser Classification & General Safety Standards
Clinical Privileges for Laser Procedures
Department Specific Policies
Laser Documentation
General Policies
Medical Surveillance for Healthcare Workers
Laser Safety Officer


MISC:

	Career Ladders
Continuing Eduction Units
	Employee Safety Training
	Important Aspects of Care
Inservice Education
	Head Nurse Responsibilities
	Nursing Responsibilities
Nursing Standards
Secretary Responsibilities
	Surgical Supervisor Responsibilities
	Surgical Technician Responsibilities
Use of the Nursing Unit

PAIN CLINIC

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS


POLICIES:

	Approved Abbreviations
	Biomedical Engineering Service
	Connecting New Electrical Equipment
	Dress Code
	Electrical Hazards
	What to do When You Hear a Fire Alarm
	Your Duty When You Hear a Fire Alarm
	General Safety Policies
	Handwashing Policy
	Proper Handwashing Procedure
	Hospital Organization
	Mission Statement
	MSDS Policy
	New Equipment
	Patient Rights
	Red Tagging Defective Equipment
	Unusual Occurrence
	Visitor Incident Report
	Work Breaks

PROCEDURES:

	Cervical Epidural Steroid Block
	Thoracic Epidural Steroid Block
	Lumbar Epidural Steroid Block
	Stellate Ganglion Block

JOB DESCRIPTIONS:

	Physician Assistant
	Registered Nurse
	Secretary/Receptionist
PHARMACY DEPARTMENT PROCEDURE MANUAL

TABLE OF CONTENTS


TABLE OF CONTENTS


TITLE DESCRIPTION                               SECTION    NUMBER

A.  Table of Contents                              005       0200

B.  Department Overview

    l.  Purpose of Policy & Procedure Manual       010       0100

    2.  Patient Rights                             010       0150

    3.  Hospital Organization                      010       0200

    4.  Pharmacy Organization                      010       0300

    5.  Pharmacy Staffing                          010       0350

    6.  Break Periods                              010       0360

    7.  Dress & Grooming Codes                     010       0370

    8.  Job Description - Pharmacy Manager         010       0390

    9.  Job Description - Clinical Pharmacist      010       0395

   l0.  Job Description - Staff Pharmacist         010       0400

   11.  Job Description - Cardiac Rehab Pharmacist 010       0450

   12.  Job Description - Pharmacy Intern          010       0470 

   l3.  Job Description - Pharmacy Tech I          010       0500

   14.  Job Description - Pharmacy Tech II         010       0550

   15.  Job Description - Secretary                010       0600

   16.  Job Description - Volunteers               010       0690

   17.  Pharmacy Services                          010       0700

   18.  Pharmacy Policies                          010       0800

   19.  Licensing                                  010       0900

   20.  Hours of Service                           010       1000
PHARMACY DEPARTMENT PROCEDURE MANUAL


TABLE OF CONTENTS


TITLE DESCRIPTION                               SECTION    NUMBER


   21.  Pharmacy Key Control                       010       1100

   22.  Nursing Access to Pharmacy                 010       1200

C.  General Operations

    l.  Guidelines for Procurement of 
           Pharmaceuticals                         020       0100

    2.  Prime Vendor Program Synopsis              020       0200 

    3.  Maintenance of the Prime Vendor Program    020       0300

    4.  Loaning or Borrowing of Pharmacy Items     020       0400

    5.  Procurement of Medications for Ancillary
           Department                              020       0500

    6.  Unit Dose Drug Distribution System         020       0600

    7.  Medication Discrepancy Forms               020       0650
 
    8.  Checking the Unit Dose Cart                020       0700

    9.  Drugs Returned from Nursing Units          020       0800

   l0.  Messenger Service                          020       0900

   ll.  Valid Medication Orders                    020       1000

   12.  Physicians' Assistants                     020       1100

   13.  Automatic Stop Order Policy                020       1200

   14.  Cancellation of Medication Orders          020       1250

   15.  Transfer of Service                        020       1300

   16.  Patient Transfer/Discharge Procedure       020       1350

   l7.  Administration of Drugs Policy             020       1400

   l8.  Administration of Drugs Procedure          020       1500

PHARMACY DEPARTMENT PROCEDURE MANUAL


TABLE OF CONTENTS


TITLE DESCRIPTION                               SECTION    NUMBER

   l9.  Administration of Oral Medications         020       1550

   20.  Scheduled Time Policy					 020       1560

   21.  Medication Administration Personnel		 020       1570

   22.  Medication Administration Record 
            Procedure                              020       1600

   23.  Drug Information Service                   020       1630

   24.  Aminoglycoside Dosing Service              020       1660

   25.  Controlled Drug System                     020       1700

   26.  Controlled Drugs in Anesthesia Dept.       020       1800

   27.  Controlled Drugs in Ambulance Dept.        020       1840

   28.  Tax Free Alcohol Control                   020       1900

   29.  Patients Taking Their Own Medications      020       2000

   30.  Labeling of Medications                    020       2100

   31.  Discharge Medications                      020       2200

   32.  Outpatient Eye Surgery Medications         020       2300

   33.  Pass Medicine                              020       2400

   34.  Bulk Compounding                           020       2500

   35.  Floor Stock Procedure                      020       2600

   36.  In-House Unit Dose Packaging               020       2700

   37.  Medication Rooms Inspection                020       2800

   38.  Outdated Drug Control                      020       2900

   39.  Insulin Floor Stock Procedure              020       3000

   40.  Patient Consent for Estrogens              020       3050

   41.  Vendor Representatives Policy              020       3100
PHARMACY DEPARTMENT PROCEDURE MANUAL


TABLE OF CONTENTS


TITLE DESCRIPTION                               SECTION    NUMBER

   42.  Documed Policy                             020       3200

D.  Intravenous Admixtures

    l.  Personnel Responsibilities                 030       0100
  
    2.  Administration Sets                        030       0200

    3.  Intravenous Fluid Control                  030       0250

    4.  Pharmacy IV Additive Program               030       0300

    5.  Piggyback Preparation by Pharmacy          030       0400

    6.  Vertical Flow Hood                         030       0500

    7.  Mixing of Intravenous Solutions by 
          Nursing                                  030       0600

    8.  Hyperalimentation Policy                   030       0700

    9.  Hyperalimentation Procedure                030       0750

   l0.  TPN Level I Protocol                       030       0760

   ll.  TPN Level II Protocol                      030       0770 

   12.  Morphine Infusion                          030       0800

   13.  Dilantin Infusion                          030       0900

E.  Chemotoxic Drugs           

    l.  Drug Preparation

        a.  Personal Protocol                      040       0200

        b.  Preparation Equipment                  040       0300

        c.  Preparation Area                       040       0400

        d.  Work Practices                         040       0500



PHARMACY DEPARTMENT PROCEDURE MANUAL


TABLE OF CONTENTS


TITLE DESCRIPTION                               SECTION    NUMBER


    2.  Drug Administration

        a.  Personal Protective EQuipment          040       0600

        b.  Administration Equipment               040       0700

        c.  Work Practices                         040       0800

    3.  Caring for Patients 

        a.  Personal Protective Equipment          040       0900

        b.  Linen                                  040       1000

    4.  Waste Disposal

        a.  Equipment                              040       1100

        b.  Proper Handling                        040       1200

        c.  Disposal Methods                       040       1300

    5.  Spills

        a.  Policy                                 040       1400

        b.  Personnel Contamination                040       1500

        c.  Cleanup of Small Spills                040       1600

        d.  Cleanup of Large Spills                040       1700

        e.  Spills in Hood                         040       1800

        f.  Spill Kits                             040       1900

   6.  Medical Surveillance for CD Exposure        

       a.  Policy                                  040       2000

       b.  Pregnancy                               040       2100

       c.  Acute Exposure                          040       2200

PHARMACY DEPARTMENT PROCEDURE MANUAL


TABLE OF CONTENTS


TITLE DESCRIPTION                               SECTION    NUMBER



   7.  Storage and Transport

       a.  Storage Areas                           040       2300

       b.  Receiving Damaged Packages              040       2400

       c.  Transporting of Drugs                   040       2500

   8.  Training and Personnel                      040       2600

   9.  Evaluation of Staff Performance             040       2700

  l0.  Maintaining Proper Information              040       2800

  ll.  The Avoidance and Treatment of
           Extravasation                           040       2900

F.  Emergency Procedures

    l.  Poison Control Center                      050       0100

    2.  Antidote List                              050       0200

    3.  Emergency Medicine Carts                   050       0300

    4.  Code 4 Cart Procedure                      050       0400

    5.  Power Failure                              050       0500

G.  Employee Education                             

    l.  Pharmacy Orientation                       060       0100

    2.  Pharmacy Continuing Education              060       0100

    3.  Pharmacy Orientation Checklist             060       0200

    4.  Technician Orientation                     060       0240

    5.  Employee Educational Records               060       0250

    6.  Nursing Orientation and Inservice          060       0300

    7.  Nursing Orientation Checklist              060       0400
PHARMACY DEPARTMENT PROCEDURE MANUAL


TABLE OF CONTENTS


TITLE DESCRIPTION                               SECTION    NUMBER

    8.  Award for Excellence					 060       0500

H.  Infection Control

    l.  Pharmacy Policies                          070       0100

    2.  Pharmacy Procedures                        070       0200

    3.  Equipment and Supplies                     070       0300

    4.  Housekeeping Responsibilities              070       0400

    5.  IV Admixtures                              070       0500

    6.  Dating of Sterile Containers               070       0600

    7.  Handwashing Policy                         070       0700

    8.  Handwashing Procedures                     070       0800

I.  Pharmacy & Therapeutics Committee Function

    l.  Functions of the Committee                 080       0100

    2.  Formulary System                           080       0200

    3.  Non-Formulary Requests                     080       0300

    4.  Medication Error Reporting                 080       0400

    5.  Adverse Drug Reaction Reporting            080       0500

    6.  Adverse Drug Reaction Checklist            080       0600

    7.  Drugs Product Defects                      080       0700

    8.  Drug Recall Procedure                      080       0800

    9.  Investigational Drugs                      080       0900

   l0.  Institutional Review Board                 080       1000




PHARMACY DEPARTMENT PROCEDURE MANUAL


TABLE OF CONTENTS



TITLE DESCRIPTION                               SECTION    NUMBER

J.  Quality Assurance Program

    l.  Antibiotic Monitoring                      090       0100

    2.  Drug Utilization Review                    090       0100

    3.  Selections of Drugs                        090       0200

    4.  On-going Critical Indicators               090       0200

    5.  Department Wide QA Program                 090       0300

    6.  Assignment of QA Priorities                090       0400

K.  Reference Files

    l.  Metric System                              100       0100

    2.  Drug Formulary                             100       0100

    3. Physicians Signatures                       l00       0l00

    4. Approved Abbreviations                      l00       0200

L.  Index					   900       0100
PHYSICAL THERAPY DEPARTMENT

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS



POLICIES:


Administrative Policies
Biomedical Service
Charting Regulations
Connecting Electrical Equipment
Disaster Plan 
Electrical Equipment Hazards
Equipment Malfunctions
Fire:
     Your Duty
     What To Do When An Alarm Sounds
General Safety Precautions
Maintenance Requests
New Electrical Equipment
Patient Abuse and Neglect
Physical Therapy Record
Physical Therapy Modality Contraindications
Premature Patient Treatment Termination
Record Maintenance
Scheduling Treatments
Scheduling Policies
Treating The Patient
Transporting In-Patients
Unusual Occurrences
Visitor Incident Report


PROCEDURES:

Bakers
Cold Packs
Contrast Bath
Drip Sheet Bath
Electrodiagnosis
Electrostimulation (Unipolar & Bipolar)
Exercise
Faradic Current
Fractures
Galvanic Current
Head Compress
Hot Fomentation Compress
Hot Moist Dressings
Hot Sitz Bath
Hubbard Tank
PHYSICAL THERAPY DEPARTMENT

POLICY & PROCEDURE MANUAL

TABLE OF CONTENTS (CONT'D)


PROCEDURES: (CONT'D)

Infrared Radiation
Iontophoresis
Low Frequency Current
Massage
Melted Paraffin
Microwave Diathermy
Sheet Bath
Short-Wave Diathermy
Therapeutic Pools
Throat Compress
Transporting Isolation Patients
Trunk Compress
Ultrasound
Ultrasound - Under Water Technique
Whirlpool Bath



JOB DESCRIPTIONS:

Department Manager
Physical Therapy Supervisor
Physical Therapist
Physical Therapy Aide

RADIOLOGY POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS


POLICY

	DRESS & GROOMING POLICY
	ON-CALL POLICY
	RADIOLOGY DEPARTMENT OBJECTIVES
	SCHEDULING POLICY
	PERFORMANCE OF FLUOROSCOPY
	HOURS AND TYPE OF RADIOLOGY COVERAGE
	GENERAL DEPARTMENTAL POLICIES
		PERSONAL CONVERSATION
		TECHNICAL DIFFICULTIES
		ANSWERING TELEPHONE (ETIQUETTE)
		PATIENT IDENTIFICATION BRACELETS
		CONDUCT
		REQUESTS FOR SERVICES
		SCHEDULING OF SERVICES
		A.RADIOLOGIC PROCEDURES
			1.FLUOROSCOPY
			2.PORTABLE X-RAY
			3.ROUTINE PROCEDURES
		B.SPECIAL PROCEDURES
		C.ULTRASOUND PROCEDURES
		D.NUCLEAR MEDICINE
		E.COMPUTED TOMOGRAPHY
		TRANSPORTATION OF PATIENTS
		HANDLING OF CRITICAL PATIENTS
		A.CONDITION ESTABLISHED AS CRITICAL BY NURSING
			PERSONNEL OR PHYSICIAN
		B.EMERGENCY SITUATION OR DRUG REACTION
		ADMINISTRATION OF IV CONTRAST MEDIA AND RADIOISOTOPES
		A.INTRAVENOUS INJECTION OF CONTRAST MEDIA:
		B.INTRAVENOUS INJECTION OF PRE-CALIBRATED
			RADIOISOTOPES:
		MEDICAL RECORD REQUIREMENTS:
		STUDENT TECHNOLOGISTS IN THE DEPARTMENT
		INSERVICE AND CONTINUING EDUCATION:
		MEETINGS:
		ELECTRICAL SAFETY TEST
		PREVENTIVE MAINTENANCE
		HISTORICAL DATA
		MONTHLY ACTIVITY REPORT
RADIOLOGY POLICY AND PROCEDURE MANUAL

	INSPECTION INTERVALS
		1.LIFE-SAVING DEVICES
		2.LIFE-SUPPORT DEVICES
		3.SUBSTANTIVE ANCILLARY DEVICES
		4.ANCILLARY DEVICES
		INSPECTION LEVELS
			LEVEL ONE (I) - ANNUAL
			LEVEL TWO (II) - SEMIANNUAL
			LEVEL THREE (III) - QUARTERLY
			LEVEL FOUR (IV) - FUNCTIONAL VERIFICATION
		PATIENT CARE EQUIPMENT--CAT SCAN
		PATIENT CARE EQUIPMENT--ULTRASOUND
		POLICY FOR RADIATION SAFETY PROGRAM
		RADIOGRAPHIC EQUIPMENT CHECK
		DOSE MONITORING OF PATIENT PROCEDURES
		INFECTION CONTROL
		RADIOLOGY SAFETY POLICIES AND PROCEDURES
		GONADAL SHIELDING
		RADIATION DURING PREGNANCY--PATIENTS
		RADIATION DURING PREGNANCY--EMPLOYEES
		POLICY FOR RADIUM IMPLANTS
		RADIUM IMPLANTS - PRECAUTIONS
		NURSING INSTRUCTIONS FOR PATIENTS TREATED WITH SEALED
				RADIOACTIVE SOURCES


PROCEDURES

	COMPUTED TOMOGRAPHY PROCEDURES
	RADIOLOGY PROCEDURES - I
		STATEMENT OF REVIEW FOR DIAGNOSTIC IMAGES
			RADIOLOGY/COMPUTED TOMOGRAPHY
		ABDOMEN - 1 VIEW: 
		ABDOMEN - 2 VIEWS:
		ABDOMEN - 3 VIEWS:
		A/C JOINTS:
		ANKLE:
		BARIUM ENEMA:
		BARIUM ENEMA WITH AIR:
		BARIUM SWALLOW:
		BONE AGE:
		BONE LENGTH:
		BONE SURVEY (METASTATIC):
		CARDIAC SERIES:
		CHEST APICAL LORDOTIC:
		CHOLECYSTOGRAM:
		CLAVICLE:
		CYSTOGRAPHY:
RADIOLOGY POLICY AND PROCEDURE MANUAL

		ELBOW ROUTINE:
		ESOPHAGUS:
		FACIAL BONES:
		FEMUR:
		FETOGRAM:
		FINGER:
		FISTULA-SINUS TRACT: 
		FLUOROSCOPY:
		FOOT 3-VIEWS:
		FOREARM:
		GALL BLADDER:
		GASTRO BE:
		GASTRO GI:
		GI-UPPER:
		HAND 2 VIEWS:
		HAND 3-VIEWS:
		HEEL:
		HIP-AP & LATERAL:
		HIP BILATERAL:
		HIP-1 VIEW:
		HIP INCLUDING PELVIS:
		HIPS (PEDIATRIC):
		HUMERUS:
		HYPERTENSIVE IVP:
		INTERNAL AUDITORY CANAL:
		INTRAVENOUS CHOLANGIOGRAM:
		INTRAVENOUS PYELOGRAM:
		KNEE (ROUTINE)
		KUB:
		LOWER LEG:
		MANDIBLE:
		MASTOIDS:
		MYELOGRAM AMIPAQUE:
		MYELOGRAPHY COMPLETE/CERVICAL:
		MYELOGRAPHY LUMBAR:
		NASAL BONE: 
		NASOLACRIMAL DUCT:
		NECK-SOFT TISSUE:
		NEPHROSTOMY:
		OPERATIVE NEPHROGRAM:
		OPTIC FORAMINA:
		ORBITS:
		OS CALCIS:
		PATELLA:
		PELVIMETRY:
		PELVIS:
		PELVIS AND HIPS PEDIATRIC:
		RENAL CYST PUNCTURE:
		RETROGRADE PYELOGRAM:
RADIOLOGY POLICY AND PROCEDURE MANUAL

		RETROGRADE URETHROGRAM:
		RIBS-BILATERAL:
		RIBS-UNILATERAL:
		SALIVARY GLAND:
		SCAPULA:
		SELLA TURCICA:
		SHOULDER:
		SIALOGRAPHY:
		SINOGRAM:
		SINUSES:
		SKULL-ROUTINE:
		SKULL-3 VIEWS:
		SKULL-2 VIEWS:
		SKULL-1 VIEW:
		SKULL INCLUDING FACIAL BONES:
		SMALL BOWEL ONLY:
		SPINE SURVEY:
		SPINE CERVICAL ROUTINE:
		SPINE LUMBAR ROUTINE:
		SPINE SCOLIOSIS STUDY:
		SPINE-THORACO/LUMBAR JUNCTION:
		SPINE-THORACIC:
		STERNOCLAVICULAR JOINTS:
		STERNUM:
		STYLOID PROCESSES:
		T-TUBE CHOLANGIOGRAM:
		TEMPEROMANDIBULAR JOINTS:
		THUMB:
		TIBIA AND FIBULA:
		TOE:
		TRANSHEPATIC CHOLANGIOGRAM:
		UROGRAPHY RETROGRADE:
		VENOGRAM-BILATERAL:
		VOIDING CYSTOGRAM:
		WRIST-COMPLETE:
		WRIST-PA AND LATERAL:
		WRIST GAMBET:


	RADIOLOGY PROCEDURES - II
         	CRASH CARTS - ADULT & PEDIATRIC
		CRASH CART SUPPLIES
         	PEDIATRIC CRASH CART INVENTORY LIST
		ROTATION EXCHANGE CRASH CARTS
		MAINTENANCE & SECURITY OF EMERGENCY
                   DRUG BOXES
RADIOLOGY POLICY AND PROCEDURE MANUAL

		PREP AND INFORMATION MANUAL FOR RADIOLOGY
			ABDOMEN AP-LAT FOR AAA:
			ABDOMEN-1 VIEWS:
			ABDOMEN-3 VIEWS (ROUTINE):
			ABDOMEN-FLAT & UPRIGHT:
			ACROMIO-CLAVICULAR JOINTS:
			ANGIOPLASTY:
			ANKLE:
			ARTERIO-4 VESSEL-VERTEBRAL:
			ARTERIO-ABDOMINAL AORTA:
			ARTERIO-ABDOMINAL SELECTIVE:
			ARTERIO-ADRENAL SELECTIVE:
			ARTERIO-AORTO-ILIAC-FEMORAL:
			ARTERIO-CAROTID-CEREBRAL: 
			ARTERIO-CELIAC SELECTIVE:
			ARTERIO-EXTREMITY:
			ARTERIO-RENAL SELECTIVE:
			ARTERIO-SUP MESENTERIC SEL:
			ARTERIO-THORACIC AORTIC ARCH:
			ARTHROGRAPHY-SINGLE:
			BARIUM ENEMA:
			IN-PATIENT PREP:
			OUT-PATIENT PREP:
				WATER ENEMA PREP:
				WITH COLOSTOMY:
				CHILD'S PREP
			BARIUM ENEMA WITH AIR:
			BARIUM SWALLOW:
			BARIUM SWALLOW W/105 CAMERA:
			BIOPSIES (ALL):
			BONE AGE:
			BONE LENGTH:
			BONE SURVEY-METASTATIC:
			BRONCHOGRAPHY-UNILATERAL:
			BRONCHOSCOPY:
			CARDIAC SERIES:
			CHEST-APICAL LORDOTIC VIEW:
			CHEST-INCLUDING FLUOROSCOPY:
			CHEST-PA:
			CHEST-PA & LATERAL (ROUTINE):
			CHEST-WITH DECUBITUS VIEWS:
			CHEST-WITH OBLIQUES:
			CHOLECYSTOGRAM-ORAL:
			PREP:
			CHILD'S PREP:
			CHYMOPAPAINE (INIT 30 MIN):
			CLAVICLE:
			CYSTOGRAPHY:
			DYE MARKING:
RADIOLOGY POLICY AND PROCEDURE MANUAL

			ERCP:
			ELBOW (ROUTINE):
			ELBOW-AP & LATERAL:
			ENDO SPHINCTEROTOMY-INT 30:
			ESOPHAGUS:
			EYE-FOREIGN BODY AP & LAT:
			EYE-FOREIGN BODY COMP:
			FACIAL BONES:
			FEMUR:
			FETOGRAM:
			FINGER:
			FISTULA-SINUS TRACT:
			FLUOROSCOPY-INITIAL 30 MIN:
			FOOT-3 VIEWS:
			FOREARM:
			GALL BLADDER:
			GALL BLADDER-OPERATIVE:
			GALL BLADDER-TRANSHEPATIC:
			GASTROGRAFIN BE:
			GASTROGRAFIN GI:
			GASTROGRAFIN SMALL BOWEL:
			GASTROGRAFIN SWALLOW:
			GI-UPPER:
			CHILD'S PREP:
			GI-UPPER AND SMALL BOWEL:
			HAND INCLUDING WRIST:
			HAND-2 VIEWS:
			HAND-3 VIEWS (ROUTINE):
			HEEL:
			HIP INCLUDING PELVIS:
			HIP-AP & LATERAL:
			HIP-ONE VIEW:
			HUMERUS:
			HYPOTONIC DUODENOGRAPHY:
			HYSTEROSALPINGOGRAM:
			IMAGE INTENSIFIER INT 30 MIN:
			INTERNAL AUDITORY CANAL:
			INTRA-VENOUS CHOLANGIOGRAM:
			INTRA-VENOUS PYELOGRAM:
			PREP:
				CHILD'S PREP:
			INTRA-VENOUS PYELOGRAM W/TOM:
			IVP HYPERTENSIVE:
			KNEE-AP & LATERAL:
			KUB:
			LARYNGOGRAPHY:
			LOWER LEG:
			LUMBAR PUNCTURE:
			LYMPHANGIOGRAM-BILATERAL:
RADIOLOGY POLICY AND PROCEDURE MANUAL

			LYMPHANGIOGRAM-UNILATERAL:
			MANDIBLE:
			MANDIBLE W/PANOREX:
			MASTOIDS:
			MYELOGRAM AMIPAQUE:
				PREPROCEDURE:
				POSTPROCEDURE:
			MYELOGRAPHY-COMP/CERVICAL:
			MYELOGRAPHY-LUMBAR:
				PREPROCEDURE:
				POSTPROCEDURE:
			NASAL BONE:
			NASOLACRIMAL DUCT:
			NECK-SOFT TISSUE:
			NEPHROLITHOTOMY INIT 30 MIN:
			NEPHROSTOMY:
			OPERATIVE NEPHROGRAM:
			OPTIC FORAMINA:
			ORBITS:
			OS CALCIS:
			PACEMAKER INSERTION - 30 MIN:
			PANOREX FILM-EACH:
			PATELLA:
			PELVIMETRY:
			PELVIS:
			PELVIS & HIPS-PEDIATRIC:
			PELVIS & LATERAL VIEW HIP:
			PNEUMOPERITONEUM:
			POST REDUCTION FILM-ED ONLY:
			RENAL CYST PUNCTURE:
			RENAL RENINS (INIT 30 MIN):
			RETROGRADE PYELOGRAM:
			RETROGRADE-URETHROGRAM:
			RIBS-BILATERAL:
			RIBS-UNILATERAL:
			SACRO-ILIAC JOINTS:
			SACRUM-COCCYX AP & LATERAL:
			SALIVARY GLAND:
			SCAPULA:
			SELLA TURCICA AP & LATERAL:
			SELLA TURCICA COMPLETE:
			SHOULDER:
			SHOULDER INCL CLAVICLE:
			SIALOGRAPHY:
			SINOGRAM:
			SINUSES:
			SKULL (ROUTINE):
			SKULL INCL FACIAL BONES:
RADIOLOGY POLICY AND PROCEDURE MANUAL

			SKULL-1 VIEW:
			SKULL-3 VIEWS:
			SKULL-AP & LATERAL:
			SMALL BOWEL ONLY:
			SPINE SURVEY:
			SPINE-CERVICAL (ROUTINE):
			SPINE-CERVICAL AP & LATERAL:
			SPINE-CERVICAL W/FLEX & EXT:
			SPINE-CERVICAL-1 VIEW:
			SPINE-LUMBAR (ROUTINE):
			SPINE-LUMBAR AP & LATERAL:
			SPINE-SCOLIOSIS STUDY:
			SPINE-THOR DORSO/LUM JUNCT:
			SPINE-THORACIC:
			SPLENOPORTOGRAPHY:
			STERNOCLAVICULAR JOINTS:
			STERNUM:
			SWANZ-GANZ INSERTION-30 MIN:
			T-TUBE CHOLANGIOGRAM:
			TEMPERO-MANDIBULAR JOINT:
			THUMB:
			TIBIA AND FIBULA:
			TOE:
			TOMOGRAPHY INIT 6 FILMS:
			TUBE PASSAGE:
			UNBRELLA PLACEMENT-30 MIN:
			UROGRAPHY-RETROGRADE:
			VASOGRAPHY-VESICULOGRAM:
			VENOGRAM-ABDOMINAL SELECT:
			VENOGRAM-ADRENAL SELECTIVE:
			VENOGRAM-BILATERAL:
			VENOGRAM-HEPATIC SELECTIVE:
			VENOGRAM-INFERIOR VENA CAVA:
			VENOGRAM-RENAL SELECTIVE:
			VENOGRAM-SUPERIOR VENA CAVA:
			VENOGRAM-UNILATERAL:
			VENTRICULOGRAPHY:
			VOIDING CYSTOGRAM:
			WRIST-COMPLETE (ROUTINE):
			WRIST-PA & LATERAL:
			XEROMAMMOGRAM-BIL:
			XEROMAMMOGRAM-UNI:
			ZYGOMATIC ARCH-L VIEW:
			BARIUM ENEMA-WATER ENEMA PREP:
			BARIUM ENEMA WITH COLOSTOMY:


RADIOLOGY POLICY AND PROCEDURE MANUAL

	RADIOLOGY PROCEDURES - III

		POLICY FOR PROVIDING RADIOLOGY PROCEDURES
           			IN SURGERY
		DARKROOM POLICY AND PROCEDURE
		RECOVERY OF SILVER FLAKE FROM EXPENDED FIXER
          			IN PROCESSOR WASTE
		FILM SUBTRACTION TECHNIQUE



	FLUOROSCOPY PROCEDURES

	SPECIAL PROCEDURES

		DIRECT STICK ARTERIOGRAM
		RENAL RENIN STUDY TO ARTERIOGRAM SET-UP
		ROUTINE PERCUTANEOUS TRANSHEPATIC
           CHOLANGIOGRAM SET-UP
		LUNG BIOPSY SET-UP
		RENAL RENIN STUDY WITH ARTERIOGRAM
		POST RADIUM IMPLANT FILM PROCEDURE
		OPERATIVE NEPHROGRAM


JOB DESCRIPTIONS
	RADIOLOGY MEDICAL DIRECTOR
	RADIOLOGY MANAGER
	CHIEF TECHNOLOGIST
	CHIEF NUCLEAR MEDICINE TECHNOLOGIST
	RADIOLOGY SERVICES TECH - I
	RADIOLOGY SERVICES TECH - II
	RADIOLOGY SERVICES TECH - II, NUCLEAR MEDICINE
	RADIOLOGY SERVICES TECH - II, ULTRASOUND
	RADIOLOGY SERVICES TECH - II, CT SCAN
	RADIOLOGY TECH RESIDENT
	RADIOLOGY SERVICES VOLUNTEER
	RADIOLOGY CLERICAL SUPERVISOR
	RADIOLOGY CLERK
	CLERK/TRANSPORTER
	TRANSPORTER
	CT AIDE
	DARKROOM TECHNICIAN
RADIOLOGY POLICY AND PROCEDURE MANUAL


MISC

	APPROVED ABBREVIATIONS
	TECHNOLOGISTS QUALIFIED TO OPERATE CT EQUIPMENT
	CRASH CART SUPPLIES
	CONSENT FORMS
	QUALITY CONTROL
	ORIENTATION CHECK LIST - RADIOLOGY TECH I, II, & III
					   - RADIOLOGY TECH II, NM
					   - RADIOLOGY TECH II, CT
					   - RADIOLOGY TECH II, U/S
					   - RADIOLOGY CLERK
					   - CT AIDE
					   - DARKROOM TECH
					   - TRANSPORTER
RESPIRATORY CARE DEPARTMENT
POLICY AND PROCEDURE MANUAL
TABLE OF CONTENTS

Job Descriptions:

Director, Respiratory Care
Respiratory Care Supervisor
Respiratory Therapist
Respiratory Technician 
Pulmonary Technician
Respiratory Assistant
Medical Secretary
     Day Shift Duties
     Evening Shift Duties
     Night Shift Duties 


Policies:

Authorization Form
Dress Code
Hand Washing
New Equipment
Departmental Orientation
General Policies:
     Time Schedule   
General
Transfer to Another Institution  
Undesirable Side Effects
Patient Charts
Incomplete Orders
Service Listing
Verbal Orders
Work Break


Procedures:

Aerosols
Bronchoscopies
Connecting New Equipment
CPT
Handwashing
Incentive Spirometry
Intubation
IPPB
Mechanical Ventilation


               RESPIRATORY CARE DEPARTMENT
TABLE OF CONTENTS
                       (CONT'D)


Procedures: (Cont'd)

Methacholine
Data
History
Information
Instructions
Oxygen
Nasal Cannula
Pediatric Tent
Simple Mask
Partial Re-Breathing Mask
Venti Mask
Passive Nebulizers
Pulmonary Function Test
Pulse Oximeter
Red Tagging Equipment
Bedside Spirometry
Suctioning With An Artificial Airway
Suctioning Without An Artificial Airway


Safety:

Disaster Plan
Electrical Hazards
Fire Alarm
Fire Duty
General Safety
Infection Control
MSDS Policies


Quality Assurance:

QA Plan
Objective
Responsibility
Scope of Care
Important Aspects of Care
Indicators
Data Collection
Evaluation
Action
Assess Effectiveness of Action
Communicate Relevant Information
QA Forms
RESPIRATORY CARE DEPARTMENT
TABLE OF CONTENTS
(CONT'D)


Miscellaneous:

Approved Abbreviations
Patient's Rights
Unusual Occurrences
Visitor Incident Report
Arterial Blood Gas Manual
List of Services
Personnel Qualifications
Daily Maintenance
Establishing & Changing Q.C. Reference Ranges
Q.C. 1312 BGM
Q.C.  282 Co-Ox
Q.C. 482 Co-Ox
Arterial Puncture
Capillary Puncture
Allen's Test
Q.C. Troubleshooting
1312 Blood Gas Machine
Q.C. Troubleshooting
282 & 482 Co-Ox
RISK MANAGEMENT

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS


POLICIES:

	APPROVAL OF RISK MANAGEMENT PLAN
	EMPLOYEE FIRE MANUAL
	GENERAL DISASTER PLAN OF ACTION
	FIRE SAFETY PRECAUTIONS FOR ENVIRONMENTAL SERVICES
	LOCATION OF PROTECTIVE LIGHTING
	MEETING REQUIREMENTS
	RISK MANAGEMENT ORGANIZATION STRUCTURE
	PHARMACY RISK MANAGEMENT RESPONSIBILITIES
	RISK MANAGEMENT PHILOSOPHY
	PROBLEM IDENTIFICATION
	PROBLEM EVALUATION
	HAZARDOUS EMERGENCY PROCEDURE
	PROTECTIVE LIGHTING
	RISK MANAGEMENT PURPOSE
	RISK MANAGEMENT RESPONSIBILITIES
	RISK MANAGEMENT GOALS
	RISK MANAGEMENT OBJECTIVES
	RISK MANAGEMENT SCOPE
	TESTING FIRE ALARMS


SAFETY:

	SAFETY PROGRAM
	FUNCTIONS OF THE SAFETY COMMITTEE
	ADDITIONAL FUNCTIONS OF THE SAFETY COMMITTEE
	RESPONSIBILITIES OF THE SAFETY COMMITTEE
	EMPLOYEE SAFETY PRECAUTIONS FOR USING TOOLS AND EQUIPMENT
	EMPLOYEE PRECAUTIONARY SAFETY MEASURES
	EMPLOYEE TRAINING IN SAFE PRACTICES
	OBSERVING AND FOLLOWING SAFETY RULES


HAZARDOUS MATERIALS:

	DISPOSING OF RECALLED PRODUCTS
	HANDLING PRODUCT RECALLS AND HAZARD WARNINGS
	LEGAL RESPONSIBILITIES
	PRODUCT RECALLS AND HAZARD WARNINGS
	RADIATION ACCIDENT DISASTER PLAN
	RADIATION SAFETY IN THE LABORATORY
	SAFE USE OF RADIOACTIVE MATERIALS
	SAFELY OPENING PACKAGES CONTAINING RADIOACTIVE MATERIALS
RISK MANAGEMENT

POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS


EQUIPMENT:

		BIOMEDICAL ENGINEERING - BASIC EQUIPMENT INSPECTION
		EMPLOYEE CARE OF EQUIPMENT AFTER USE
		EMPLOYEE CAUTIONS WHEN USING EQUIPMENT
		EXERCISING CARE WHEN USING ELECTRICAL EQUIPMENT
		ELECTRICAL EQUIPMENT HAZARDS
		OFFICE SAFETY PRECAUTIONS
		INJURY PREVENTION WHEN HANDLING "SHARPS"
		PROCEDURE WHEN EQUIPMENT FAILS SAFETY STANDARDS
		PROVIDING SERVICE ON ALL ELECTRICAL EQUIPMENT
		RED-TAGGING MALFUNCTIONING EQUIPMENT
		SAFE HOUSEKEEPING PRACTICES
		SUFFICIENT SPACE FOR EQUIPMENT OPERATION
		WHO TO CALL FOR EQUIPMENT MALFUNCTION OR MAINTENANCE


	UNUSUAL OCCURRENCE:

		CHECKLIST FOR DETERMINING CONDITION OF ELECTRICAL
			EQUIPMENT
		CHECKLIST FOR DETERMINING CONDITION OF ALL EQUIPMENT
		DAILY INSPECTIONS
		EMPLOYE INJURY REPORT
		EXPOSURE TO TOXIC SUBSTANCES
		FIRE INSPECTION
		NEW ELECTRICAL EQUIPMENT INSPECTION
		INSPECTION TO CORRECT CONDITIONS
		OSHA REGULATIONS CHECKLIST
		PATIENT/VISITOR INCIDENT REPORT
		PATIENT/VISITOR INCIDENT REPORT INSTRUCTIONS
		PERIODIC FIRE SYSTEM TESTS AND INSPECTIONS
		REPORTING UNUSUAL OCCURRENCES


	MISCELLANEOUS:

		APPROVED ABBREVIATIONS
SLEEP DISORDERS CENTER

POLICY & PROCEDURE MANUAL

TABLE OF CONTENTS



POLICY

	Safety
	-	Department Safety
	-	Employee Safety
	-	Injury Reporting
	-	Hazard Reporting
	-	Safety Regulations
	-	Safety Inspections
	-	Safety Committee
	-	O.S.H.A.
	-	Safety Training

	Disaster Plan

	General Policies
	-	Departmental Purpose
	-	Patient Rights & Responsibilities
	-	Organization Chart
	-	Hours of Coverage
	-	Department Meetings
	-	New Employee Orientation

	Fire Plan


PROCEDURE:

	E.O.G. Recordings
	E.M.G. Recordings
	E.E.G. Recordings
	E.K.G. Recordings
	Thermocouple Recordings
	Respiratory Effort Recording
	Oxygen Saturation Recording

SLEEP DISORDERS CENTER

POLICY & PROCEDURE MANUAL

TABLE OF CONTENTS (CONT'D)



JOB DESCRIPTIONS:

	Sleep Center Coordinator
	Sleep Technician
	Daytime Duties
	Nighttime Duties


FORMS:

	Bedtime Questionnaire
	Morning Questionnaire
	Insurance Form
	Patient Information Form


MISC:

	Service on Biomedical Equipment
	Hazards From Electrical Equipment
	Handwashing
	Material Data Safety Sheets
	Arrival of New Electrical Equipment
	Visitor Incident Report
	Red Tagging Malfunctioning Equipment
	Unusual Occurrences
	Connecting Electrical Equipment
	Approved Abbreviations
TOTAL QUALITY MANAGEMENT

Table of Contents

TQM PROCESS:
Philosophy
Definition
Plan
Teamwork
Issue Identification
Implementation
Suggested Reading

EXAMPLES:
Ambulatory Care Billing
Cost Control-Biomedical Engineering
Case Management-Orthopaedics
Implementing Coordinated Care
Cost Control-Equipment Maintenance
Reduction Hospital Operating Costs
Culture Change & Delivery of Care System & Projects
DRG 209
DRG 89
Emergency Department Waiting Times
Emergency Department Utilization
Equipment Concerns
Flow Charting Equipment
Educational Process for Implementing TQM
Infection Control
Labeling Wheelchairs
Quality Improvement of Laboratory Process
Conversion of Labor, Delivery, Recovery
Long Range Monitoring Project
Mobile Mammography Service
Cost Impact of Substitution
Media Editorial Coverage
Documentation & Charging Medications
Case Management
Clinical Pathways
Nursing Assessments
Designing & Implementing Department of Nursing Plan
Restructuring Outpatient Care Services
Patient Satisfaction
Pillow Shortage
Poor Lighting on Nursing Units
Productivity Improvement-Benefit of TQM
Repair Tags
Recognizing & Rewarding Team Excellance
Maintaining Hospital Scrub Suits
Universal Precautions
Value Analysis
Wheelchair Standardization
Wheelchair Survey

DEPARTMENT SUPERVISOR'S TRAINING MANUAL
TABLE OF CONTENTS


EMPLOYEE COUNSELING

 People Skills Leadership, What's In It For You?
 Leading People As Opportunities.  Attendee Survey.
 Communication Skills Awareness Inventory.
 Communication Skills Awareness Feedback.
 Communication Skills.  Seminar Presentation.
 Poor Work Habits.  Awareness Inventory.
 Poor Work Habits.  Awareness Feedback.
 Role Play Negative Example
 Poor Work Habits Seminar Presentation.
 Role Play, Positive Example.
 Positive Discipline.  Awareness Inventory.
 Positive Discipline.  Awareness Feedback.
 Positive Discipline.  Seminar Presentation.
 Terminating Employees.  Awareness Inventory.
 Terminating Employees.  Awareness Feedback.
 Terminating Employees.  Seminar Presentation.
 Handling Substance Abuse.


LEADERSHIP

	Objectives	
	Leadership, What's In It For You?
	Overview Of Leadership Skills
	Leadership Skills.  Attendee Survey
	Leadership Skills.  Awareness Inventory
	Leadership Skills .  Awareness Feedback
	Part 1.  Your Leadership Personality
	Leadership Personality.  Self-Administered Inventory
	Leadership Personality.  Seminar Presentation
	Part 2.  Your Leadership Style	
	Leadership Style.  Self-Administered Inventory
	Leadership Style.  Seminar Presentation


EMPLOYEE MOTIVATION

	Objectives	
	Delegation, What's In It For You?
	Motivation By Delegation.  Attendee Survey.
	Time Management.  Awareness Inventory.
	Time Management.  Awareness Feedback.
	Time Management.  Seminar Presentation.
	Delegation.  Awareness Inventory.
	Delegation.  Awareness Feedback.
	Delegation.  Seminar Presentation.
DEPARTMENT SUPERVISOR'S TRAINING MANUAL
TABLE OF CONTENTS


RECRUITING AND INTERVIEWING EFFECTIVE HEALTH CARE TEAMS

	Overview Of Health Care Hiring Skills
	Hiring Organization And Recruitment.  
	Attendee Survey.
 		Exercise 1  Hiring Organization Awareness Inventory
 		Exercise 2  Hiring Organization Awareness Feedback.
 	Seminar Presentation.  Hiring Organization
		Step 1.	Setting Hiring Goals.
		Step 2.	JOB DESCRIPTIONS AND BEHAVIOR ANALYSIS.
		Step 3.	JOB BEHAVIOR SPECIFICATION ANALYSIS.
		Step 4.	JOB SALARY ANALYSIS.
 	Seminar Presentation.  Recruiting And Pre-screening
		Step 1.	Set A Recruiting Strategy
		Step 2.	Prescreening
	Prescreening Planning
	Exercise 3.  Hiring Organization And Recruitment.  
	Summary Of Revised Awareness.
	Interviewing, References, And Negotiating.
	Attendee Survey.
		Exercise 1.  Interviewing, References, Negotiating And 
			Termination Awareness Inventory
		Exercise 2  Interviewing Awareness Feedback.
	Seminar Presentation.  Interviewing
		Planning The Interview Environment.
		Controlling Professional Skilled Job Seekers
		Administrating The Interview.
		Peak Performance Evaluation Interview Model
		Self-Assessment Questioning Techniques.
	Seminar Presentation.  Hiring Referencing And Termination.
		Making The Hiring Decision.
		Getting Applicants On Board.
		Negotiating The Compensation Package.
		Reference Checking.
	Sample Job Description
	Management Performance and Development Summary
	Associate Performance and Development Summary
	Critical Incident Example
	Commendable Citation Example




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