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Policies
Incident Reporting
Pediatric Nutrition Care Manual (PNCM)
Work Order
Contact IT
Contact EMR Support
Administrative
1. Leadership
AM 1.3 Mission, Vision, Values Statement
AM 1.4 Philosophy Statement; Definition of Culture
AM 1.5 Organizational Ethics Statement
AM 1.6 Integrity of Clinical Decisions
AM 1.7 Code of Conduct
AM 1.8 Conflict of Interest, Governing Body, Medical and Leadership / Staff
AM 1.9 Just Culture
AM 1.10 Improving Health Outcomes for All
2. Health Information Management
AM 2.0 Notice of Name Change – ALIAS
AM 2.0a Alias First Names A to Z
AM 2.01 Patient Alias Notice (Form)
AM 2.02 Medical Record Onsite Review
3. Administration
AM 3.0 Administrative Management
AM 3.1 Strategic Plan
AM 3.2 Information Management Plan
AM 3.22 System Methodology
AM 3.23 Internet Use
AM 3.24 Technical Support
AM 3.25 Duplication of Software
AM 3.26 Electronic Mail (E-mail)
AM 3.27 Data / Internet / Phone Outage
AM 3.28 Visitor Internet Access
AM 3.29 Portable Device Guidelines
AM 3.29.1 Request for Portable Device (Form)
AM 3.30 ePHI Onsite Backup and EMR Downtime
AM 3.31 Social Media
AM 3.32 Portal Patient Provider Communication
AM 3.33 Patient Provider Communication via Permedion Portal
AM 3.34 Data Visualization Tool Downtime (Tableau)
AM 3.35 Consumer Voice Assistant Devices
4. Management
AM 4.1 Administrator
AM 4.1.1 Departmental Leadership
AM 4.2 Changes Within the Organization
AM 4.3 Licensure
AM 4.4 Inspection Reports
AM 4.5 Reportable Events
AM 4.7 News Media
AM 4.9 Administrator On Call
AM 4.10 Law Enforcement Agency Interaction
AM 4.13 Conflicts of Interest
AM 4.15 Confidentiality and Release of Information
AM 4.15.1 Privacy Officer
AM 4.15.2 Notice of Privacy Information Practices
AM 4.15.3 Photographing, Video Recording, Audio Recording and Other Imaging of Patients, Visitors and WorkForce Members
AM 4.15.3.1 Consent for Recording or Filming
AM 4.15.3.1a Consent for Recording or Filming (Form)
AM 4.15.4 Consent to Photograph/Videograph Patients (Form)
AM 4.15.5 Secure Text Messaging
AM 4.15.6 ROI Social Services
AM 4.16 Confidentiality Code
AM 4.16.1 Confidentiality Code Sheet (Form)
AM 4.17 Fraud, Waste, and Abuse
AM 4.18 Admission Criteria
AM 4.19 Medical Records Forms
AM 4.20 Inability to Pay
AM 4.21 Care Coordination
AM 4.22 Resuscitation Services
AM 4.23 Clinical Alarm Management
5. Patient Rights
AM 5.1 Patient Rights
AM 5.2 Notice of Patient Rights and Responsibilities
AM 5.3 Assignment of Patient Rights
AM 5.5 Designation of a Physician
AM 5.7 Refusal of Care, Treatment or Services
AM 5.10 Academic Education
AM 5.13 Interpretation and Communication
AM 5.14 Grievances/Complaints – Patients
AM 5.14a Grievances/Complaint Report (Form)
AM 5.16 Patient Abuse, Neglect, & Exploitation
AM 5.18 Telephones – Patient Use or Restrictions
AM 5.19 Patient/Family Satisfaction
AM 5.20 Visitation/Security
AM 5.21 Personal Property
AM 5.22 Provision of Spiritual Services
6. Patient Care
AM 6.1 Pain Management
AM 6.3 Team Conferences /Care Planning
AM 6.4 Documentation: Military Time
AM 6.5 Behavioral Management Referral Process
AM 6.7 Fall Prevention
AM 6.7.1 Fall: Care of a Patient After a Fall
AM 6.7.2 Newborn/Infant Drop Prevention
AM 6.8 Dental Care
AM 6.9 Diagnostic Services
AM 6.10 Medical Emergency Care
AM 6.11 Blood and Blood Products
AM 6.12 Informing Patient/Family About Outcomes/Unanticipated Outcomes of Care, Treatment and Services
AM 6.13 Critical Airway Precautions and Staffing
AM 6.14 Safe Use of Infant Equipment and SIDS Prevention
AM 6.15 Audio/Visual Baby Monitors
AM 6.16 Immunizations
AM 6.20 Notice of An Involuntary Transfer and/or Discharge
AM 6.21 Patient Identification
AM 6.22 Discharge Plan
AM 6.23 Documentation Guidelines for Discharge/Transfer Summary
AM 6.23.1 Discharge/Transfer Summary (Form)
AM 6.24 Discharge Against Medical Advice (AMA)
AM 6.25 Home Ventilation Discharges
AM 6.26 Leave the Floor – Within WCRH Campus
AM 6.26.1 Day Pass
AM 6.26.2 Therapeutic Community Outing
AM 6.27 Patient and Family Education Interventions
AM 6.28 Documentation: Patient and Family Education
AM 6.28.1 Interdisciplinary Teaching Checklist – Patient (Form)
AM 6.28.2 Teaching Checklist by Discipline (Form)
AM 6.29 Patient Assessment and Evaluation
AM 6.30 Safe Patient Handling
AM 6.32 Safety: Medication Management
AM 6.33 Non-Emergent Interdisciplinary Communication of Patient Care Needs
AM 6.47 Restraints: Care of the Patient at Risk for Physical Harm, RAP One to One, Continuous Observation
AM 6.48 Care of Psychiatrically Ill Patients and/or Patients with Alcoholism or Drug Addiction
AM 6.49 Suicide Screening and Precautions
AM 6.50 Response to Changes in Patient’s Medical Condition
AM 6.51 Child Safety/Restraint Transportation Guidelines
AM 6.51.1 Child Safety/Restraint Transportation Guidelines: Car Seat Testing
AM 6.51.2 Transportation Guidelines: Caregiver Education for Child Safety Restraints and Wheelchair Transportation
AM 6.53 Approved and Unapproved Medical Abbreviations
AM 6.54 Diabetes Management
AM 6.55 Telehealth
AM 6.55.1 Informed Consent for Telehealth Services (Form)
AM 6.56 Animals in Hospital Facilities
AM 6.57 Motorized Infant Swing Guidelines
7. Finance / Business Office
AM 7.1 Admission, Transfer, and Discharge Register
AM 7.5 Business Office Operations
AM 7.7 Financial Arrangements Third Party Payers
AM 7.8 Financial Reports
AM 7.11 Purchasing Policy
AM 7.13 Capital Equipment
AM 7.14 Capital Equipment & Major Project or Service Approval Process
AM 7.22 Guidelines for Classification of HCFA Diagnostic Categories
AM 7.26 Free Care
8. Human Resources
AM 8.1 Policies, Employee Notification of New & Revised
AM 8.2 Equal Opportunity Employer
AM 8.3 Employee Recognition
AM 8.6 Pre-Employment Screening: Licensure Verification
AM 8.7 Absenteeism and Lateness
AM 8.7a Employee Warning Report (Form)
AM 8.8 Orientation
AM 8.9 Job Descriptions/Performance Evaluation
AM 8.10 Education Competency Program and Annual Competency Evaluation Record (CBER)
AM 8.11 Annual Learning and Competency
AM 8.11b HealthStream Policy
AM 8.12 Termination: Voluntary or Involuntary
AM 8.13 Dress Code, Hygiene, and Grooming
AM 8.14 Paid Time Off
AM 8.15 Leave of Absence – Family Medical Leave
AM 8.15.2 Personal Leave of Absence
AM 8.16 Medical Insurance Opt-Out
AM 8.17 Drug Testing/Substance Abuse
AM 8.18 Sexual Harrassment
AM 8.19 Exclusion from Patient Care
AM 8.20 Jury Duty
AM 8.21 Time Records
AM 8.22 Progressive Corrective Intervention
AM 8.23 Severe Weather Emergency
AM 8.24 Education Tuition Assistance
AM 8.24a Education Tuition Assistance Application (Form)
AM 8.25 Employment Status
AM 8.26 Smoking Policy
AM 8.27 Volunteer Services Program
AM 8.28 Peer Review
AM 8.29 Staffing Effectiveness
AM 8.30 Computer/EMR Access for Employees and Students
AM 8.31 Health Care Professional Responsibility & Reporting
AM 8.32 Employee Referral Bonus Program – Critical Positions
AM 8.32a Employee Referral Bonus (Form)
AM 8.33 Employee Sign On Bonus Program – Critical Positions
AM 8.34 Disaster Responsibilities – Volunteer Practitioners
AM 8.36 Resuscitation Services: Emergency Preparedness Education CPR Certification
AM 8.38 Intra-Hospital Transfers, Additional Employment and Promotions
AM 8.39 Work-Related Injuries
AM 8.40 Employee Cell Phone Use
AM 8.41 Mileage Reimbursement
AM 8.41a Mileage Reimbursement Log (Form)
AM 8.42 Decoration Use
AM 8.43 Telecommuting Work From Home
AM 8.43.1 Telecommuting Agreement (Form)
AM 8.44 Employee Restraining Orders
AM 8.45 Fleet Program
AM 8.46 Personal Vehicle Usage Policy
9. Medical Staff
AM 9.1 Bylaws/Medical Practices
AM 9.5 Advance Directives
AM 9.6 Definition/Determination of Death
AM 9.7 Foregoing Life-Sustaining Treatment
AM 9.8 Bioethics Committee
AM 9.9 Informed Consent
AM 9.13 Care of Patient at Death
AM 9.13a Certificate of Death (Form)
AM 9.13b Communicable Diseases Alert (Form)
AM 9.14 Autopsy
AM 9.15 Reporting Requirement/Funeral Director
AM 9.16 Deaths Reportable to the Medical Examiner
AM 9.17 Information Reportable to the State Board of Medical Examiners
AM 9.18 Reporting of Diagnosed and/or Suspected Cases of Child Abuse and/or Neglect
AM 9.18.1 Division of Child Protection & Permanency – Hospital Hold
AM 9.20 Referral to Medical Consultation and Other Health Care Providers
AM 9.21 Organ Donation
AM 9.22 Interdisciplinary Care of the NAS Infant
View Entire Administrative Manual
Care Coordination
CC.CM 206: Patient Admission, Transfer, Discharge
CC.CM: 202 Referrals to Providers
CC.CM: 204 Utilization Review Plan
CC.CM: 204a Utilization Control Plan Inpatient Services
CC.CM: 205 Discharge Planning
View Entire Care Coordination/ Case Management Manual
Infection Control
1. General Infection Control
IC 100: Infection Control Program
IC 101: Infection Control Professional
IC 102: Elements of the Infection Control Program
IC 102a: Communications with Other Facilities (Form)
IC 103: Surveillance Program
IC 104: Guidelines for Infection Control Statistics
IC 105: Guidelines for Determining Presence, Classification, and Definition of Infections
2. Preventative Actions / Mitigation
IC 200: Standard Precautions
IC 201: Transmission-Based Isolation Precautions
IC 201a: Isolation by Disease Entity
IC 202: Preventing Transmission of Infections – Including Hand Hygiene
IC 202a: Hand Hygiene
IC 203: Fingernails
IC 204: Preventative Actions Employees Must Take
IC 205: Susceptible Restrictions
IC 206: Diseases Not Requiring Isolation
IC 207: Initiation of Isolation Precautions
IC 208: Discontinuing Isolation Precautions
IC 209: Visitors of Patients in Isolation
IC 209a: Visitor Information
IC 210: Restrictions for Sick Visitors
IC 211: Preventative Actions for Selected Patients
IC 212: Private Room for Prevention of Spread of Infection
IC 213: Transporting Patients on Isolation / Precautions
IC 214: Emergency Response Employee Exposure Notification
IC 215: Therapy Guidelines for Patients on Isolation
IC 217: Infectious Disease Patient Influx Management
IC 218: Pet Therapy
3. Cleaning / Disinfection
IC 300: Cleaning and Disinfection Practices
IC 301: Use of Disinfectant Wipes
IC 302: Care of Equipment Used in Isolation Rooms
IC 303: Clean up of Blood / Body Fluid Spill
IC 304: Labeling Laboratory Specimens
IC 305: Management of Contaminated Sharps
IC 306: Management of Infectious (Red Bag) Waste
IC 307: Guidelines for Cleaning Toys, Strollers, Playpens, Swings, and Exersaucers
IC 308: Guidelines for Cleaning Feeding Equipment
IC 309: Care of Washer and Dryer
IC 310: Cleaning of Ice Machine
4. Allergy and Infectious Disease
IC 400: Latex Allergic or Latex Sensitive Patient
IC 401: Influenza Vaccination Program for Patients
IC 402: Influenza Vaccination Program for Community Members
IC 403: Pneumococcal Immunization
IC 404: Respiratory Syncytial Virus (RSV)
IC 405: Varicella-Zoster Virus (VZV)
IC 406: Precautions for VRE Isolation
IC 407: Pool Therapy Guidelines
IC 408: Precautions for the Patient Infected/Colonized with Methicillin Resistant Staphylococcus Aureus
IC 409: Rubeola
IC 410: Hierarchy of Controls to Prevent Influenza Transmission in Healthcare Settings
IC 410a: Hierarchy of Controls to Prevent Influenza Transmission (attachments)
IC 411: Mpox
IC 412: Clostridioides Difficile
IC 414: Bedbugs, Lice, Scabies
5. Tuberculosis
IC 500: Tuberculosis Infection Control Plan
6. Bloodborne Pathogen / Exposure
IC 600: Bloodborne Pathogen Exposure Control Plan
IC 601: Employee Risk Categories
IC 601a: Exposure Determination/Assignment of Categories to Employees: Administration
IC 601b: Exposure Determination/Assignment of Categories to Employees: Medical Staff
IC 601c: Exposure Determination/Assignment of Categories to Employees: Nursing Staff
IC 601d: Exposure Determination/Assignment of Categories to Employees: Respiratory
IC 601e: Exposure Determination/Assignment of Categories to Employees: Therapy
IC 602: Blood-borne Pathogen Post-Exposure Protocol
IC 603: Training Programs
IC 604: Qualitative Fit Testing
IC 604a: OSHA Respirator Medical Evaluation Questionnaire (Form)
IC 604b: Respiratory Medical Evaluation: Annual (Form)
7. Employee Health
EH 100: Employee Health Program
EH 100a: Volunteer Health Program
EH 101: Safety and Security
EH 102: Drug and Alcohol Testing
EH 103: Reporting Requirement Re: Change in Health Status
EH 104: Protection of the Patient
EH 105: Exposure to Communicable Diseases – Including Disease of Concern to the Pregnant Employee
EH 106: Employee Injury/Exposure
EH 107: Post Exposure Prophylaxis Protocol
EH 108: Employee Tuberculosis Screening and Exposure
EH 109: Back Injury
EH 110: System for Monitoring of Employee Illness or Injury
EH 111: Influenza Vaccination Program for Employees
EH 111a: Influenza Vaccine Medical Exemption (Form)
EH 111b: Influenza Vaccine Request for Religious Accommodation (Form)
EH 112: Student/Agency Affiliations
EH 113: Latex Allergy/Employees
EH 114: Consent and Counseling for HIV Testing
EH 115: Hepatitis B Prevention Program
EH 116: Small Pox Vaccine Recipients
EH 117: COVID-19 Vaccination Program for Employees
EH 117a: COVID-19 Vaccine Medical Exemption (Form)
EH 117b: COVID-19 Vaccine Religious Accommodation (Form)
EH 119: COVID-19 Exposure/Positive Employee Return to Work
EH 119a: Returning to Work After COVID-19 Exposure (Form)
EH 119b: Returning to Work After COVID-19 Infection
EH 120: Employee Call Out Tracking
View Entire Infection Control Manual
Inpatient Rehabilitation
1. Inpatient Rehabilitation Department Structure
Inpatient Rehabilitation Organizational Chart
TD001: Rehab Department Mission and Philosophy Statement
TD002: Rehab Code of Ethics
2. Inpatient Rehabilitation: General
TD100: Preferred Practice Plans
TD102: Rehabilitation Orientation Program
TD103: Annual Competency Requirement
TD104: Staff Licensure/Credentials
TD108: Compensation for Weekend & Holiday Clinical Service Provision
TD1502: IP Group Services
TD1509: Clinical Ladder
TD1509b: Petition for Clinical Advancement (Form)
TD1509c: Clinical Ladder Template
3. Physical Therapy
TD1100: Physical Therapy Provision of Services
TD1101: Physical Therapy Standards of Practice
TD1102: Physical Therapy Purpose and Goals
TD1103: Physical Therapy Scope of Services/Practice
4. Occupational Therapy
TD1200: Occupational Therapy Provision of Services
TD1201: Occupational Therapy Standards of Practice
TD1202: Occupational Therapy Purpose and Goals
TD1203: Occupational Therapy Scope of Services/Practice
5. Speech Therapy
TD1300: Speech Language Pathology Department Provision of Service
TD1301: Speech Language Pathology Department Preferred Practice Patterns
TD1302: Speech Language Pathology Department Purpose & Goals
TD1303: Speech Language Pathology Department Scope of Practice
6. Therapeutic Recreation
TD1400: Therapeutic Recreation Provision of Services
TD1401: Standards for the Practice of Therapeutic Recreation/Child Life
TD1402: Therapeutic Recreation Purpose Goals
TD1403: Therapeutic Recreation Scope of Services
View Entire Inpatient Rehabilitation Manual
Medical Staff
0. Medical Staff Bylaws
1. Organized Medical Staff Structure
MS 100: Organization of the Medical Staff
MS 101.01: Medical Director Responsibilities
MS 101: Medical Staff Responsibilities of the Medical Director
2. Management of Patient Care, Treatment, and Services
PP 200: Physician Coverage
PP 201: Pulmonary Services
PP 202: Nurse Practitioner Role
PP 203: Sedation
PP 205: Impaired Driver
PP 206: Graduate Medical Education
3. Performance Improvement
PP 300: Medical Staff Role in Quality Assurance
4. Credentialing, Privileges, and Appointment
PP 400: Credentialing
PP 401: Initial Medical Staff Applications
PP 402.00: Primary Source Verification
PP 402.01: National Practitioner Data Bank Queries
PP 403: Criteria for Clinical Privileges
PP 404: Expedited Credentialing
PP 405: Medical Staff Peer Review
PP 406: Temporary Privileges
PP 407: Disaster Privileges
PP 408: Focused Professional Practice Evaluation
PP 409: Ongoing Professional Practice Evaluation (Maintaining Privileges)
5. Continuing Education
PP 500: Continuing Medical Education
View Entire Medical Staff Manual
Nursing Administrative
1. Overview & Responsibilities
101: Provision of Nursing Services Plan of Care
102: Philosophy of Nursing Service
103: The Role of the Nurse Executive & Nursing Leadership
104: Nursing Administration Chain of Command
105: Charge Nurse’s Role, Responsibilities, and Authority Within the Hospital
106: Nursing Care Patient Services, Standards of Nursing Care and Practice
107: Nursing Administration Communication System Pathways
108: Committees/Assemblies for Nursing Services
2. Staffing, Education, & Competency
109: Staffing Patterns
110: Patient Care Assignment
112: Staffing & Scheduling Process
115: Nursing Education & Competency Program
116 Professional and Practical Licenses
117: Nursing Education Programs
118: Competency Assessment, Education Competency Program, & Annual Competency Based Evaluation Record (CBER)
119: Equipment Orientation and In-service for Nursing Staff
120: Nursing Education Needs Assessment
122: Nurses Orientation (RN & LPN)
122a: Pathway for New RN LPN Hires: New Grad
122b: Pathway for New RN LPN Hires: With Experience
122c: Pathway for New RN LPN Hires: Per Diem
122d: Pathway for New Nursing Assistant Hires: No Experience
122e: Pathway for New Nursing Assistant Hires: With Experience
123: Unlicensed Assistive Personnel Orientation
124: Special Rates
125: Preceptor
126: Clinical Affiliation of Nursing Students
127A: Nursing Clinical Ladder Program (RN)
127B: Nursing Clinical Ladder Program (LPN)
128: Outpatient Services: Determination of Registered Nurse (RN) Coverage
View Entire Nursing Administrative Manual
Nursing Clinical
1. Medication Safety & Adverse Reactions
A102: Adverse Drug Reactions
A104: Allergies: Communication of Information
2. Basic Nursing Care & Comfort Measures
B200: Bathing/Showering
B204: Bed: Enclosed Net Bed
B206: Binder: Application of Abdominal Binder
B210: Bowel Management Program
3. Clinical Procedures & Specialized Care
C307: Code Cart Checks, Exchanges and Restocking
C308: Care of Patient in Case
C309: Calf/Thigh Measurements
C312: Catheter: Suprapubic
C313: Cathflo, Activase, Alteplace, Use for Central Venous Access Devices
C324A: Venous Access Device
C324B: Venous Access Device Dressing Change, Venous Access Device Needleless Connector Change
C324C: Flushing Vascular Access Device, Blood Draws via Vascular Access Device, Ethanol Lock, Accessing/De-accessing Ports
C324D: Venous Access Device Maintenance Tables
C324E: Physician-Inserted Peripheral IV (PIV) as Last-Line Venous Access
C325: Cervical Collar: Care
C326: Critical Laboratory Results Procedure
4. Documentation & Clinical Monitoring
D401: Continuous Glucose Monitor Use During Hospitalization
D402: Admission Assessment
D403: Chart Checks
D404: Nursing Flowcharts
D405: Documentation: Day Hospital Nursing Flow Sheet
D409: Immunizations
D418: Documentation: Telephone Verbal Orders & Telephonic Reporting
D419: Documentation: Clinical Opiate Withdrawal Scale
D419A: Clinical Opiate Withdrawal Scale (Form)
D421 Dressing Change
5. Enteral & Specialized Medical Devices
E501: Enteral Tubes (G-Tube, J-Tube, PEG-Tube, NG-Tube, ND/NJ Tube, G-J Tube, O-G Tube)
E502: Enteral Nutrition: Checking Residual Volume
E503: Enteral Feeding (GT, GJT, JT, NGT/OGT, ND/NJ)
E504: Use of Enteral Nutrition Portable Pump
E505: Life Vest Wearable Cardioverter Defibrillator (WCD)
E505A: ZOLL Life Vest Model 4000 Patient Manual
E505B: ZOLL Life Vest Quick Reference Guide
6. Feeding & Nutrition
F602A: Feeding Patient – Orally
F602B: Attachment – Readiness and Quality Scale
F602B: Feeding an Infant – Orally (Dysphagia)
F603: Formula Preparation
F604: Storage and Handling of Infant Feeding Bottle and Nipple
F605: Human Milk Storage
F605A: Human Milk Feeding
F606: Formula Formulary
F606A: WCHR Formula Formulary (Attachment)
7. Growth & Development
G700: Growth Measurements: Weight, Length/Height, Head Circumference
8. Orthopedic Devices & Traction
H800: Halo
H800A: Halo Patient Care Guide For The Halo Traction
9. Insulin & Integumentary Care
I901: Ambulatory Insulin Pump Management During Hospitalization
I901A: MEDTRONIC MiniMed 780G Automated Insulin Delivery System Pump Therapy Order Form
I902: Infant Skin Care
10. LVAD & Environmental Care
L1200: Linen (Clean vs. Soiled)
L1201: Care of the LVAD Patient at Inpatient Rehabilitation
11. Medication High-Risk Management
M1339: Anticoagulation
12. Nutrition Monitoring & Safety
N100: Nutrition Refrigerator Temperature Log
13. Oral Care
O500: Oral Hygiene
14. Personal Care, Positioning, & Skin Integrity
P1601: Perineal Care
P1602: Pin Site Care
P1603: Positioning: Principles of Body Alignment
P1604: Pressure Ulcers: Prevention
P1604A: Braden Scale For Predicting Pressure Sore Risk (Over 5 Years)
P1604B: Modified Braden Q Scale (5 Years & Younger)
P1605: pH Probe Study: Care of the Child
15. Rehabilitation & Respiratory Care
R1800: Range of Motion Exercise: Active/Passive
R1802A: Tracheostomy Cleaning (With Inner Cannula) & Stoma Care
R1803: Respiratory Equipment: Role of Staff in Handling
16. Safety & Protective Interventions
S1900: Safety: Patient
S1901: Safety: Medication Use
S1902: Seizures: Management of Seizures
S1903: Seizure Precautions
S1904: Sling: Application
S1912: Splints, Cones, Bi-valved Casts
S1913: Stump Wrapping
S1913A: Stump Wrapping: Above Knee Amputee
S1913B: Stump Wrapping: Below Knee Amputee
17. Transfers, Treatments, & TPN
T2000: Transfers
T2001: Treatment Room
T2002: TPN/PPN Infusion
T2002A: TPN Order Sheet (Form)
18. Vital Signs & Shunt Precautions
V2200: Vital Sign Standard of Care
V2206: Ventriculoperitoneal Shunt (VP Shunt): Precautions
19. Waived Testing
W2300: Waived Testing: Point of Care Testing (POCT)
W2301: Waived Testing: Accu-Chek Inform II
W2302: Waived Testing: Urine Dipstick Testing
W2303: Waived Testing: Gastric pH Testing
View Entire Nursing Clinical Manual
Nutrition
1. Mission – Scope
100: Food Service and Nutrition Care Mission Statement
101: Scope of Food Service and Nutrition Care Services
102: Delineation of Dietitian & Food Services
103: Committee Membership
104: Continuing Education
105: Education of Staff
106. Nutrition Code of Ethics
2. Clinical Nutrition Manual
200: Clinical Diet Manual
201: Nutrition Screening, Assessment & Reassessment
202: Medical Nutritional Therapy Plan
203: Documentation in the Medical Record
204: Infant Nutrition
204a: Full Term Infants: Nutrition Therapy (PNCM)
205: Infant Formula
206: Lactating Mother/Human Milk Fed Infant
207: Enteral and Parenteral Nutrition
208: Nutrition Management of Pressure Ulcer
209: Menu Planning
210: Diets/Clarification of Diets
211: Food Service Communication, Diet Orders, and the Delegate Dining System
212: Menu Selection
213: Meal Times and Tray Distribution
214: Snack Group
215: Patient and Caregiver Education
216: Food & Medication Interactions
217: Food & Medication Interactions/Warfarin (Coumadin) Therapy
218: Quality and Performance Improvement Program
219: Test Tray Evaluations
220: Formula Formulary
221: Therapeutic Kitchen
View Entire Nutrition Manual
Outpatient
1. General Policy and Procedure
401: Safety and Security
402: CPR Certification
403: Departmental Communication
405: Resolution of Complaints
406: Quality Improvement Plan
407: Department Hours of Operation
408: Incident Reports: Non-Employee
409: Escalation to a Higher Level of Care
Outpatient Rehabilitation Organizational Chart
2. Operations
800: Outpatient Admission Criteria
801: Outpatient Intake/Admission Process
802.01: Insurance Extension
802: Insurance Verification
803: Coordination of Transfer From Inpatient or Day Hospital Services to Outpatient Services
809: Discharge Process
810: Waiting List for Outpatient Services
3. Emergency Management
900: Code Blue/Code White Procedure/Emergency Procedure
901: Code Yellow – Bomb Threat
902: Code Gray – Security
903: Code Red – Fire
904: Heat Emergency
905: Power Failure Procedure
906: Active Shooter
911: Severe Weather Emergency
916: Code Silver – Person With A Weapon/Hostage Situation
917: Code Amber – Pediatric Abduction
4. Other Policy and Procedure
1000: Documentation – General Guidelines
1001: Clinical Guidelines
1002: Clinical Ladder
1201: Wheelchair, Orthotic, and Prosthetic, Augmentative Communication Vendor Services
View Entire Outpatient Rehabilitation Services Manual
Pharmacy
1. Pharmacy Management
100: Medication Management
101: Pharmacy and Therapeutic Committee
102: Consultant Pharmacist
103: Patient Drug Regimen Reviews
104: Patient Specific Information: Admitting the Patient Into the System
105: Pharmacist Collaborative Practice Agreement (CPA) for Weisman Children’s Rehabilitation Hospital
2. Medication Management
200: Selection and Procurement
201: Formulary
202: Storage
203 Checking in Medication Deliveries
204: Medication Storage and Vaccine Storage
205: Medication Refrigerator Temperature Log
206: Medication Keys
207: Medication Carts
208: Controlled Substances
209: Accountability of Controlled Substances
210: Medications Returned to Pharmacy
211: Medication Dispensing System
212: Medication Storage
213: Unit Inspection
214: Pharmacy Services: Daily Ordering and Delivery Schedule
215: Emergency Medication Services
216: House Stock Medications
217: Emergency Medications
219: Medications Brought From Home
220: Medications of Patients Being Discharged
3. Medication Ordering
300: Medication Ordering
301: Telephone Verbal Orders
302: Pediatric Dosing
303: Dosing Ranges
304: Lab Ordering in Reference to Medications
305: Generic Substitution
306: Look Alike & Sound Alike Medications
307: Medication Order Verification
308: Medication Reconciliation
4. Medication Preparing and Dispensing
400: Medication Preparing and Dispensing
401: Labelling of Medication
402: Medication Dispensing
403: Drug Recall Procedure
5. Medication Administration
500: Medication Administration
501: Medication Administration Documentation
502: Medication: Documentation of Controlled Substances
503: Medication Education Program
504: Self Administration Program By Parent/Guardian or Patient
505: Day Pass Medication Administration
506: Day Hospital Medication Administration
507: Medication: Administration via Enteral Tubes
508: Medication: Administration Injection (Intramuscular or Subcutaneous)
509: Medication: Peripheral IV Therapy General Policies
510: Medication: Venipuncture for Intravenous Therapy
511: Medication: IV Peripheral Cannula Care and Maintenance
512: Medication: Peripheral IV Therapy Dressing & Tubing Change
513: Medication: Change IV Solution/Medication (Central Venous or Peripheral Line)
514: Medication: Admixing IV Medication
515: Medication: Discontinuation of Intravenous Fluids
6. Medication Effects
600: Monitoring Medication Effects
601: Notification of Potential Drug Interactions
602: Adverse Drug Reactions
603: Medication Errors
604: Anticoagulation
605: Pharmacologic Pain Management Guidelines
7. High Alert, Investigational Medications and Antibiotic Stewardship
700: High Risk – High Alert & Hazardous Medications
701: Use of Investigational Medications
702: Procurement of Investigational, Orphan, or Compassionate Care Medications
703: Investigational Medications
704: Antibiotic Stewardship Program
704a: Antibiotic Stewardship Program: Pediatric Antibiotic Prescribing Guidelines
8. Evaluation of the Medication Management System
800: Evaluation of Medication Management System
View Entire Pharmacy Manual
Respiratory Care
1. Mission/Scope
101: Respiratory Therapy Mission and Philosophy
102: Provision of Respiratory Care Services
2. (Section Reserved)
3. Job Descriptions
4. Licensure/Credentials
5. Orientation/Competency
6. (Section Reserved)
7. Documentation
8. Billing
9. Respiratory Care Department Policy
9a. Equipment Management
View Entire Respiratory Care Manual
Safety- EOC
EOC 1
Administrative
1. Leadership
AM 1.3 Mission, Vision, Values Statement
AM 1.4 Philosophy Statement; Definition of Culture
AM 1.5 Organizational Ethics Statement
AM 1.6 Integrity of Clinical Decisions
AM 1.7 Code of Conduct
AM 1.8 Conflict of Interest, Governing Body, Medical and Leadership / Staff
AM 1.9 Just Culture
AM 1.10 Improving Health Outcomes for All
2. Health Information Management
AM 2.0 Notice of Name Change – ALIAS
AM 2.0a Alias First Names A to Z
AM 2.01 Patient Alias Notice (Form)
AM 2.02 Medical Record Onsite Review
3. Administration
AM 3.0 Administrative Management
AM 3.1 Strategic Plan
AM 3.2 Information Management Plan
AM 3.22 System Methodology
AM 3.23 Internet Use
AM 3.24 Technical Support
AM 3.25 Duplication of Software
AM 3.26 Electronic Mail (E-mail)
AM 3.27 Data / Internet / Phone Outage
AM 3.28 Visitor Internet Access
AM 3.29 Portable Device Guidelines
AM 3.29.1 Request for Portable Device (Form)
AM 3.30 ePHI Onsite Backup and EMR Downtime
AM 3.31 Social Media
AM 3.32 Portal Patient Provider Communication
AM 3.33 Patient Provider Communication via Permedion Portal
AM 3.34 Data Visualization Tool Downtime (Tableau)
AM 3.35 Consumer Voice Assistant Devices
4. Management
AM 4.1 Administrator
AM 4.1.1 Departmental Leadership
AM 4.2 Changes Within the Organization
AM 4.3 Licensure
AM 4.4 Inspection Reports
AM 4.5 Reportable Events
AM 4.7 News Media
AM 4.9 Administrator On Call
AM 4.10 Law Enforcement Agency Interaction
AM 4.13 Conflicts of Interest
AM 4.15 Confidentiality and Release of Information
AM 4.15.1 Privacy Officer
AM 4.15.2 Notice of Privacy Information Practices
AM 4.15.3 Photographing, Video Recording, Audio Recording and Other Imaging of Patients, Visitors and WorkForce Members
AM 4.15.3.1 Consent for Recording or Filming
AM 4.15.3.1a Consent for Recording or Filming (Form)
AM 4.15.4 Consent to Photograph/Videograph Patients (Form)
AM 4.15.5 Secure Text Messaging
AM 4.15.6 ROI Social Services
AM 4.16 Confidentiality Code
AM 4.16.1 Confidentiality Code Sheet (Form)
AM 4.17 Fraud, Waste, and Abuse
AM 4.18 Admission Criteria
AM 4.19 Medical Records Forms
AM 4.20 Inability to Pay
AM 4.21 Care Coordination
AM 4.22 Resuscitation Services
AM 4.23 Clinical Alarm Management
5. Patient Rights
AM 5.1 Patient Rights
AM 5.2 Notice of Patient Rights and Responsibilities
AM 5.3 Assignment of Patient Rights
AM 5.5 Designation of a Physician
AM 5.7 Refusal of Care, Treatment or Services
AM 5.10 Academic Education
AM 5.13 Interpretation and Communication
AM 5.14 Grievances/Complaints – Patients
AM 5.14a Grievances/Complaint Report (Form)
AM 5.16 Patient Abuse, Neglect, & Exploitation
AM 5.18 Telephones – Patient Use or Restrictions
AM 5.19 Patient/Family Satisfaction
AM 5.20 Visitation/Security
AM 5.21 Personal Property
AM 5.22 Provision of Spiritual Services
6. Patient Care
AM 6.1 Pain Management
AM 6.3 Team Conferences /Care Planning
AM 6.4 Documentation: Military Time
AM 6.5 Behavioral Management Referral Process
AM 6.7 Fall Prevention
AM 6.7.1 Fall: Care of a Patient After a Fall
AM 6.7.2 Newborn/Infant Drop Prevention
AM 6.8 Dental Care
AM 6.9 Diagnostic Services
AM 6.10 Medical Emergency Care
AM 6.11 Blood and Blood Products
AM 6.12 Informing Patient/Family About Outcomes/Unanticipated Outcomes of Care, Treatment and Services
AM 6.13 Critical Airway Precautions and Staffing
AM 6.14 Safe Use of Infant Equipment and SIDS Prevention
AM 6.15 Audio/Visual Baby Monitors
AM 6.16 Immunizations
AM 6.20 Notice of An Involuntary Transfer and/or Discharge
AM 6.21 Patient Identification
AM 6.22 Discharge Plan
AM 6.23 Documentation Guidelines for Discharge/Transfer Summary
AM 6.23.1 Discharge/Transfer Summary (Form)
AM 6.24 Discharge Against Medical Advice (AMA)
AM 6.25 Home Ventilation Discharges
AM 6.26 Leave the Floor – Within WCRH Campus
AM 6.26.1 Day Pass
AM 6.26.2 Therapeutic Community Outing
AM 6.27 Patient and Family Education Interventions
AM 6.28 Documentation: Patient and Family Education
AM 6.28.1 Interdisciplinary Teaching Checklist – Patient (Form)
AM 6.28.2 Teaching Checklist by Discipline (Form)
AM 6.29 Patient Assessment and Evaluation
AM 6.30 Safe Patient Handling
AM 6.32 Safety: Medication Management
AM 6.33 Non-Emergent Interdisciplinary Communication of Patient Care Needs
AM 6.47 Restraints: Care of the Patient at Risk for Physical Harm, RAP One to One, Continuous Observation
AM 6.48 Care of Psychiatrically Ill Patients and/or Patients with Alcoholism or Drug Addiction
AM 6.49 Suicide Screening and Precautions
AM 6.50 Response to Changes in Patient’s Medical Condition
AM 6.51 Child Safety/Restraint Transportation Guidelines
AM 6.51.1 Child Safety/Restraint Transportation Guidelines: Car Seat Testing
AM 6.51.2 Transportation Guidelines: Caregiver Education for Child Safety Restraints and Wheelchair Transportation
AM 6.53 Approved and Unapproved Medical Abbreviations
AM 6.54 Diabetes Management
AM 6.55 Telehealth
AM 6.55.1 Informed Consent for Telehealth Services (Form)
AM 6.56 Animals in Hospital Facilities
AM 6.57 Motorized Infant Swing Guidelines
7. Finance / Business Office
AM 7.1 Admission, Transfer, and Discharge Register
AM 7.5 Business Office Operations
AM 7.7 Financial Arrangements Third Party Payers
AM 7.8 Financial Reports
AM 7.11 Purchasing Policy
AM 7.13 Capital Equipment
AM 7.14 Capital Equipment & Major Project or Service Approval Process
AM 7.22 Guidelines for Classification of HCFA Diagnostic Categories
AM 7.26 Free Care
8. Human Resources
AM 8.1 Policies, Employee Notification of New & Revised
AM 8.2 Equal Opportunity Employer
AM 8.3 Employee Recognition
AM 8.6 Pre-Employment Screening: Licensure Verification
AM 8.7 Absenteeism and Lateness
AM 8.7a Employee Warning Report (Form)
AM 8.8 Orientation
AM 8.9 Job Descriptions/Performance Evaluation
AM 8.10 Education Competency Program and Annual Competency Evaluation Record (CBER)
AM 8.11 Annual Learning and Competency
AM 8.11b HealthStream Policy
AM 8.12 Termination: Voluntary or Involuntary
AM 8.13 Dress Code, Hygiene, and Grooming
AM 8.14 Paid Time Off
AM 8.15 Leave of Absence – Family Medical Leave
AM 8.15.2 Personal Leave of Absence
AM 8.16 Medical Insurance Opt-Out
AM 8.17 Drug Testing/Substance Abuse
AM 8.18 Sexual Harrassment
AM 8.19 Exclusion from Patient Care
AM 8.20 Jury Duty
AM 8.21 Time Records
AM 8.22 Progressive Corrective Intervention
AM 8.23 Severe Weather Emergency
AM 8.24 Education Tuition Assistance
AM 8.24a Education Tuition Assistance Application (Form)
AM 8.25 Employment Status
AM 8.26 Smoking Policy
AM 8.27 Volunteer Services Program
AM 8.28 Peer Review
AM 8.29 Staffing Effectiveness
AM 8.30 Computer/EMR Access for Employees and Students
AM 8.31 Health Care Professional Responsibility & Reporting
AM 8.32 Employee Referral Bonus Program – Critical Positions
AM 8.32a Employee Referral Bonus (Form)
AM 8.33 Employee Sign On Bonus Program – Critical Positions
AM 8.34 Disaster Responsibilities – Volunteer Practitioners
AM 8.36 Resuscitation Services: Emergency Preparedness Education CPR Certification
AM 8.38 Intra-Hospital Transfers, Additional Employment and Promotions
AM 8.39 Work-Related Injuries
AM 8.40 Employee Cell Phone Use
AM 8.41 Mileage Reimbursement
AM 8.41a Mileage Reimbursement Log (Form)
AM 8.42 Decoration Use
AM 8.43 Telecommuting Work From Home
AM 8.43.1 Telecommuting Agreement (Form)
AM 8.44 Employee Restraining Orders
AM 8.45 Fleet Program
AM 8.46 Personal Vehicle Usage Policy
9. Medical Staff
AM 9.1 Bylaws/Medical Practices
AM 9.5 Advance Directives
AM 9.6 Definition/Determination of Death
AM 9.7 Foregoing Life-Sustaining Treatment
AM 9.8 Bioethics Committee
AM 9.9 Informed Consent
AM 9.13 Care of Patient at Death
AM 9.13a Certificate of Death (Form)
AM 9.13b Communicable Diseases Alert (Form)
AM 9.14 Autopsy
AM 9.15 Reporting Requirement/Funeral Director
AM 9.16 Deaths Reportable to the Medical Examiner
AM 9.17 Information Reportable to the State Board of Medical Examiners
AM 9.18 Reporting of Diagnosed and/or Suspected Cases of Child Abuse and/or Neglect
AM 9.18.1 Division of Child Protection & Permanency – Hospital Hold
AM 9.20 Referral to Medical Consultation and Other Health Care Providers
AM 9.21 Organ Donation
AM 9.22 Interdisciplinary Care of the NAS Infant
View Entire Administrative Manual
Care Coordination
CC.CM 206: Patient Admission, Transfer, Discharge
CC.CM: 202 Referrals to Providers
CC.CM: 204 Utilization Review Plan
CC.CM: 204a Utilization Control Plan Inpatient Services
CC.CM: 205 Discharge Planning
View Entire Care Coordination/ Case Management Manual
Infection Control
1. General Infection Control
IC 100: Infection Control Program
IC 101: Infection Control Professional
IC 102: Elements of the Infection Control Program
IC 102a: Communications with Other Facilities (Form)
IC 103: Surveillance Program
IC 104: Guidelines for Infection Control Statistics
IC 105: Guidelines for Determining Presence, Classification, and Definition of Infections
2. Preventative Actions / Mitigation
IC 200: Standard Precautions
IC 201: Transmission-Based Isolation Precautions
IC 201a: Isolation by Disease Entity
IC 202: Preventing Transmission of Infections – Including Hand Hygiene
IC 202a: Hand Hygiene
IC 203: Fingernails
IC 204: Preventative Actions Employees Must Take
IC 205: Susceptible Restrictions
IC 206: Diseases Not Requiring Isolation
IC 207: Initiation of Isolation Precautions
IC 208: Discontinuing Isolation Precautions
IC 209: Visitors of Patients in Isolation
IC 209a: Visitor Information
IC 210: Restrictions for Sick Visitors
IC 211: Preventative Actions for Selected Patients
IC 212: Private Room for Prevention of Spread of Infection
IC 213: Transporting Patients on Isolation / Precautions
IC 214: Emergency Response Employee Exposure Notification
IC 215: Therapy Guidelines for Patients on Isolation
IC 217: Infectious Disease Patient Influx Management
IC 218: Pet Therapy
3. Cleaning / Disinfection
IC 300: Cleaning and Disinfection Practices
IC 301: Use of Disinfectant Wipes
IC 302: Care of Equipment Used in Isolation Rooms
IC 303: Clean up of Blood / Body Fluid Spill
IC 304: Labeling Laboratory Specimens
IC 305: Management of Contaminated Sharps
IC 306: Management of Infectious (Red Bag) Waste
IC 307: Guidelines for Cleaning Toys, Strollers, Playpens, Swings, and Exersaucers
IC 308: Guidelines for Cleaning Feeding Equipment
IC 309: Care of Washer and Dryer
IC 310: Cleaning of Ice Machine
4. Allergy and Infectious Disease
IC 400: Latex Allergic or Latex Sensitive Patient
IC 401: Influenza Vaccination Program for Patients
IC 402: Influenza Vaccination Program for Community Members
IC 403: Pneumococcal Immunization
IC 404: Respiratory Syncytial Virus (RSV)
IC 405: Varicella-Zoster Virus (VZV)
IC 406: Precautions for VRE Isolation
IC 407: Pool Therapy Guidelines
IC 408: Precautions for the Patient Infected/Colonized with Methicillin Resistant Staphylococcus Aureus
IC 409: Rubeola
IC 410: Hierarchy of Controls to Prevent Influenza Transmission in Healthcare Settings
IC 410a: Hierarchy of Controls to Prevent Influenza Transmission (attachments)
IC 411: Mpox
IC 412: Clostridioides Difficile
IC 414: Bedbugs, Lice, Scabies
5. Tuberculosis
IC 500: Tuberculosis Infection Control Plan
6. Bloodborne Pathogen / Exposure
IC 600: Bloodborne Pathogen Exposure Control Plan
IC 601: Employee Risk Categories
IC 601a: Exposure Determination/Assignment of Categories to Employees: Administration
IC 601b: Exposure Determination/Assignment of Categories to Employees: Medical Staff
IC 601c: Exposure Determination/Assignment of Categories to Employees: Nursing Staff
IC 601d: Exposure Determination/Assignment of Categories to Employees: Respiratory
IC 601e: Exposure Determination/Assignment of Categories to Employees: Therapy
IC 602: Blood-borne Pathogen Post-Exposure Protocol
IC 603: Training Programs
IC 604: Qualitative Fit Testing
IC 604a: OSHA Respirator Medical Evaluation Questionnaire (Form)
IC 604b: Respiratory Medical Evaluation: Annual (Form)
7. Employee Health
EH 100: Employee Health Program
EH 100a: Volunteer Health Program
EH 101: Safety and Security
EH 102: Drug and Alcohol Testing
EH 103: Reporting Requirement Re: Change in Health Status
EH 104: Protection of the Patient
EH 105: Exposure to Communicable Diseases – Including Disease of Concern to the Pregnant Employee
EH 106: Employee Injury/Exposure
EH 107: Post Exposure Prophylaxis Protocol
EH 108: Employee Tuberculosis Screening and Exposure
EH 109: Back Injury
EH 110: System for Monitoring of Employee Illness or Injury
EH 111: Influenza Vaccination Program for Employees
EH 111a: Influenza Vaccine Medical Exemption (Form)
EH 111b: Influenza Vaccine Request for Religious Accommodation (Form)
EH 112: Student/Agency Affiliations
EH 113: Latex Allergy/Employees
EH 114: Consent and Counseling for HIV Testing
EH 115: Hepatitis B Prevention Program
EH 116: Small Pox Vaccine Recipients
EH 117: COVID-19 Vaccination Program for Employees
EH 117a: COVID-19 Vaccine Medical Exemption (Form)
EH 117b: COVID-19 Vaccine Religious Accommodation (Form)
EH 119: COVID-19 Exposure/Positive Employee Return to Work
EH 119a: Returning to Work After COVID-19 Exposure (Form)
EH 119b: Returning to Work After COVID-19 Infection
EH 120: Employee Call Out Tracking
View Entire Infection Control Manual
Inpatient Rehabilitation
1. Inpatient Rehabilitation Department Structure
Inpatient Rehabilitation Organizational Chart
TD001: Rehab Department Mission and Philosophy Statement
TD002: Rehab Code of Ethics
2. Inpatient Rehabilitation: General
TD100: Preferred Practice Plans
TD102: Rehabilitation Orientation Program
TD103: Annual Competency Requirement
TD104: Staff Licensure/Credentials
TD108: Compensation for Weekend & Holiday Clinical Service Provision
TD1502: IP Group Services
TD1509: Clinical Ladder
TD1509b: Petition for Clinical Advancement (Form)
TD1509c: Clinical Ladder Template
3. Physical Therapy
TD1100: Physical Therapy Provision of Services
TD1101: Physical Therapy Standards of Practice
TD1102: Physical Therapy Purpose and Goals
TD1103: Physical Therapy Scope of Services/Practice
4. Occupational Therapy
TD1200: Occupational Therapy Provision of Services
TD1201: Occupational Therapy Standards of Practice
TD1202: Occupational Therapy Purpose and Goals
TD1203: Occupational Therapy Scope of Services/Practice
5. Speech Therapy
TD1300: Speech Language Pathology Department Provision of Service
TD1301: Speech Language Pathology Department Preferred Practice Patterns
TD1302: Speech Language Pathology Department Purpose & Goals
TD1303: Speech Language Pathology Department Scope of Practice
6. Therapeutic Recreation
TD1400: Therapeutic Recreation Provision of Services
TD1401: Standards for the Practice of Therapeutic Recreation/Child Life
TD1402: Therapeutic Recreation Purpose Goals
TD1403: Therapeutic Recreation Scope of Services
View Entire Inpatient Rehabilitation Manual
Medical Staff
0. Medical Staff Bylaws
1. Organized Medical Staff Structure
MS 100: Organization of the Medical Staff
MS 101.01: Medical Director Responsibilities
MS 101: Medical Staff Responsibilities of the Medical Director
2. Management of Patient Care, Treatment, and Services
PP 200: Physician Coverage
PP 201: Pulmonary Services
PP 202: Nurse Practitioner Role
PP 203: Sedation
PP 205: Impaired Driver
PP 206: Graduate Medical Education
3. Performance Improvement
PP 300: Medical Staff Role in Quality Assurance
4. Credentialing, Privileges, and Appointment
PP 400: Credentialing
PP 401: Initial Medical Staff Applications
PP 402.00: Primary Source Verification
PP 402.01: National Practitioner Data Bank Queries
PP 403: Criteria for Clinical Privileges
PP 404: Expedited Credentialing
PP 405: Medical Staff Peer Review
PP 406: Temporary Privileges
PP 407: Disaster Privileges
PP 408: Focused Professional Practice Evaluation
PP 409: Ongoing Professional Practice Evaluation (Maintaining Privileges)
5. Continuing Education
PP 500: Continuing Medical Education
View Entire Medical Staff Manual
Nursing Administrative
1. Overview & Responsibilities
101: Provision of Nursing Services Plan of Care
102: Philosophy of Nursing Service
103: The Role of the Nurse Executive & Nursing Leadership
104: Nursing Administration Chain of Command
105: Charge Nurse’s Role, Responsibilities, and Authority Within the Hospital
106: Nursing Care Patient Services, Standards of Nursing Care and Practice
107: Nursing Administration Communication System Pathways
108: Committees/Assemblies for Nursing Services
2. Staffing, Education, & Competency
109: Staffing Patterns
110: Patient Care Assignment
112: Staffing & Scheduling Process
115: Nursing Education & Competency Program
116 Professional and Practical Licenses
117: Nursing Education Programs
118: Competency Assessment, Education Competency Program, & Annual Competency Based Evaluation Record (CBER)
119: Equipment Orientation and In-service for Nursing Staff
120: Nursing Education Needs Assessment
122: Nurses Orientation (RN & LPN)
122a: Pathway for New RN LPN Hires: New Grad
122b: Pathway for New RN LPN Hires: With Experience
122c: Pathway for New RN LPN Hires: Per Diem
122d: Pathway for New Nursing Assistant Hires: No Experience
122e: Pathway for New Nursing Assistant Hires: With Experience
123: Unlicensed Assistive Personnel Orientation
124: Special Rates
125: Preceptor
126: Clinical Affiliation of Nursing Students
127A: Nursing Clinical Ladder Program (RN)
127B: Nursing Clinical Ladder Program (LPN)
128: Outpatient Services: Determination of Registered Nurse (RN) Coverage
View Entire Nursing Administrative Manual
Nursing Clinical
1. Medication Safety & Adverse Reactions
A102: Adverse Drug Reactions
A104: Allergies: Communication of Information
2. Basic Nursing Care & Comfort Measures
B200: Bathing/Showering
B204: Bed: Enclosed Net Bed
B206: Binder: Application of Abdominal Binder
B210: Bowel Management Program
3. Clinical Procedures & Specialized Care
C307: Code Cart Checks, Exchanges and Restocking
C308: Care of Patient in Case
C309: Calf/Thigh Measurements
C312: Catheter: Suprapubic
C313: Cathflo, Activase, Alteplace, Use for Central Venous Access Devices
C324A: Venous Access Device
C324B: Venous Access Device Dressing Change, Venous Access Device Needleless Connector Change
C324C: Flushing Vascular Access Device, Blood Draws via Vascular Access Device, Ethanol Lock, Accessing/De-accessing Ports
C324D: Venous Access Device Maintenance Tables
C324E: Physician-Inserted Peripheral IV (PIV) as Last-Line Venous Access
C325: Cervical Collar: Care
C326: Critical Laboratory Results Procedure
4. Documentation & Clinical Monitoring
D401: Continuous Glucose Monitor Use During Hospitalization
D402: Admission Assessment
D403: Chart Checks
D404: Nursing Flowcharts
D405: Documentation: Day Hospital Nursing Flow Sheet
D409: Immunizations
D418: Documentation: Telephone Verbal Orders & Telephonic Reporting
D419: Documentation: Clinical Opiate Withdrawal Scale
D419A: Clinical Opiate Withdrawal Scale (Form)
D421 Dressing Change
5. Enteral & Specialized Medical Devices
E501: Enteral Tubes (G-Tube, J-Tube, PEG-Tube, NG-Tube, ND/NJ Tube, G-J Tube, O-G Tube)
E502: Enteral Nutrition: Checking Residual Volume
E503: Enteral Feeding (GT, GJT, JT, NGT/OGT, ND/NJ)
E504: Use of Enteral Nutrition Portable Pump
E505: Life Vest Wearable Cardioverter Defibrillator (WCD)
E505A: ZOLL Life Vest Model 4000 Patient Manual
E505B: ZOLL Life Vest Quick Reference Guide
6. Feeding & Nutrition
F602A: Feeding Patient – Orally
F602B: Attachment – Readiness and Quality Scale
F602B: Feeding an Infant – Orally (Dysphagia)
F603: Formula Preparation
F604: Storage and Handling of Infant Feeding Bottle and Nipple
F605: Human Milk Storage
F605A: Human Milk Feeding
F606: Formula Formulary
F606A: WCHR Formula Formulary (Attachment)
7. Growth & Development
G700: Growth Measurements: Weight, Length/Height, Head Circumference
8. Orthopedic Devices & Traction
H800: Halo
H800A: Halo Patient Care Guide For The Halo Traction
9. Insulin & Integumentary Care
I901: Ambulatory Insulin Pump Management During Hospitalization
I901A: MEDTRONIC MiniMed 780G Automated Insulin Delivery System Pump Therapy Order Form
I902: Infant Skin Care
10. LVAD & Environmental Care
L1200: Linen (Clean vs. Soiled)
L1201: Care of the LVAD Patient at Inpatient Rehabilitation
11. Medication High-Risk Management
M1339: Anticoagulation
12. Nutrition Monitoring & Safety
N100: Nutrition Refrigerator Temperature Log
13. Oral Care
O500: Oral Hygiene
14. Personal Care, Positioning, & Skin Integrity
P1601: Perineal Care
P1602: Pin Site Care
P1603: Positioning: Principles of Body Alignment
P1604: Pressure Ulcers: Prevention
P1604A: Braden Scale For Predicting Pressure Sore Risk (Over 5 Years)
P1604B: Modified Braden Q Scale (5 Years & Younger)
P1605: pH Probe Study: Care of the Child
15. Rehabilitation & Respiratory Care
R1800: Range of Motion Exercise: Active/Passive
R1802A: Tracheostomy Cleaning (With Inner Cannula) & Stoma Care
R1803: Respiratory Equipment: Role of Staff in Handling
16. Safety & Protective Interventions
S1900: Safety: Patient
S1901: Safety: Medication Use
S1902: Seizures: Management of Seizures
S1903: Seizure Precautions
S1904: Sling: Application
S1912: Splints, Cones, Bi-valved Casts
S1913: Stump Wrapping
S1913A: Stump Wrapping: Above Knee Amputee
S1913B: Stump Wrapping: Below Knee Amputee
17. Transfers, Treatments, & TPN
T2000: Transfers
T2001: Treatment Room
T2002: TPN/PPN Infusion
T2002A: TPN Order Sheet (Form)
18. Vital Signs & Shunt Precautions
V2200: Vital Sign Standard of Care
V2206: Ventriculoperitoneal Shunt (VP Shunt): Precautions
19. Waived Testing
W2300: Waived Testing: Point of Care Testing (POCT)
W2301: Waived Testing: Accu-Chek Inform II
W2302: Waived Testing: Urine Dipstick Testing
W2303: Waived Testing: Gastric pH Testing
View Entire Nursing Clinical Manual
Nutrition
1. Mission – Scope
100: Food Service and Nutrition Care Mission Statement
101: Scope of Food Service and Nutrition Care Services
102: Delineation of Dietitian & Food Services
103: Committee Membership
104: Continuing Education
105: Education of Staff
106. Nutrition Code of Ethics
2. Clinical Nutrition Manual
200: Clinical Diet Manual
201: Nutrition Screening, Assessment & Reassessment
202: Medical Nutritional Therapy Plan
203: Documentation in the Medical Record
204: Infant Nutrition
204a: Full Term Infants: Nutrition Therapy (PNCM)
205: Infant Formula
206: Lactating Mother/Human Milk Fed Infant
207: Enteral and Parenteral Nutrition
208: Nutrition Management of Pressure Ulcer
209: Menu Planning
210: Diets/Clarification of Diets
211: Food Service Communication, Diet Orders, and the Delegate Dining System
212: Menu Selection
213: Meal Times and Tray Distribution
214: Snack Group
215: Patient and Caregiver Education
216: Food & Medication Interactions
217: Food & Medication Interactions/Warfarin (Coumadin) Therapy
218: Quality and Performance Improvement Program
219: Test Tray Evaluations
220: Formula Formulary
221: Therapeutic Kitchen
View Entire Nutrition Manual
Outpatient
1. General Policy and Procedure
401: Safety and Security
402: CPR Certification
403: Departmental Communication
405: Resolution of Complaints
406: Quality Improvement Plan
407: Department Hours of Operation
408: Incident Reports: Non-Employee
409: Escalation to a Higher Level of Care
Outpatient Rehabilitation Organizational Chart
2. Operations
800: Outpatient Admission Criteria
801: Outpatient Intake/Admission Process
802.01: Insurance Extension
802: Insurance Verification
803: Coordination of Transfer From Inpatient or Day Hospital Services to Outpatient Services
809: Discharge Process
810: Waiting List for Outpatient Services
3. Emergency Management
900: Code Blue/Code White Procedure/Emergency Procedure
901: Code Yellow – Bomb Threat
902: Code Gray – Security
903: Code Red – Fire
904: Heat Emergency
905: Power Failure Procedure
906: Active Shooter
911: Severe Weather Emergency
916: Code Silver – Person With A Weapon/Hostage Situation
917: Code Amber – Pediatric Abduction
4. Other Policy and Procedure
1000: Documentation – General Guidelines
1001: Clinical Guidelines
1002: Clinical Ladder
1201: Wheelchair, Orthotic, and Prosthetic, Augmentative Communication Vendor Services
View Entire Outpatient Rehabilitation Services Manual
Pharmacy
1. Pharmacy Management
100: Medication Management
101: Pharmacy and Therapeutic Committee
102: Consultant Pharmacist
103: Patient Drug Regimen Reviews
104: Patient Specific Information: Admitting the Patient Into the System
105: Pharmacist Collaborative Practice Agreement (CPA) for Weisman Children’s Rehabilitation Hospital
2. Medication Management
200: Selection and Procurement
201: Formulary
202: Storage
203 Checking in Medication Deliveries
204: Medication Storage and Vaccine Storage
205: Medication Refrigerator Temperature Log
206: Medication Keys
207: Medication Carts
208: Controlled Substances
209: Accountability of Controlled Substances
210: Medications Returned to Pharmacy
211: Medication Dispensing System
212: Medication Storage
213: Unit Inspection
214: Pharmacy Services: Daily Ordering and Delivery Schedule
215: Emergency Medication Services
216: House Stock Medications
217: Emergency Medications
219: Medications Brought From Home
220: Medications of Patients Being Discharged
3. Medication Ordering
300: Medication Ordering
301: Telephone Verbal Orders
302: Pediatric Dosing
303: Dosing Ranges
304: Lab Ordering in Reference to Medications
305: Generic Substitution
306: Look Alike & Sound Alike Medications
307: Medication Order Verification
308: Medication Reconciliation
4. Medication Preparing and Dispensing
400: Medication Preparing and Dispensing
401: Labelling of Medication
402: Medication Dispensing
403: Drug Recall Procedure
5. Medication Administration
500: Medication Administration
501: Medication Administration Documentation
502: Medication: Documentation of Controlled Substances
503: Medication Education Program
504: Self Administration Program By Parent/Guardian or Patient
505: Day Pass Medication Administration
506: Day Hospital Medication Administration
507: Medication: Administration via Enteral Tubes
508: Medication: Administration Injection (Intramuscular or Subcutaneous)
509: Medication: Peripheral IV Therapy General Policies
510: Medication: Venipuncture for Intravenous Therapy
511: Medication: IV Peripheral Cannula Care and Maintenance
512: Medication: Peripheral IV Therapy Dressing & Tubing Change
513: Medication: Change IV Solution/Medication (Central Venous or Peripheral Line)
514: Medication: Admixing IV Medication
515: Medication: Discontinuation of Intravenous Fluids
6. Medication Effects
600: Monitoring Medication Effects
601: Notification of Potential Drug Interactions
602: Adverse Drug Reactions
603: Medication Errors
604: Anticoagulation
605: Pharmacologic Pain Management Guidelines
7. High Alert, Investigational Medications and Antibiotic Stewardship
700: High Risk – High Alert & Hazardous Medications
701: Use of Investigational Medications
702: Procurement of Investigational, Orphan, or Compassionate Care Medications
703: Investigational Medications
704: Antibiotic Stewardship Program
704a: Antibiotic Stewardship Program: Pediatric Antibiotic Prescribing Guidelines
8. Evaluation of the Medication Management System
800: Evaluation of Medication Management System
View Entire Pharmacy Manual
Respiratory Care
1. Mission/Scope
101: Respiratory Therapy Mission and Philosophy
102: Provision of Respiratory Care Services
2. (Section Reserved)
3. Job Descriptions
4. Licensure/Credentials
5. Orientation/Competency
6. (Section Reserved)
7. Documentation
8. Billing
9. Respiratory Care Department Policy
9a. Equipment Management
View Entire Respiratory Care Manual
Safety- EOC
EOC 1
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