emembership POLICIES & PROCEDURE
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Welcome to your
All Access e-membership
Policies & Procedures Library
Categories
Patient's Rights & Responsibilities
Governance
Administration
Quality of Care Provided
QMI-Quality Improvement Program
QMI-Risk Management
Clinical Records & Health Information
Infection Control
Facilities and Environment
Anesthesia Care Services
Surgical and Related Services
Pharmaceutical Services
Pathology & Medical Laboratory
Diagnostic & Other Imaging
Patient's Rights & Responsibilities Back to Categories
- Abuse, Neglect & Identification Reporting
- Advance Directives
- Americans with Disabilities Act
- Business Associates
- Confidentiality
- Financial Ownership & Billing Information
- Non-Discrimination Policy
- Notice of Privacy Policy
- Outside Personnel in the Facility
- Patient Complaints & Grievances
- Patient Complaints & Grievances Follow-Up
- Patient Dismissal From Care
- Patients Bill of Rights and Responsibilities
- Privacy Facilities Overview
- Privacy Officer
- Provision of Services for Effective Communication
- Staff Knowledge of Patient Rights
Governance Back to Categories
- Accrediting Agency Notification
- Adherence to Regulatory Agency Rules
- Admission Criteria
- Approved Procedures
- Chain of Command
- Communication with External Organizations
- Corporate Compliance
- Credentialing Medical Staff
- Facility Mission, Philosophy & Objectives
- Governing Body ByLaws, Rules & Regulations
- Medical Staff ByLaws
- Medical Staff Rules & Regulations
- Medicare Compliance Program
- Organizational Chart
- Patient Satisfaction
- Peer Review of Anesthesiologists
- Peer Review of CRNAs
- Peer Review of Physician and Nursing Staff
- Renewal of Medical Staff Privileges
- Reporting Incidents to the State
Administration Back to Categories
- Body Mechanics
- Clinical Competency Program
- Code Drill Evaluation
- Continuing Education
- Deductibles, Copayments & Coinsurance
- Employee Discipline
- Employee Orientation
- Employment Practices
- Impaired Employee Provider
- Job Description - Director of Nursing
- Job Description - Receptionist / Medical Records
- Job Description - Staff Nurse - LPN
- Job Description - Staff Nurse -RN
- Job Description - Technician
- Performance Evaluation
- Staff Grievances, Complaints & Suggestions
Quality of Care Provided Back to Categories
- Ambulance Service
- Hours of Operation / After Hours Emergencies
- Laboratory Services
- Pharmaceutical Services
- Radiology Services
- Referral Service for Continuity of Care
QMI-Quality Improvement Program Back to Categories
- Quality Assessment / Performance Improvement Plan
- Quality Assessment / Performance Improvement Collection of Data
- Quality Assessment / Year End Committee Evaluation
- Quality Assurance Study Report
QMI-Risk Management Back to Categories
- Active Shooter / Armed Intruder Procedure
- Adverse Incident Report
- Blanket Warmer Policy
- Construction Risk Assessment
- Handling of Patients Valuables
- Hazard Reporting Safe Environment for Patients
- Incapacitated or Physically Ill Physician
- Patient Cart Brakes & Side Rails
- Reporting Device Failure
- Risk Management
- Risk Management Follow Up
- Risk Management Reporting
- Risk Management Reporting Quality Assessment
- Smoking Policy
- Violence in the Workplace
Clinical Records & Health Information Back to Categories
- Approved Abbreviations
- Consent for Procedure
- History and Physical
- Intra-procedure Documentation
- Medical Record Content
- Medical Records Destruction
- Medical Records Maintenance
- Medical Records Overview
- Missed, Cancelled Procedures and Follow Up
- Physician Standing Orders
- Procedure Report / OP Note
- Release of Patient's Medical Records
Infection Control Back to Categories
- Acute or Infectious Communicable Diseases
- Air Exchanges, Temperature, and Humidity
- Approved Germicides Used Within the Facility
- Aseptic Technique
- Autoclave Sterilization & Processing Reusable Devices
- Bloodborne Pathogen Exposure Control Plan
- Borrowed Instruments and Equipment
- Classification of Surgical Procedures
- Cleaning on Non-Critical Equipment
- Cleaning of Surgical Procedure Site
- Construction, Renovation, Repair, and Demolition
- Disposal of Blades, Glass & Needles
- Dress Code & Surgical Attire
- Education
- Emergent Infectious Diseases-Coronavirus
- Employee Health Policy
- Environmental Cleaning
- Gloving Methods for Infection Control
- Glucometer Testing Devices
- Hand Hygiene
- Handling of Sterile Supplies
- Immediate Use of Steam Sterilization ie: IUSS
- Infection Control in the O.R.
- Infection Control Program
- Infection Log Policy
- Injectable Medication Usage
- Laundry
- Linen
- Management of Biohazardous Wastes
- Mask and Scrub Technique
- Multi-Drug Resistant Organisms
- Pest Control
- Red Bag Contents
- Refrigerator Freezer Cleaning
- Sanitation in Employee Break Area
- Selection and Use of Personal Protection Equipment
- Selection of Barrier Materials & Surgical Gowns
- Sharps Hands-Free Technique
- Shelf Life of Sterile Supplies
- Single Use Devices
- Skin Prep
- Spills Policy Infection Control
- Standard and Transmission-Based Precautions
- Sterile Packaging
- Sterilization Performance Monitoring
- Surgical Hand Scrub
- Surgical Site Validation
- Surgical Spaces
- Traffic Patterns
- Universal Precautions Bloodborne Pathogen Training
- Visitors in the O.R.
- Voluntary Respirator Use
- Would Cultures & Tissue Specimens in the O.R.
Facilities and Environment Back to Categories
- Advanced Cardiac Life Support Certification
- Annual Fire Inspection and Inservice
- Basic Cardiac Life Support (BCLS) Certification
- Bioterrorism
- Blood Products
- Bomb Threat Procedure Code Orange
- Cardiopulmonary Resuscitation Code Blue
- Crash Cart
- Defibrillator Testing
- Disaster Preparedness Plan
- Equipment Preventative Maintenance
- External Disaster
- Facility Evacuation
- Fire Code Red
- Fire Drill and Procedure for Fires
- Fire Watch
- Internal Disaster
- Interruption of Water Service Code Green
- Maintenance Overview
- Oxygen Manifold and Tank Maintenance
- Transfer of Patient to the Hospital
- Use and Maintenance of Fire Extinguishers
Anesthesia Care Services Back to Categories
- Administration and Monitoring of Propofol
- ASA Physical Status Classification
- Cardiac Monitoring
- Cart and Workroom Keys
- Certified Registered Nurse Anesthetist Admin IV Moderate
- CRNA Competency Assessment Program
- Equipment Supplies and Daily Drug Checks
- I.V. Moderate Sedation Analgesia Administered by RN
- I.V. Moderate Sedation Analgesia Considerations for Colonoscopy
- I.V. Moderate Sedation Analgesia Considerations for Upper Endoscopy
- Monitoring Oxygen Saturation
- Malignant Hyperthermia
- Monitoring Oxygen Saturation
- Purpose and Responsibilities of Anesthesia Services
- Responsibilities of Anesthesia Personnel
- Responsibilities of the Supervising Anesthesiologist
Surgical and Related Services Back to Categories
- Assisting Patient to the Ambulance
- Dietary Policy
- Discharge Criteria
- Fall Risk Assessment
- Fire Risk Assessment
- Goals and Objectives of Nursing Personnel
- Handling and Reporting of Specimens
- Implementing and Evaluating Nursing Policies & Procedures
- IV Insertion (Venous Cannulation)
- Latex Allergy
- Nursing Duties for Pre-procedure
- Operating Room Daily Maintenance
- Pain Management
- Patient Call System
- Patient Care Duties During Procedures
- Patient Identification
- Patient Transportation to Home after Sedation
- Post Procedure Care for Sedated Patients
- Post Procedure Follow Up
- Post Procedure Instructions
- Pre & Post-Procedure Area Daily Maintenance
- Pre-Procedure Patient Medication Guidelines
- Pre-Procedure Requirements
- Sequential Compression Devices for DVT Prophylaxis
- Sponge, Sharps & Instrument Counts
- Staffing Requirements
- Time Out Policy
- Transporting Patients
- Verification of Nursing License
Pharmaceutical Services Policies & Procedures Library Back to Categories
- Administration of Medications
- Adverse Drug Reactions
- Disposition of Outdated Drugs Reagents & Solutions
- Drug Allergies & Sensitivities
- Manufacturer Recall of Medical Drugs, Devices and Supplies
- Medication Reconciliation
- Medication Error
- Mishandling of Drugs
- Narcotic Ordering, Storage, Counts, Access & Keys
- Prescription Pads
- Storage of Refrigerated Medication
- Verbal Drug Orders
- Wasting of Unused Narcotics
Pathology & Medical Laboratory Back to Categories
Diagnostic & Other Imaging Back to Categories
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