TTUHSC El Paso Campus

Policy and Procedures

All Campus Policies & Procedures (ACP) Click here

El Paso Policies & Procedures

Numerical Index

Table of Contents

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0.

Administration

1.

Finance

2.

Emergency Procedures

3.

Patient Care/Nursing

4.

Medical Records

5.

Infection Control

6.

Performance Improvement Plan

7.

Risk Management

8.

Patient Relationships and Agreements

9.

Volunteer Services

10.

Safety Program

11.

Policy And Procedure Manual

0.

Administration
Initiation and Issuance of Policy- See All Campus Policy (ACP) 1.10
Policy Requirements for Clinical Departments- See ACP 1.12
Verification of Licensure/Certification 0.3
CPR Certification 0.4
Nurses-Advanced Practice (APN) 0.5
Open 0.6
Review of Diagnostic Study Results 0.7
Breast Pumping In The Workplace 0.8
Occurrence Reporting -Patient/Visitor -See ACP 8.02, 8.02A
Prescription Form Completion 0.10
Sentinel Event - Root Cause Analysis Policy - See ACP 8.12, 8.12A
Feral Cat Program-El Paso Campus 0.12
Dress Code Policy - Nursing Dress Code - See ACP 9.28
Protocol-TBST - (Revised 03/2008) 0.14
Volunteers and Students on the TTUHSC EP Campus - (Revised 01/2008) 0.15
Catering Safety 0.16
High School Student Assignments in Texas Tech Clinics - (New 03/2008) 0.17

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1.

Finance
Augmentation Report 1.1
Departmental Deposit Information Sheet 1.2
Reconciliation - Refund Account 1.3
Reconciliation - Trust Fund 1.4
Reconciliation - NFS Checks 1.5
Batching 1.6
Cashier Cash Control Policy 1.7
Revenue Cash Control 1.8
Billing Collection - Self Pay Accounts 1.9
Billing Collection - Commercial Insurance 1.10
Billing Collection - Medicare, Manage Care Medicare and Durable Medical Equipment 1.11
Billing Collection - Medicaid, Medicaid Manage Care, Out of State Medicaid & CIDC 1.12
Billing Collection - Special Billing Programs 1.13
Billing Collection - Company Accounts 1.14
Billing Collection - Other Government Programs 1.15
Billing Collection - Correspondence 1.16
Unreimbursed Costs of Medical Care Policy and Procedures 1.17
Charge Corrections 1.18

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2.

Emergency Procedures
Fire Safety Procedures 2.1
Bomb Threat Procedures 2.2
Medical Emergencies In Clinical and Non Clinical Areas - See ACP 2.02, 2.02A
Crash Cart And Defibrillator -See ACP 2.03, 2.03A, 2.03B, 2.03C
Emergency supplies and Equipment (inc Defibrillator) -See ACP 2.03, 2.03A, 2.03B, 2.03C
Critical Laboratory Values, Follow Up By Clinics - (Revised 12/2007) 2.6
Robbery Situations - How Staff Must React 2.7
Emergency Operations Plan 2.8
Safety Program Management Plan 2.9

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3.

Patient Care - Nursing

3
Sedation; Conscious Sedation/Analgesia-Guidelines - See ACP 3.09, 3.09A
Caring for Patients With Special Needs-Language, Vision, Hearing 3.2
Open 3.3
Nursing Care, Standardization Of 3.4
Security of Abusable Supplies 3.5
Abuse Victim, Management of  Suspected  - See ACP 6.24, 6.24A, 6.24B, 6.24C, 6.24D, 6.24E
Prisoner Patients, Treatment and Security of - See ACP 6.06, 6.06A, 6.06B, 6.06C, 6.06D
Open 3.8
Medication, Administration/Documentation of - See ACP 4.03
Administration Of Intravenous Medications - See ACP 4.08
Prescriptions By Telephone - See ACP 4.06, 4.06A
Stock Drugs And Biologicals, Management Of Clinic -See ACP 4.01
Supply / Medication Rotation 3.13
Open 3.14
Open 3.15
Open 3.16
Open 3.17
Open 3.18
Samples Medication, Handling of - See ACP 4.02, 4.02A
Medications, Disposal of 3.20

For Nursing Procedures See Policy #3.4
Laboratory Requisition, Requesting and Processing 3.36
Open 3.39
Transfer of Patients to Hospital 3.40
Requisition Completion for Ancillary Service 3.41
Interpreter, Guidelines for working with an 3.42

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4.

Medical Records (See Medical Records Table Of Contents)
Informed Consent - See ACP 6.21     * For attachments click ACP link above
Refusal to Submit to Treatment -  See ACP 6.22, 6.22A
Medical Record Documentation and Confidentiality Policy 4.1
Confidentiality Statements 4.2
Medical Records Format 4.3
Authentication of Entries into the Medical Record 4.4
Summary List-Medical Record 4.5
Progress Note Heading 4.6
Time-Frame for Returning Central Medical Records 4.7
Securement of Medical Records 4.8
Access to the Medical Records Department 4.9
Release of Health Record Information 4.10
Patient Release Permission to take Photographs 4.11
Shredding of Discarded Reports 4.12
Retirement of Medical Records 4.13
Medical Record Retention 4.14
Identifying Non-Central Medical Records 4.15
Advance Directives 4.16
Unavailable Medical Records at the Time of Clinic Visit 4.17
Transport of Medical Records To and From Clinic Sites 4.18
Retrieval of Medical Records After Hours 4.19
Completion of Forms from Outside Agencies Providing Services for Patients 4.20
Prenatal Records 4.21
Admissions 4.22
Master Index and Log of Patients 4.23
Straight Numberic Filing System 4.24
Number Control for Outlying Clinics 4.25
Block of Pre-Numbered Folders with Corresponding Medical Record Number Logs for Outlying Clinics 4.26
Retrieval Schedule 4.27
Medical Record Retrieval for Clinics 4.28
Retrieval within Department 4.29
Medical Record Pull-Slips (Locators) 4.30
Temporary Charts 4.31
Review of Medical Records 4.32
Referrals/Consultations 4.33
Research/Study/Medical Chart Pull Request 4.34
Requests for Medical Information when Patient has had Medical Treatment Elsewhere and Physician has Requested Copies be Obtained 4.35
Release of X-Ray Films from Radiology Department/Orthopaedic Clinic 4.36
Preparation for Archiving Inactive Medical Records for Storage and/or Microfilming 4.37
Obtaining Copies of Tissue Reports from Dept of Pathology Thomason Hospital 4.38
Obtaining Copies of Emergency Room Records from Thomason Hospital 4.39
Copies of Thomason Hospital Data Routinely Shared with Clinics 4.40
Filing Loose Documents into the Medical Record 4.41
Abbreviations 4.42
Medical Records-Charges for Services Rendered to Outside Agencies 4.43

5.

Infection Control
Infection Control Program 5.1
Prospective Employee Post Offer Health Assessment 5.2
Standard Precautions For Blood/Body Fluids (Universal Precautions) 5.3
Needlestick Injuries/Exposures to Body Fluids: Treatment and Reporting 5.4
Exposure Control Plan, Bloodborne Pathogens 5.4 A
Infectious Disease Exposures 5.5
Sharps, Handling and Disposal of 5.6
Immuno-Compromised Patients, Care of 5.7
Multiple-dose Medication Vials - Use, Handling & Expiration 5.8
Chemical and Biological Monitoring of Stream Sterilization Cycles for Release of Processed Items 5.9
Internal Pack (In-Pack) Monitoring of Steam Sterilization Processed Items using the Class 5 Verify Steam Integrator Strip 5.9a
Cidex-High Level Disinfectant, Guidelines For Use Of and Quality Control Of 5.10
Biohazardous / Infectious Waste Disposal Of 5.11
Communicable Disease Reporting 5.12
Waiting Room Infection Control 5.13
Cleaning Of Blood Or Body Fluid Soiled Areas 5.14
Procedure For Notifying Housekeeping For Cleaning Outside Of the Normal 5.15
Storage of Supplies and Patient Care Items 5.16
Hand Washing 5.17

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6.

Performance Improvement Plan
Performance Improvement Plan 6.1
Performance Improvement Report 2007 Form
Performance Improvement Plan 2007 Form

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7.

Risk Management
Risk Management Plan -See Risk Manager for Plan 7.1

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8.

Patient Relationships And Agreements
Patient Concern Procedures 8.1
Signing Out Against Medical Advise 8.2
Disclosure and Consent for Surgical, Medical and/or Diagnostic Procedures Forms 8.3
Patients. Rights and Responsibilities 8.4
Termination of a Physician and Patient Relationship - See ACP 8.11, 8.11A, 8.11B, 8.11C
Missed Appointments - See ACP 8.13, 8.13A, 8.13B
Disruptive Behavior In Clinics Sites 8.7
Open 8.8
Consent For Care (General) - See ACP 6.21   * For attachments click ACP link above
Consent For Treatment of Minors 8.10

9.

Volunteer Services
Volunteer Services 9.1
Recruiting Volunteers 9.2
Departmental Responsibilities For Volunteer Orientation 9.3

10.

Safety Program
Station on Emergency Eye Wash Shower and Flushing Station 10.1
Fire Extinguisher Monthly Inspection - Off Site Clinics 10.2
Hazardous Material Emergency Plan 10.3
          
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