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John Dempsey Hospital - Administrative Policies

The John Dempsey Hospital Administrative Policies can be viewed or printed using Adobe Acrobat.

To search the index for a specific key word, select Find from the Edit menu on the toolbar above and enter the word you would like to search for.

Index:	JDH Administrative Manual Index
Policy Number:	Title:
2-001	Evening or Holiday Weekend Administration
2-003	Research Studies
2-004	Snow Emergency Transportation
2-006	Guidelines for Utilization of Volunteer Services
2-007	Hospital Safety Policy
2-008	Request for Food Services
2-009	Administrative Response to Emergency Conditions
2-010	On the Job, On-Site Injuries and Emergency Treatment
2-011	Employment of Temporary Agency Personnel
2-013	Smoke-Free Environment
2-015	This policy has been combined under 2-001
2-018	Clinical Repository System (CRS) / Lifetime Clinical Record Access to Outside Credentialed Providers
2-019	Unannounced Regulatory Surveys
2-020	John Dempsey Hospital Space Policy
2-022	Medicare Post Acute Transfer Policy
3-001	Collect Calls
3-002	Monthly Telephone Bills
3-003	Paging
3-005	Media Relations
3-006	Overhead Operator Paging in University of Connecticut Health Center (UCHC)
4-001	Medical Information for Billing
4-002	Financial Screening
4-003	John Dempsey Hospital Budget Process
4-004	Annual Financial Audit
4-005	Charity Care
6-001	Pathology Slide Review
6-002	Informed Consent
	Medical Surgical Procedure
	Transfusion of Blood or Blood Components
6-003	Tissue Specimens
6-004	Automatic Stop - Orders
6-012	Informed Consent for Transfusion of Blood or Blood Related Products
	Authorization for Transfusion of Blood or Blood Components
6-013	Verbal / Telephone Orders
6-014	Autopsy Criteria
6-015	Access to Confidential, Privileged Credential / Peer Review Files
6-016	Recurring Ambulatory Orders
7-001	Venereal Disease - Treatment of a Minor
7-002	Photographs of Battered Children
7-004	DCF (Department of Children and Families) - Temporary Custody for Purposes of Medical / Dental Treatment for a Minor
7-005	Brain Death
7-006	Discharge Against Medical Advice (AMA)
7-007	Witness of a Court Document
7-008	Subpoenas
7-009	Malpractice
7-010	Death of a Patient
7-011	Medical Examiner's Case
7-012	Autopsy Services
	Permission for Autopsy Form
7-013	Living Will, Attorney-in-Fact for Health Care Decisions, Health Care Agent and Conservator of the Person
	Patient Handouts
7-014	Refusal of Blood and/or Blood Products
7-016	Organ-Tissue / Body Donations
7-017	Unclaimed Bodies
7-018	Post Mortem Authorization in Unclaimed Individuals
7-020	Identified Adoptions, Foster Care Replacements
7-021	Ethics Committee
8-001	Taxi
8-002	Rooming-In
8-003	Substance Abuse Referral Information
8-004	Patient Elopement
8-005	Transfer of Patients with Intravenous Devices by Emergency Medical Services (EMS) Personnel
8-006	Care of Psychiatric Patient in a Non-Psychiatric Unit
8-007	Interpreters / Linguistic Access for Persons with Limited English Proficiency
8-008	Patient Telephone Hours
8-009	Care Delivery to Persons who are Deaf or Hard of Hearing
8-010	Transfer of Patients and Shared Information Between Institutions
8-011	Helicopter Protocol
8-013	Conscious Sedation
8-014	Police Hold
8-015	Patient Elevators
8-016	Admission of Well Infants
8-017	Ambulance Service
8-018	Visiting Regulations
8-019	Blood Transfusion and Cross Matches
8-020	Patient Care
8-021	Linen Utilization
8-022A	CPR: Code Blue Response on Campus
	Adult Code Charts Maintained by Pharmacy Department (Appendix A)
	CPR Report (Appendix B)
	Emergency Medication Guidelines (Appendix C)
8-022B	CPR: Code Blue Response off Campus
8-022C	CPR: Equipment
	Adult Code Charts Maintained by Pharmacy Department (Appendix A)
	Contents of the Adult Code Carts Maintained by Pharmacy Department (Appendix B)
8-022D	CPR: Cardiopulmonary Resuscitation Training
8-023	Do Not Resuscitate / Comfort Measures Only Policy
8-025	Use of Microwave Ovens
8-026	Termination of Pregnancy
8-027	Department of Corrections: Flow of Inmates Between Correction Facilities, the Emergency Department and Medical Surgical 5
	Flow Chart for Emergency Department and Med-Surg 5
8-028	Transfer / Admission from other Institution
8-029	Discharge Planning Process
8-030	Patient Rights and Responsibilities
8-031	Pastoral, Religious and Spiritual Needs
8-032	Departmental Provision of Patient Care Services (Scope of Services)
8-033	Plan for Provision of Patient Care Services
8-034	Hospital Plan for Nursing Care
8-035	Consent for Sterilization
	Consent Form for Sterilization
8-036	Patients Requiring Immediate Access to the Operating Room
8-037	Advance Directive (Patient Self Determination Act)
8-038	Patient Counseling on Drug-Food Interactions
8-039	Education of Patients and Families
8-040	Charting by Exception
8-041	Chemotherapy Orders
8-042	Floor Stock
8-043	Pepper Spray or Foam: Use of in JDH/UCHS
8-044	Respiratory Therapy Services Support for Neonatal Transports
8-045	Restraints
8-046	Narcotic Analgesics: Ordering Guidelines
8-047	Latex Allergic Patient
8-048	Surgical Site Verification
8-050	Allergies: Identification of Patient Allergies
8-051	Medication Administration: Adverse Drug Reaction (ADR) Reporting System
8-052	Medication Administration
8-053	Order Writing: Medical Students Co-Signatures
8-054	Falls: Risk Identification and Prevention Management
8-055	Rapid Response Team (RRT)
8-056	DOC: Orientation of Authorized Staff
8-057	Medication Reconciliation
	Medication Reconciliation Form
8-059	Report / Handoff
8-060	Resident Supervision in the John Dempsey Hospital
8-061	Competency Evaluation of Surgical Residents
8-062	Overlapping Surgeries for Teaching Classes
8-063	Admission or Transfer of Multi-System Injury Patients
8-064	Vaccinations: Adult Pneumococcal and Influenza Vaccination
	Adult Inpatient Immunization Screening Form (HCH-1322)
8-065	Patient Handling: Safe Patient Handling
8-066	Releasing Pathology Slides / Reports for Second Opinion or Transfer of Care
	Attachment A
	Attachment B
8-067	Post-Anesthesia Evaluation
8-068	Medicare Beneficiary Notification of Discharge Appeal Rights
8-069	EMTALA - Qualified Medical Person
8-070	EMTALA - On-Call Obligations of Medical Staff Physicians
9-002	Midnight Census
9-003	Private Rooms
9-004	Emergency Room Registration
9-006	Referred Patients
9-007	Admissions Guidelines
9-008	Unidentified Patients
9-009	Patient Leave of Absence
9-010	Exempt Units
10-001	Employee Children
10-002	Employee Responsibility
10-003	Gambling
10-004	Accrued Time at Date of Resignation
10-005	Travel Authorization
10-007	Completion of Time Report Forms
10-008	Alcohol Abuse and Drug-Free Workplace Policy
10-014	Medical Certification for Disability
10-019	Annual Staff Performance Evaluations
10-020	Consulting and Honoraria
10-021	Verification of All Applicable Licensure/Certification
10-023	Competency Assessment System
10-024	Orientation of Staff
10-025	Employee Education Activities Record
10-026	Education Programs, Documentation
10-027	Mandatory Education
10-028	Unacceptable Utilization of Hospital Computers
10-029	Employee Files and Personnel Records
10-030	Staff Requests Not to Participate
10-031	Emergency Closing Due to Inclement Weather
11-001	Inspector / Lawyer Request
11-002	Equipment Used at JDH: Rental, Demo, Loaner and Other Non-Hospital Owned
11-003	Investigation and Response to Patient Complains / Grievances
11-004	Extension Cord Usage
11-005	Product Recall Information
11-006	Hospital Falls
11-007	Patient Lost Items
11-008	Incident Reports - Clinical
	State of Connecticut, Department of Public Health, Adverse Event Reporting Form
11-009	Radioactive Material Exposure Emergencies
11-010	Possession of Firearms on Hospital Property or Health Center Campus
11-011	Police / Security Services
11-012	Elevator Emergency Use
11-013	Safety of Patients
11-014	Bomb Threat and Search
11-015	Personal Electrical Equipment
11-016	Reporting Cases to the Police
11-017	Sentinel Event
11-018A	Disposal of Illegal Substances, Hazardous Items, Suspected Contraband or Weapons
11-019	Handling of Antineoplastic & Hazardous Drugs
11-020	Equipment Involved in Patient Injury
11-021	Patient Care Equipment: Repairs, Performance Assurance, Testing/Preventative Maintenance and Quality Assurance of
11-022	Infection Control - Standard Precautions
11-023	Pets Visitations
11-024	Emergency Resuscitation Equipment Check
11-025	Personal Radiation Dosimetry
11-026	Testing for Known or Suspected Human Immunodeficiency Virus Infection
	Testing for Known or Suspected Human Immunodeficiency Virus Infection Form
11-027	Management of Patients with Known or Suspected HIV Infection
11-029	The HIV-Infected Healthcare Worker
11-030	Electrically Powered Non-Patient Care Equipment
11-031	Patient Valuables
11-032	Adverse Medical Device: Incidents Reporting
11-033	Concurrent Review by Third Party Review Agencies
11-034	Non-Standard Patient Care Equipment and Drugs, and Non-Hospital Staff
11-036	Medical Devices to Provide and Effective Method for Device Recalls and an Efficient Patient Notification Process: Tracking of
11-037	Observation Status
11-038	Cellular Phones, Portable RF Transmitters and Cameras
11-039	Anatomic Pathology
11-040	Management of the Unit Medication Refrigerator
	Temperature Log
11-041	Laser Safety
11-042	Medication Errors
11-043	Clinical Alarm Systems and Patient Safety
11-044	Disclosure Policy: Unanticipated Outcome
11-045	Rapid HIV Testing in Birthing Center and Maternal-Fetal ICU
12-001	Retrieval of Charts of Discharged Patients
12-002	Abbreviations and Charting Terms - Approved and Unapproved
	Abbreviation List
	Unapproved Abbreviation List
12-003	Birth Certificate Completion / Naming of Newborns
12-004	Patients' Request to View Medical Record
12-005	Completion of Medical Records
12-006	Retrieval of Outpatient Records (Inc.: SDS, AACU, 4 Hr Holds, ED) Post Patient Visit / Test
12-007	Delinquent Records: Temporary Suspension of Physician Admitting and Surgical Privileges
12-008	Tumor Registry / Cancer Registry
12-010	Release of Autopsy Information
12-011	Transportation of Medical Records
12-012	Secured Medical Records
12-014	Writing in the Medical Record
12-015	Paternity, Acknowledgement of, Completion of Forms
12-016	Medical Record Documentation: Error Correction
12-017	Requesting Medical Records for Patient Care
12-018	Documentation Requirements For All Procedures
12-019	Medical Record Forms Development and Control Policy


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