Policy and Procedures
All Campus Policies & Procedures (ACP) Click here
El Paso Policies & Procedures
Numerical Index
TABLE OF CONTENTS
1. Leadership/Administration
All Campus Policies
1.03 Statement of Professionalism
1.08 Institutional Health Care Ethics Committee
1.10 Policy Statements Initiation and Issuance
1.11 Policy Approval Flowchart
1.12 Clinic Departmental Policy Requirements
El Paso Campus Policies
EP 1.1 Verification of Licensure/Certification
EP 1.1A Verification of Licensure Form
EP 1.3 Mid Level Provider Requirements
EP 1.4 Diagnostic Study Results, Review of
EP 1.5 Breast Pumping in The Workplace
EP 1.9 Tuberculosis Skin Testing Policy
EP 1.9A Tuberculosis Clinic Referral Acknowledgement
EP 1.10 Student Activities on El Paso Campus
EP 1.15 Non Clinical Dress Code Policy
2. Emergency Procedures
All Campus Policies
2.01 TTUHSC Emergency Paging Codes
2.02 Medical Emergencies in Clinical Areas
2.02A Cardiopulmonary Arrest Flow Sheet
2.03 Emergency Equipment: Crash Carts, Drug Boxes & Defribrillators
2.03A Crash Cart Supplies and Drugs
2.03B Emergency Equipment Check List
2.03C Amarillo - Emergency Equipment Inventory
2.03C El Paso - Emergency Equipment Inventory
2.03C Lubbock - Emergency Equipment Inventory
2.03C Odessa - Emergency Equipment Inventory
2.04 Bioterrorism Readiness Plan
2.04A Amarillo - Contact Numbers
2.04A El Paso - Contact Numbers
2.04A Lubbock- Contact Numbers
2.04A Odessa - Contact Numbers
El Paso Campus Policies
EP 2.4 Robbery Situations - How Staff Must React
EP 2.5 Emergency Operations Plan
EP 2.6 Safety Program Management Plan
3. Patient Care
All Campus Policies
3.02 Assessment and Management of Pain
3.04 Orders, Receiving and Noting
3.20 Laboratory Requisition and Processing
3.25 Latex Allergy - Suspected or Known
3.26 (Amarillo) - Universal Protocol Verification Process for Invasive Procedures (Amarillo)
3.26A (Amarillo) - Universal Protocol Checklist (Amarillo)
3.26A EP - Universal Protocol Checklist (El Paso)
3.26A LBB-PB - Universal Protocol Checklist (Lubbock and Permian Basin)
El Paso Campus Policies
EP 3.1 Critical Laboratory Reporting
EP 3.2 Nursing Care, Standardization of
EP 3.3 Security of Abusable Supplies
EP 3.4 Supply/Medication Rotation
EP 3.5 Medications, Disposal of
EP 3.6 Admission and Transfer of Patients to Hospital
EP 3.7 Requisition Completion for Ancillary Service
EP 3.9 Pharmacy Calls to Clinics
EP 3.9A Telephone Progress Note
4. Medication Management
All Campus Policies
4.01 Management of Clinic Stock Drugs & Biologicals
4.01A Medication Refrigerator Temperature Log
4.03 Medication Management, Administration & Documentation
4.04 Medication Administration for Certified Medical Assistants in Ambulatory Care
4.04A Physician Delegation Statement
4.04B CMA-Administered Approved Medication List
4.06. Prescription by Telephone
4.07 Adverse Drug Event Reporting
4.08 Intravenous Medication Administration
4.09 Prescription Form Completion - Required Information
4.10 Multi-Dose Medication Vials - Use, Handling & Expiration
4.11 Physician Delegation of Prescriptive Authority
4.11A Example of Practice Privileges and Written Protocol
4.11B Sample Delegating Physician Supervision Log
4.12 Physician Delegation to Pharmacist
5. Management of Information/Medical Record
All Campus Policies
5.01 Medical Records Documentation and Confidentiality
5.02 Medical Records Paper Format
5.02A Amarillo -Medical Records Standard Format
5.02A El Paso -Medical Records Standard Format
5.02A Lubbock -Medical Records Standard Format
5.03 Authentication of Entries into the Medical Record
5.07 Securing Medical Records Pending Litigation
5.08 Acess to the Medical Records Department
5.09 Release of Health Record Information
5.10 Guidelines for Destruction/Disposal of Protected Health Information
5.11 Retention & Retirement of Medical Records
5.15 Medial Records Abbreviations
5.15A UMC/HSC Do Not Use Abbreviations
El Paso Campus Policies
5.2 Downtime Operations Guidelines
5.2A Downtime Operations Questionnaire
5.3 Medical Records Access for Research
5.4 Medical Records Request and Documentation
6. Patient Rights/Patient Relationships and Agreements
All Campus Policies
6.01 Patient Rights and Responsibilities
6.02 Patient Concern Procedures
6.03 Obtaining Patient Feedback
6.04 Patients Who Threaten Harm to Themselves or Others
6.05 Patients with Communication, Visual, Hearing or Speech Impairment
6.05A Suggestions Regarding Meeting a Blind Person
6.06A Suggestions for Dealing with Inmate/Prisoner Patients
6.06C Amarillo - Instructions for Inmate Appointments
6.06C El Paso - Instructions for Inmate Appointments
6.06C Lubbock - Instructions for Inmate Appointments
6.06C Odessa - Instructions for Inmate Appointments
6.06D Inmate Management Plan Policy Violation
6.07 Clinical Research Patients
6.09 Family Participation in Patient Care Decisions
6.20A Advance Directive Consent Form (English)
6.20A.1 Advance Directive Consent Form (Spanish)
6.20B Disclosure Statement for Medical Power of Attorney (English)
6.20B.1 Disclosure Statement for Medical Power of Attorney (Spanish)
6.20C Surrogate Decision of Advance Directives (English)
6.20C.1 Surrogate Decision of Advance Directives (Spanish)
6.20D Mental Health Declaration (English)
6.20D.1 Mental Health Declaration (Spanish)
6.20E Out of Hospital Do-Not-Resuscitate Order
6.20F Frequently Asked Questions Regarding Advance Directives
6.20G Advance Directives - Summary Sheet (English and Spanish)
6.21A Consent for Treatment Guidelines, Who May Sign for Consent
6.21B Consent to Treatment/Health Care Agreement (English)
6.21B.1 Consent to Treatment/Health Care Agreement (Spanish)
6.21C Alternative Consent for Minor by Non-Parent
6.21D Texas Medical Disclosure Panel List A
6.21D.1 Texas Medical Disclosure Panel List B
6.21E General Medical/Surgical Procedures Consent (English)
6.21E.1 General Medical/Surgical Procedures Consent (Spanish)
6.22 Refusal to Submit to Treatment and/or Refusal to Follow Physician's Instructions
6.22A Refusal to Submit to Treatment and/or Refusal to Follow Physician's Instructions Form
6.23 Audiovisual Recording, Patient Consent
6.24 Management of Suspected Abuse Victim
6.24A Recognizing and Reporting Child Abuse
6.24B Recognizing and Reporting Elder or Disabled Abuse
6.24C Recognizing and Reporting Adult Victims of Family Violence
6.24D Checklist for DSHS Monitoring
6.24E Amarillo - Domestic Violence Notice
6.24E El Paso - Domestic Violence Notice
6.24E Lubbock - Domestic Violence Notice
6.24E Odessa - Domestic Violence Notice
6.25 Transportation of Patients
El Paso Campus Policies
EP 6.2 Persons Accompanying Patients
EP 6.3 Termination of the Physician/Patient Relationship
EP 6.4 Management of the Suspected Abuse Victim
EP 6.4A Recognizing and Reporting Child Abuse
EP 6.4B Reporting Elder Disabled Abuse
EP 6.4C Reporting Adult Victims Family Violence
EP 6.4D Child Abuse Reporting Form
EP 6.4E Notice of Family Violence
7. Infection Prevention and Control
All Campus Policies
7.01 Infection Prevention & Control Plan
7.04 Infection Control, Waiting Room/Lobby
7.05 Disposal of Needles & Sharps
7.06 Disposal of Biohazardous/Infectious Waste
7.07 Management of Blood & Body Fluid Exposures
7.07A Needlestick Injuries/Exposures to Body Fluids:(Amarillo)
7.07B Needlestick Injuries/Exposures to Body Fluids:(El Paso)
7.07C Needlestick Injuries/Exposures to Body Fluids:(Lubbock)
7.07D Needlestick Injuries/Exposures to Body Fluids:(Odessa)
7.08 Cleaning of Blood Soiled Areas
7.09 Sterilization Procedures, Autoclaves
7.11 Cleaning of Patient Exam Room
7.12 Storage of Linens and Supplies
7.13 Cleaning of Pediatric Toys and Equipment
7.14 Staff Lounge/Break Room Cleaning
7.15. High Level Disinfection for Reuseable Instruments
7.15A CIDEX® OPA Test Strip Usage Instructions
7.16 Clinical Waste Disposal Procedures for Infectious Waste
7.17. Outbreak Investigation of Infectious Diseases
7.18. Plan to Manage the Influx of Potentially Infectious Patients
7.20 Employee Communicable Disese Policy
7.20A. CDC Personnel Health Guideline
7.20B . Employee Communicable Disease Report
7.21. Notifiable Conditions Reporting
7.22. Healthcare Associated Infection Tracking
7.22A Healthcare Associated Infection Communication Form
7.23 Clinic Tuberculosis Exposure Control
El Paso Campus Policies
EP 7.1 Infection Control Screening: New Employee, Student, Visitor
EP 7.1A TTUHSC-EP Employee, Student Visitor Infections Control Screening Flow Chart
EP 7.2 Standard Precautions for Blood/Body Fluids (Universal Precautions)
EP 7.3 Needlestick Injuries/Exposures to Body Fluids: Care and Follow Up
EP 7.3A Exposure Control Plan, Bloodborne Pathogens
EP 7.4 Infectious Disease Exposures
EP 7.5 Immuno-Compromised Patients, Care of
EP 7.6 Chemical and Biological Monitoring of Stream Sterilization
EP 7.6A Internal Pack (In-Pack) Monitoring of Steam Sterilization
EP 7.9 Procedure for Notifying Housekeeping for Cleaning Outside of the Normal
EP 7.10 Prevention of Transmission of Hepatitis B, C and HIV from HCW to Patient
EP 7.10A Expert Panel -OH Review and Decisions
EP 7.10B Patient Notification of Exposure
EP 7.10C Physician Attestation
EP 7.10D Exposure Prone Procedures Listing
EP 7.11 Vaccine Administration
EP 7.11A Vaccine Administration - Appendix D
8. Performance Improvement
All Campus Policies
8.01 Performance Improvement Program
8.02A. Occurrence Report Screen
8.07. Reporting Information to the National Practitioner Data Bank of the Texas Medical Board
8.11 Termination of Physician & Patient Relationship
8.11A. Sample Patient Termination Letter (English)
8.11B Sample Confirmation of Patient Decision to Transfer or Terminate Care (English)
8.11C. Sample Patient Termination Letter (Spanish)
8.11D. Sample Confirmation of Patient Decision to Transfer or Terminate Care (Spanish)
8.12 Management of Sentinel Event
8.12A. Sentinel Event Root Cause Analysis and Action Plan
8.13 Missed Appointments/No Show Triage
8.13A Clinic No-Show Physician Triage, Pink Sheet
8.13B Missed Appointments Sample Letters (English)
8.13C Missed Appointments Sample Letters (Spanish)
El Paso Campus Policies
EP 8.1 Performance Improvement Plan
9. Management of Human Resources
All Campus Policies
9.10 Student Guidelines for Patient Care
9.21 Nursing Service Purpose, Philosophy and Objectives
9.23 Nursing Service Organizational Description and Standardization
9.24 License Verification: Registered Nurse, Licensed Vocational Nurse
9.25 Definitions and Limitations for GN, GVN & NA's
9.28 Clinical Personnel Dress Code
9.31 Nursing Budget Responsibilities
9.31A Annual Evaluation Format for Unit-Specific Staffing Plans
9.31B Nursing Management Report
9.50 Volunteer Program Philosophy, Objectives & Organizational Structure
9.50A Volunteer Rights and Responsibilities
10. Environment of Care
All Campus Policies
El Paso Campus Policies
EP 10.2 Fire Extinguisher Monthly Inspection - Off site Clinics
EP 10.3 Hazardous Material Emergency Plan
EP 10.4 Formaldehyde Safety Program
EP 10.5 Facility Use Committee
EP 10.6 Strange Ordor Procedure