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John Dempsey Hospital Administrative Policies

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

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John Dempsey Hospital Administrative Manual Index

2-001	Administrator On-Call
2-003	Research Studies
2-006	Guidelines for Utilization of Volunteer Services
2-007	Safety Policy
2-008	Request for Food Services
2-015	This policy has been combined under 2-001
2-016	Medical Surgical Supply Purchasing
2-020	John Dempsey Hospital Space Policy
2-025	Conflict Management
2-027	Holiday Decorations Polices
2-029	Healthcare Worker Workplace Violence and the Prevention of Workplace Violence Committee
2-030	Food Brought in From the Outside

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
4-005	Charity Care
4-006	Patient Self Pay Policy
4-007	Condition 44 / Medicare
4-008	Hospital Evaluation and Management (E/M) Services

5-001

Handling and Use of Compressed Gases

6-002	Informed Consent: Obtaining and Documenting
	Medical Surgical Procedure
	Transfusion of Blood or Blood Components
6-012	Informed Consent for Transfusion of Blood or Blood Related Products - See HAM 06-002
6-014	Autopsy Criteria
6-017	History and Physical
6-018	Electronic Order Writing "by Protocol" Within CPOE Inpatient System
6-019	Medical Orders
6-002	Informed Consent: Obtaining & Documenting

7-001	Venereal Disease - Treatment of a Minor
07-002	Battered Children
7-001	Venereal Disease - Treatment of a Minor
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 and Tissue Donation
7-017	Unclaimed Bodies
7-018	Post Mortem Authorization in Unclaimed Individuals
7-020	Identified Adoptions, Foster Care Replacements
7-022	Patient Advocate Access
7-023	Admission/Discharge Responsibilities
07-024	Ordering Outpatient Services
07-025	Focused Professional Practice Evaluation
07-026	Ongoing Professional Practice Evaluation

8-001	Taxi
8-002	Rooming-In
8-003	Substance Abuse Referral Information
8-003	Alcohol Substance Abuse Treatment
8-003	Detox Facilities & Outpatient Detox
8-003	Inpatient Alcohol Rehab
8-005	Interfacility Transfer: Guidelines for the Safe Transfer of Inpatients Between Acute Care Facilities
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
8-011	Helicopter Protocol
8-013	Moderate Sedation
8-014	Police Hold
8-015	Patient Elevators
8-016	Admission of Well Infants
8-017	Ambulance Service
8-018	Visitor Policy
8-019	Request for Blood Components and Audit Criteria for Blood Component Usage
	Audit Criteria for Blood and Blood Component Usage (Attachment)
8-020	Department of Correction: Supervision of Inmates Undergoing Surgical Procedures
08-021	Linen Utilization - Archived 4/13
8-022A	CPR: Code Blue Response on Campus
	Adult Code Carts Maintained by Pharmacy Department (Appendix A)
	CPR Report (Appendix B)
8-022C	CPR: Equipment
	Adult Code Carts 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	Patient Care Directives Formerly titled Do Not Resuscitate / Comfort Measures Only
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
8-035	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)
	Your Rights to Make Health Care Decisions - A Summary of Connecticut Law
8-038	Patient Counseling on Drug-Food Interactions
8-039	Education of Patients and Families
8-041	Chemotherapy Orders
8-042	Floor Stock
8-043	Pepper Spray or Foam: Use of in John Dempsey Hospital/UConn Health Center
8-044	Respiratory Therapy Services Support for Neonatal Transports
8-045	Restraints
8-047	Latex Allergic Patient
	Latex Allergy Sign
8-048	Universal Protocol
8-050	Allergies: Identification of Patient Allergies
8-051	Medication Administration: Adverse Drug Reaction (ADR) Reporting System
8-052	Medication Administration
8-054	Falls Risk Identification and Prevention Management (Nursing Practice Manual)
8-055	Rapid Response Team (RRT)
8-056	DOC: Orientation of Authorized Staff
8-057	Medication Reconciliation
	Medication Reconciliation Form
8-058	Admission of Patient from Emergency Department
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)
	Standing Orders
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
8-073	Critical Incident Support Program (CIS)
8-075	Emergency Department Chart Completion Policy
8-076	Tissue Management
	Attachment A
8-077	Critical Results Reporting Policy
8-078	Code Pink Infant or Child Abduction
8-079	Code Strong
8-080	Health Care Industry Representatives in Clinical Areas
8-081	Preoperative Transfusion Services: Extended Type & Screen and Day of Surgery
8-082	Electronic Order Writing "by Protocol" within CPOE
8-083	Confirmation of Endotracheal Tube Placement
8-084	Lock Boxes: Use of for Continuous Infusions of Controlled Substances
08-085	Patient Care Abuse: Child
08-086	Patient Care Abuse: Elderly
08-087	Domestic Violence
08-088	Therapeutic Interchange
08-089	Patient Care: Decentralized Lab Testing; Program Scope, Responsibility and Competency Assessment /Validation
08-091	Standing Order Sets/Protocol Orders for Necessary & Emergency Care
08-092	Clinical Observation & Training Opportunities for Visiting Health Care Professionals
08-093	Code Silver
08-094	Code Mr./Ms. Free Bird
08-095	Deep Sedation/General Anesthesia
08-096	EMTALA - Ambulance Diversion
08-097	Chemotherapy Consent
08-098	Oxygen Administration
08-099	Patient Identification

9-007	Admissions Guidelines
9-010	Exempt Units

10-005	Travel Authorization
10-019	Annual Staff Performance Evaluations
10-021	Verification of All Applicable Licensure/Certification
10-023	Evaluation: Competency Assessment System
10-024	Orientation of Staff
10-025	Employee Education Activities Record Attachment: Employee Education Activities Records
10-026	Education Programs, Documentation Attachment: Report of Educational Offering
10-027	Mandatory Education
10-029	Employee Files and Personnel Records
10-030	Staff Requests Not to Participate
10-032	Sleeping on Duty / Inattentiveness to Duty

11-001	Inspector / Lawyer Request
11-002	Equipment Used at John Dempsey Hospital: 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
11-007	Patient Lost Items
11-009	Radioactive Material Exposure Emergencies
11-011	Police / Security Services
11-012	Elevator Emergency Use
11-016	Reporting Cases to the Police
11-017	Sentinel Event
	Appendices A, B, C
	Adverse Event Communication and Decision Flowchart
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
11-023	Pets Visitations
11-024	Emergency Resuscitation Equipment Check
	Emergency Equipment Checklist
11-025	Personal Radiation Dosimetry
11-027	Management of Patients with Known or Suspected HIV Infection
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	Patient Owned Equipment and Non-Standard Medical Devices
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
11-040	Management of the Unit Medication Refrigerator
	Temperature Log
11-041	Laser Safety
11-043	Clinical Alarm Systems and Patient Safety
11-044	Disclosure Policy: Unanticipated Outcome
11-046	Grievance Committee
11-048	Equipment: Safety of Patient in Case of Malfunction
11-049	Vendor Management

12-001	Retrieval of Charts of Discharged Patients
12-002	Abbreviations and Charting Terms - Approved and Unapproved Approved Abbreviation List Unapproved Abbreviation List
12-003	Birth Certificate Completion / Naming of Newborns
12-004	Patients' Request to View Medical Record
12-006	Retrieval of Outpatient Records (Inc.: SDS, AACU, 4 Hr Holds, ED) Post Patient Visit / Test
12-008	Tumor Registry / Cancer Registry Attachment to 12-008
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
12-020	Medical Records Access to Outside Credentialed Providers
12-021	Documentation Requirements for Discharge Summaries
12-022	Medical Records Form Development and Control Policy
12-023	Entries in the Medical Record
12-026	Records Management: Problem List

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