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John Dempsey Hospital Administrative Policies

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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
2-020 John Dempsey Hospital Space Policy
2-025 Conflict Management
2-026 Chain of Command
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
2-031 Volunteer Health Requirements

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

7-001 Venereal Disease - Treatment of a Minor
7-002 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
7-021 Medical Ethics Committee
7-022 Patient Advocate Access
7-023 Admission/Discharge Responsibilities
7-024 Ordering Outpatient Services
7-025 Focused Professional  Practice Evaluation
7-026 Ongoing Professional Practice Evaluation

8-001 Taxi
8-002 Rooming-In
8-003 Substance Abuse Referral Information
  Alcohol Substance Abuse Treatment
  Detox Facilities & Outpatient Detox
  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
8-021 Linen Utilization - Archived 4/13
8-022 A CPR: Code Blue Response on Campus
  Adult Code Carts Maintained by Pharmacy Department (Appendix A)
  CPR Report (Appendix B)
8-022 C CPR: Equipment
  Adult Code Carts Maintained by Pharmacy Department (Appendix A)
  Contents of the Adult Code Carts Maintained by Pharmacy Department (Appendix B)
8-022 D Required Certification 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 Cancer Therapy:  Ordering and Administration
  PART I:  Cancer Therapy:  Ordering Policy and Procedure
  PART II:  Cancer Therapy:  Clearance Procedure
  PART III:  Cancer Therapy:   Administration Policy & Procedure
PART IV:  Infusion Reactions:  Management of Patients Receiving Chemotherapy/Biotherapy
PART V: Extravasation: Assessment and Management of Chemotherapy - Related
ONS Vesicant Extravasation Guidelines
  Extravasation Patient Information Sheet
  PART VI:   Cancer Therapy:  Patient Teaching Procedure
  PART VII:  Procedure for Scheduling of Cancer Therapy Appointments in the Neag Cancer Center
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
8-059 Report / Handoff
8-061 Competency Evaluation of Surgical Residents
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
8-085 Patient Care Abuse:  Child
8-086 Patient Care Abuse:  Elderly
8-087 Domestic Violence
8-088 Therapeutic Interchange
8-089 Patient Care:  Decentralized Lab Testing; Program Scope, Responsibility and Competency Assessment /Validation
8-091 Standing Order Sets/Protocol Orders for Necessary & Emergency Care
8-092 Clinical Observation & Training Opportunities for Visiting Health Care Professionals
8-093 Code Silver
8-094 Code Mr./Ms. Free Bird
8-095 Deep Sedation/General Anesthesia
8-096 EMTALA - Ambulance Diversion
8-097 Chemotherapy Consent
8-098 Oxygen Administration
8-099 Patient Identification
8-100 Inpatient Telemetry Monitoring
8-101 Safe Administration of Intra-Cerebrospinal Fluid Chemotherapy (ICC)
8-102 Psychological/Spiritual Services for Cancer Patients

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


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
11-018 A 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
11-039 Pathology Specimen Transport
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
12-021 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
12-027 Medical Record Services - Clinical Documentation Improvement

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