The Ambulatory Care Policies and Procedures formerly for the Lubbock campus only are under revision to include all campuses. Links on this page are updated as changes are made. If you experience difficulties, please notify Tim.Hayes@ttuhsc.edu. Thank you.
Link to All Campus Policies
School of Medicine Clinical Affairs
Lubbock Campus Policies and Procedures
Manuals
1. Leadership
- 1.01 - Mission and Vision
- 1.02 - Organizational Chart
- 1.03 - Statement of Professionalism
- 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
- 1.23 - Disruptive Conduct by Members of the Professional Staff
2. Emergency Procedures
- 2.01 - TTUHSC Emergency Paging Codes
- 2.02 - Medical Emergencies in Clinical Areas
- 2.03 - Emergency Equipment: Crash Carts, Drug Boxes & Defribrillators
- 2.04 - Bioterrorism Readiness Plan
3. Patient Care
- 3.01 - Patient Assessment
- 3.02 - Assessment and Management of Pain
- 3.03 - Patient Education
- 3.04 - Orders, Receiving and Noting
- 3.05 - Central Lines
- 3.10 - Removal of a PICC Line
- 3.11 - Extravasation Management
- 3.20 - Laboratory Requisition and Processing
- 3.21 - Lab Specimen Collection
- 3.25 - Latex Allergy - Suspected or Known
- 3.26 (EP-Lbb-PB) - Universal Protocol Verification Process for Invasive Procedures (El Paso, Lubbock and Permian Basin)
- 3.27 - Critical Tests and Critical Result Communication
- 3.28 - Direct Admit Policy
4. Medication Management
- 4.01 - Management of Clinic Stock Drugs & Biologicals
- 4.02 - Sample Drugs Control
- 4.03 - Medication Management, Administration & Documentation
- 4.04 - Medication Administration for Certified Medical Assistants in Ambulatory Care
- 4.06 - Prescriptions 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
- 4.12 - Physician Delegation to Pharmacist
5. Management of Information
- 5.01 - Medical Records Documentation and Confidentiality
- 5.02 - Medical Records Paper Format
- 5.03 - Authentication of Entries into the Medical Record
- 5.04 - Primary Care Patient Summary List
- 5.05 - Medical Record Forms
- 5.07 - Securing Medical Records Pending Litigation
- 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
- 5.16 - Charges for Services Rendered to Outside Agencies
6. Patient Rights
- 6.01 - Patient Rights & 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
- 6.06 - Inmate Management Plan
- 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
- 6.20.G - Advance Directives - Summary Sheet (English and Spanish)
- 6.21 - Informed Consent
- 6.21.A - Consent for Treatment Guidelines, Who May Sign for Consent
- 6.21.B - Consent to Treatment/Health Care Agreement (English)
- 6.21.B.1 - Consent to Treatment/Health Care Agreement (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) (PDF) (Word)
- 6.21.E.1 - General Medical/Surgical Procedures Consent (Spanish) (PDF) (Word)
- 6.22 - Refusal to Submit to Treatment and/or Refusal to Follow Physician's Instructions
- 6.23 - Audiovisual Recording, Patient Consent
- 6.24 - Management of Suspected Abuse Victim
- 6.25 - Transportation of Patients
7. Infection Prevention & Control
- 7.01 - Infection Prevention & Control Plan
- 7.02 - Exposure Control Plan/Isolation Systems: Standard Precautions and Transmission-Based Precautions
- 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 - 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
- 7.16 - 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 Disease Policy
- 7.21 - Notifiable Conditions Reporting
- 7.22 - Healthcare Associated Infection Tracking
- 7.23 - Clinic Tuberculosis Exposure Control
8. Performance Improvement
- 8.01 - Performance Improvement Program
- 8.02 - Occurrence Reporting
- 8.03 - Medical Record Review
- 8.05 - Provider Office Review, Site Visit
- 8.06 - Medical Record Review
- 8.07 - Reporting Information to the National Practitioner Data Bank or the Texas Medical Board
- 8.10 - Risk Management Plan
- 8.11 - Termination of Physician & Patient Relationship
- 8.11.A - Sample Patient Termination Letter (English - PDF) (Word)
- 8.11.B - Sample Confirmation of Patient Decision to Transfer or Terminate Care (English - PDF) (Word)
- 8.11.C - Sample Patient Termination Letter (Spanish - PDF) (Word)
- 8.11.D - Sample Confirmation of Patient Decision to Transfer or Terminate Care (Spanish - PDF) (Word)
- 8.12 - Management of Sentinel Event
- 8.13 - Missed Appointments/No Show Triage
9. Management of Human Resources
- 9.01 - Credentialing and Provider Enrollment Process
- 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
- 9.26 - Nursing Orientation
- 9.28 - Clinical Personnel Dress Code
- 9.29 - Competency Validation
- 9.30 - Resource Pool Staff
- 9.31 - Nursing Budget Responsibilities
- 9.50 - Volunteer Program Philosophy, Objectives & Organizational Structure
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 Management Plan
- 10.40 - Fire Safety Management Plan
- 10.50 - Medical Equipment Management Plan
- 10.60 - Utility Systems Management Plan