This page is currently under construction. The Ambulatory Care Policies and Procedures are being reorganized to match the categories indicated below. Links with a parenthetical reference at the end indicate policies that have not yet been converted to the new format and numbering system. If you find a broken link on this page, please notify Tim.Hayes@ttuhsc.edu. Thank you for your understanding.
Link to All Campus Policies
School of Medicine Clinical Affairs
Lubbock Campus Policies and Procedures
Manuals
TTUHSC is accredited by the Joint Commission
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
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
- 2.03.A - Crash Carts Supplies and Drugs
- 2.03.B - Emergency Equipment Check List
- 2.03.C - Emergency Equipment Inventory
- 2.04 - Bioterrorism Readiness Plan
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 - 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
- 3.11 - Extravasation Management
- 3.20 - Laboratory Requisition and Processing
- 3.21 - Lab Specimen Collection
- 3.25 - Latex Allergy - Suspected or Known
4. Medication Management
- 4.01 - Management of Clinic Stock Drugs & Biologicals
- 4.02 - Sample Drugs Control
- 4.03 - Medication, Administration & Documentation
- 4.06 - Prescription by Telephone
- 4.07 - Adverse Drug Event Reporting
- 4.08 - Intravenous Medication Administration
5. Management of Information
- 5.01 - Medical Records Documentation & Confidentiality
- 5.02 - Medical Records Format
- 5.03 - Authentication of Entries into the Medical Record
- 5.04 - Primary Care Patient Summary List
- 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
- 5.16 - Charges for Services Rendered to Outside Agencies
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
- 6.23 - 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
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
- 7.21 - Communicable Diseases Reporting
- 7.22 - Nosocomial Infection Tracking
- 7.23 - Clinic Tuberculosis Exposure Control
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
- 8.05 - Provider Office Review, Site Visit
- 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
- 8.13 - Missed Appointments/No Show Triage
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)
- 9.53 - Recruiting of Volunteers (9:4)
- 9.54 - Volunteer Rights and Responsibilities (9:5)
- 9.55 - Volunteer Job Descriptions .
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
