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
- 1.05 - 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
- 2.02.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
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
- 4.09 - Prescription Form Completion - Required Information
- 4.10 - Multi-Dose Medication Vials - Use, Handling & Expiration
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
- 6.02.A - Patient/Physician Relations Concern Form
- 6.02.B - Patient Relations Information Intake Form
- 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
- 6.06.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
- 7.07.B - Needlestick Injuries/Exposures to Bodily Fluids: Treatment and Reporting
- 7.07.C - Bloodborne Pathogen Exposure Protocol
- 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
- 7.20 - 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
- 8.02 - 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
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
- 10.60 - Utility Systems Management Plan