School of Medicine Clinical Affairs

Manuals

1. Leadership

• 1.01 - Mission and Vision
• 1.02 - Organizational Chart
• 1.03 - Statement of Professionalism
• 1.05 - Code of Ethical Behavior
• 1.08 - Institutional Health Care Ethics Committee
• 1.09 - Department/Clinic Map
• 1.10 - Policy Statements Initiation and Issuance
• 1.11 - Policy Approval Flowchart
• 1.12 - Clinic Departmental Policy Requirements
• 1.20 - Departmental Retreats & Meetings

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2. Emergency Procedures

• 2.01 - TTUHSC Emergency Paging Codes
• 2.02 - Medical Emergencies in Clinical Areas
• 2.02.A - Cardiopulmonary Arrest Flow Sheet
• 2.03 - Emergency Equipment: Crash Carts, Drug Boxes & Defribrillators
• 2.03.A - Crash Carts Supplies and Drugs
• 2.03.B - Emergency Equipment Check List
• 2.03.C - Emergency Equipment Inventory
• 2.04 - Bioterrorism Readiness Plan
• 2.04.A - Lubbock Contact Numbers

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3. Patient Care

• 3.01 - Patient Assessment
• 3.02 - Assessment and Management of Pain
• 3.02.A - Pain Scales
• 3.02.B - Pain Assessment Form
• 3.03 - Patient Education
• 3.04 - Orders, Receiving and Noting
• 3.05 - Blood Samples, Obtaining from Central Line
• 3.06 - Examinations, Position and Assisting
• 3.08 - Central Line IV Site Care and Discontinuation
• 3.09 - Conscious Sedation
• 3.09.A - Conscious Sedation Record
• 3.11 - Extravasation Management
• 3.20 - Laboratory Requisition and Processing
• 3.21 - Lab Specimen Collection
• 3.25 - Latex Allergy - Suspected or Known

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4. Medication Management

• 4.01 - Management of Clinic Stock Drugs & Biologicals
• 4.02 - Sample Drugs Control
• 4.02.A - Sample Drugs Log
• 4.02.B - Sample Drugs Disposal
• 4.03 - Medication, Administration & Documentation
• 4.06 - Prescription by Telephone
• 4.06.A - Staff Designations for Phone Prescriptions
• 4.07 - Adverse Drug Event Reporting
• 4.07.A - Patient/Visitor Occurrence Screen
• 4.08 - Intravenous Medication Administration

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5. Management of Information

• 5.01 - Medical Records Documentation & Confidentiality
• 5.02 - Medical Records Format
• 5.02.A - Medical Records Standard Format
• 5.03 - Authentication of Entries into the Medical Record
• 5.04 - Primary Care Patient Summary List
• 5.04.A - Summary List, Adult
• 5.04.B - Summary List, Child
• 5.04.C - Medication Sheet
• 5.05 - Medical Record Forms
• 5.07 - Securement of Medical Records
• 5.08 - Access 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
• 5.12 - Adoption Records
• 5.15 - Medical Records Abbreviations
• 5.15.A - UMC/HSC Do Not Use Abbreviations
• 5.16 - Charges for Services Rendered to Outside Agencies

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6. Patient Rights

• 6.01 - Patient Rights & Responsibilities
• 6.02 - Patient Concern Procedures
• 6.02.A - Patient/Physician Relations Concern Form
• 6.02.B - Patient Relations Infomration Intake Form
• 6.04 - Patients Who Threaten Harm to Themselves or Others
• 6.05 - Patients with Communication Difficulties, Visual or Hearing
• 6.06 - Inmate Management Plan
• 6.06.A - Suggestions for Dealing with Inmate/Prisoner Patients
• 6.06.B - Inmate Management Plan Policy Violation
• 6.06.C - Inmate Management Log
• 6.06.D - Instructions for Inmate Appointments
• 6.07 - Clinical Research Patients
• 6.08 - Spiritual Care
• 6.09 - Family Participation in Patient Care Decisions
• 6.20 - Advance Directives
• 6.20.A - Advance Directive Consent Form (English)
• 6.20.A.1 - Advance Directive Consent Form (Spanish)
• 6.20.B - Disclosure Statement for Medical Power of Attorney (English)
• 6.20.B.1 - Disclosure Statement for Medical Power of Attorney (Spanish)
• 6.20.C - Surrogate Decision of Advance Directives (English)
• 6.20.C.1 - Surrogate Decision of Advance Directives (Spanish)
• 6.20.D - Mental Health Declaration (English)
• 6.20.D.1 - Mental Health Declaration (Spanish)
• 6.20.E - Out of Hospital Do-Not-Resuscitate Order
• 6.20.F - Frequently Asked Questions Regarding Advance Directives
• 6.21 - Informed Consent
• 6.21.A - Who May Sign for Consent
• 6.21.B - General Consent to Treatment (English)
• 6.21.B.1 - General Consent to Treatment (Spanish)
• 6.21.C - Alternative Consent for Minor by Non-Parent
• 6.21.D - Texas Medical Disclosure Panel List A
• 6.21.D.1 - Texas Medical Disclosure Panel List B
• 6.21.E - General Medical/Surgical Procedures Consent (English)
• 6.21.E.1 - General Medical/Surgical Procedures Consent (Spanish)
• 6.22 - Refusal to Submit to Treatment and/or Refusal to Follow Physician's Instructions
• 6.22.A - Refusal to Submit to Treatment and/or Refusal to Follow Physician's Instructions Form
• 6.23 - Audiovisual Recording, Patient Consent
• 6.23.A - Consent to Audiovisual Recording Form
• 6.23.B - Consent to Audiovisual Recording Form (Spanish)
• 6.24 - Management of Suspected Abuse Victim
• 6.24.A - Recognizing and Reporting Child Abuse
• 6.24.B - Recognizing and Reporting Elder or Disabled Abuse
• 6.24.C - Recognizing and Reporting Adult Victims of Family Violence
• 6.24.D - Checklist for DSHS Monitoring
• 6.24.E - Domestic Violence Notice
• 6.25 - Transportation of Patients

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7. Infection Prevention & Control

• 7.01 - Infection Prevention & Control Plan
• 7.02 - Standard Precautions, Exposure Control Plan
• 7.03 - Hand Hygiene
• 7.04 - Infection Control, Waiting Room
• 7.05 - Disposal of Needles/Sharps
• 7.06 - Disposal of Biohazardous/Infectious Waste
• 7.07 - Management of Blood & Bodily Fluid Exposures
• 7.08 - Cleaning of Blood Soiled Areas
• 7.09 - Incidental Housekeeping
• 7.10 - Sterilization Procedures, Autoclaves
• 7.11 - Cleaning of Patient Exam Room
• 7.12 - Linen and Supply Storage
• 7.13 - Cleaning of Pediatric Toys and Equipment
• 7.14 - Cleaning of Staff Lounge/Break Room
• 7.15 - High Level Disinfection for Reuseable Instruments
• 7.16 - Clinical Waste Disposal Procedures for Infectious Waste
• 7.20 - Employee Communicable Disease
• 7.20.A - CDC Suggested Work Restrictions
• 7.20.B - Clinic Tuberculosis Exposure Control
• 7.21 - Communicable Diseases Reporting
• 7.21.A - Notifiable Conditions Report Form
• 7.22 - Nosocomial Infection Tracking
• 7.22.A - Nosocomial Infection Communication Form
• 7.23 - Clinic Tuberculosis Exposure Control
• 7.23.A - Regimen Options for the Treatment of Tuberculosis

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8. Performance Improvement

• 8.01 - Performance Improvement Program
• 8.01.A - Performance Improvement/Patient Safety Plan
• 8.01.B - Performance Improvement Model (6:2B)
• 8.01.C - Performance Improvement Report (6:2C)
• 8.01.D - Performance Improvement Information Flow (6:2D)
• 8.02 - Occurrence Reporting
• 8.02.A - Occurrence Report Screen
• 8.05 - Provider Office Review, Site Visit
• 8.05.A - Provider Office Review Request Form
• 8.05.B - Provider Office Review Assessment Tool
• 8.06 - Medical Record Review
• 8.06.A - Medical Record Review Assessment Tool
• 8.06.B - Provider Office Review/Medical Record Review Report
• 8.06.C - Physician Profile (10:4C)
• 8.10 - Risk Management Plan
• 8.11 - Termination of Physician & Patient Relationship
• 8.11.A - Sample Patient Termination Letter
• 8.11.B - Sample Confirmation of Patient Decision to Transfer or Terminate Care
• 8.11.C - Sample Patient Termination Letter (Spanish)
• 8.12 - Sentinel Event, Management of
• 8.12.A - Sentinel Event Root Cause Analysis and Action Plan
• 8.13 - Missed Appointments/No Show Triage
• 8.13.A - Clinic Now Show Physician Triage, Pink Sheet
• 8.13.B - Missed Appointment Sample Letters

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9. Management of Human Resources

• 9.01 - Credentialing and Provider Enrollment Process
• 9.10 - Medical Students Guidelines for Patient Care
• 9.20 - Definition of Nursing
• 9.21 - Nursing Service Purpose, Philosophy & Objectives (3:13:2)
• 9.22 - Nursing Care Standardization (3:13:3)
• 9.23 - Nursing Service Organizational Description (3:13:4)
• 9.24 - License Verification, Registered Nurse, LVN (3:13:5)
• 9.25 - Definitions and Limitations for GN, GVN & NA's (3:13:6)
• 9.26 - Nursing Orientation (3:13:13)
• 9.26.A - Nurse Manager Orientation Checklist (3:13:13A)
• 9.26.B - General Nursing Orientation Checklist (3:13:13B)
• 9.26.D - Nursing Orientation Evaluation (3:13:13D)
• 9.27 - Nursing Compliance (3:13:14)
• 9.28 - Nursing Dress Code
• 9.29 - Competency Validation (3:13:10)
• 9.30 - Resource Pool Staff
• 9.31 - Nursing Budget Responsibilities (3:13:7)
• 9.50 - Volunteer Program Philosophy, Objectives & Organizational Structure (9:1)
• 9.51 - Volunteer Historical Summary
• 9.52 - Volunteer Orientation, Departmental Responsibilities (9:3)
• 9.52.A - Volunteer Orientation Checklist (9:3A)
• 9.52.B - Volunteer Competency Monitor (9:3B)
• 9.53 - Recruiting of Volunteers (9:4)
• 9.54 - Volunteer Rights and Responsibilities (9:5)
• 9.55 - Volunteer Job Descriptions
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• 9.55.A - Greeter (9:6A)
• 9.55.B - Clerical Assistant (9:6B)
• 9.55.C - Lab Assistant (9:6D)
• 9.55.D - Storytellers
• 9.55.E - Clinic Assistant (9:6C)

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10. Environment of Care

• 10.01 - Safety Management Plan
• 10.10 - Security Management Plan
• 10.20 - Hazardous Materials and Waste Management Plan
• 10.30 - Emergency Preparedness Management Plan
• 10.40 - Life Safety Management Plan
• 10.50 - Medical Equipment Management Plan
• 10.51 - Medical Equipment Management (6:8)
• 10.60 - Utility Systems Management Plan

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