Skip to content
  • Policies
  • Incident Reporting
  • Pediatric Nutrition Care Manual (PNCM)
  • Work Order
  • Contact IT
  • Contact EMR Support
  • 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
      • 103: Scope of Practice
      • 104: Purpose / Goals of Respiratory Care
    • 2. (Section Reserved)
    • 3. Job Descriptions
      • 300.1: Job Description, Staff Therapist
      • 300.2: Job Description, Supervisor WCRH
      • 300: Job Descriptions
    • 4. Licensure/Credentials
      • 400: Licensure
    • 5. Orientation/Competency
      • 500: Orientation Program
      • 501: Orientation, Checklist
      • 502: Clinical Competency Assessment
    • 6. (Section Reserved)
    • 7. Documentation
      • 700: Respiratory Evaluation / Assessment
      • 701.1: Guidelines for Documentation of Respiratory Services; Medact, MAR, Ventilator/Pt., system flowsheet, Respiratory evaluation Treatment flowsheet, progress, change of status, termination of services, Discharge flowsheet
      • 703: Discharge Summaries / Instructions
    • 8. Billing
      • 800: Billing
    • 9. Respiratory Care Department Policy
      • 900: Respiratory Care Services Departmental Plan 2026
      • 902.1 Assisted Coughing
      • 902.2: Airway Clearance; In-Exsufflator
      • 902.4 Suctioning, Pre-measured
      • 902: Identification of Adverse Reactions
      • 903: BIPAP (Bi-level Positive Airway Pressure)
      • 904: Cofflator-Cough Assist
      • 905: Cardio Respiratory Monitoring Placement
      • 906: Care Planning
      • 907: Clinical Standard & Evidence-Based Practice
      • 908.1 Code Bell Activation / Response
      • 908: IPV
      • 909: Chest Physiotherapy / Breathing / Cough
      • 910: Cuff Care, Using Posey Cufflator
      • 911: Cuff Care; Bivona TTS
      • 912: Cuff Care Bivona Foam-filled Silicone Tracheostomy Cuffs
      • 914: Discharge Planning; Family Training
      • 915: Dysphagia Evaluations
      • 916: Hyperinflation / Breathe Stacking
      • 917: Induced Sputum Through Natural Airway
      • 920: Medication Delivery; Nebulizer Delivery
      • 921: Metered Dose Inhalers
      • 924: Expired Respiratory Medications and Supplies
      • 925: Nasopharyngeal Aspiration
      • 926: Oxygen Analyzer
      • 927.1: Transuctaneous: TCOM 4 Monitoring
      • 927: Transporting Residents Within/out of Facility
      • 928: Tracheal Suctioning
      • 931: Emergency Reinsertion of a Chronic, Stable Tracheostomy Tube
      • 932: Tracheostomy: Use of a Tracheostomy Cap or Plug
      • 933: Routine Trach Changes
      • 934: Trach Changing Certification
      • 937.1: Tracheostomy Management Protocol
      • 937: Trach Care: Bleeding at Trach Site
      • 938: Ventilator Management Protocol
      • 939: Confidentiality in Patient Care
      • 942: Treatment Services
      • 944: High-Frequency Chest Wall Oscillation
      • 946: Speech Valve Evaluation and Use
      • 947: Initiation of Service
      • 948: Replacement of Respiratory Equipment
      • 949: Skin Integrity Management
      • 958: Prone Positioning
      • 960: Suction Jar Maintenance
      • 961: Emergency Bedside Equipment
      • 962: Ongoing Re-Assessment Process
      • 964: Physician Orders Update
      • 967: Handling of Medical Equipment, Role of Rehabilitation Staff
      • 968: Acapella with Huff Cough
      • 1235: Monitoring: Pulse Oximetry
      • 1257.1: Suction Machine/Canister/Tubing Maintenance
      • 1300: Staffing Plan
      • 1319: Family and Caregiver Respiratory Competency Training
    • 9a. Equipment Management
      • 918: Loss of Medical Gas/Vacuum
      • 951: New Equipment Intake Process
      • 952: Rental Equipment Intake Process
      • 953: Equipment for Home Care
      • 954: Equipment Failure / Problems and Reporting
      • 955: Rental Equipment Failure / Problems
      • 956: Equipment Failure, Emergency Clinical Intervention
      • 957: Discontinuing Equipment Use
      • 1110.2: Selecting and Purchasing Equipment
      • AM 11.32: Reporting Incidents Related to Medical Devices
      • AM 11.38: Staff Education and Competency of New Equipment
      • Medical Equipment Management Plan
    • View Entire Respiratory Care Manual
  • Safety- EOC
    • 0. Burlington County Hazard Vulnerability
    • 1. Risk Management & Governance
    • 2. Incident Reporting & Event Management
  • 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
      • 103: Scope of Practice
      • 104: Purpose / Goals of Respiratory Care
    • 2. (Section Reserved)
    • 3. Job Descriptions
      • 300.1: Job Description, Staff Therapist
      • 300.2: Job Description, Supervisor WCRH
      • 300: Job Descriptions
    • 4. Licensure/Credentials
      • 400: Licensure
    • 5. Orientation/Competency
      • 500: Orientation Program
      • 501: Orientation, Checklist
      • 502: Clinical Competency Assessment
    • 6. (Section Reserved)
    • 7. Documentation
      • 700: Respiratory Evaluation / Assessment
      • 701.1: Guidelines for Documentation of Respiratory Services; Medact, MAR, Ventilator/Pt., system flowsheet, Respiratory evaluation Treatment flowsheet, progress, change of status, termination of services, Discharge flowsheet
      • 703: Discharge Summaries / Instructions
    • 8. Billing
      • 800: Billing
    • 9. Respiratory Care Department Policy
      • 900: Respiratory Care Services Departmental Plan 2026
      • 902.1 Assisted Coughing
      • 902.2: Airway Clearance; In-Exsufflator
      • 902.4 Suctioning, Pre-measured
      • 902: Identification of Adverse Reactions
      • 903: BIPAP (Bi-level Positive Airway Pressure)
      • 904: Cofflator-Cough Assist
      • 905: Cardio Respiratory Monitoring Placement
      • 906: Care Planning
      • 907: Clinical Standard & Evidence-Based Practice
      • 908.1 Code Bell Activation / Response
      • 908: IPV
      • 909: Chest Physiotherapy / Breathing / Cough
      • 910: Cuff Care, Using Posey Cufflator
      • 911: Cuff Care; Bivona TTS
      • 912: Cuff Care Bivona Foam-filled Silicone Tracheostomy Cuffs
      • 914: Discharge Planning; Family Training
      • 915: Dysphagia Evaluations
      • 916: Hyperinflation / Breathe Stacking
      • 917: Induced Sputum Through Natural Airway
      • 920: Medication Delivery; Nebulizer Delivery
      • 921: Metered Dose Inhalers
      • 924: Expired Respiratory Medications and Supplies
      • 925: Nasopharyngeal Aspiration
      • 926: Oxygen Analyzer
      • 927.1: Transuctaneous: TCOM 4 Monitoring
      • 927: Transporting Residents Within/out of Facility
      • 928: Tracheal Suctioning
      • 931: Emergency Reinsertion of a Chronic, Stable Tracheostomy Tube
      • 932: Tracheostomy: Use of a Tracheostomy Cap or Plug
      • 933: Routine Trach Changes
      • 934: Trach Changing Certification
      • 937.1: Tracheostomy Management Protocol
      • 937: Trach Care: Bleeding at Trach Site
      • 938: Ventilator Management Protocol
      • 939: Confidentiality in Patient Care
      • 942: Treatment Services
      • 944: High-Frequency Chest Wall Oscillation
      • 946: Speech Valve Evaluation and Use
      • 947: Initiation of Service
      • 948: Replacement of Respiratory Equipment
      • 949: Skin Integrity Management
      • 958: Prone Positioning
      • 960: Suction Jar Maintenance
      • 961: Emergency Bedside Equipment
      • 962: Ongoing Re-Assessment Process
      • 964: Physician Orders Update
      • 967: Handling of Medical Equipment, Role of Rehabilitation Staff
      • 968: Acapella with Huff Cough
      • 1235: Monitoring: Pulse Oximetry
      • 1257.1: Suction Machine/Canister/Tubing Maintenance
      • 1300: Staffing Plan
      • 1319: Family and Caregiver Respiratory Competency Training
    • 9a. Equipment Management
      • 918: Loss of Medical Gas/Vacuum
      • 951: New Equipment Intake Process
      • 952: Rental Equipment Intake Process
      • 953: Equipment for Home Care
      • 954: Equipment Failure / Problems and Reporting
      • 955: Rental Equipment Failure / Problems
      • 956: Equipment Failure, Emergency Clinical Intervention
      • 957: Discontinuing Equipment Use
      • 1110.2: Selecting and Purchasing Equipment
      • AM 11.32: Reporting Incidents Related to Medical Devices
      • AM 11.38: Staff Education and Competency of New Equipment
      • Medical Equipment Management Plan
    • View Entire Respiratory Care Manual
  • Safety- EOC
    • 0. Burlington County Hazard Vulnerability
    • 1. Risk Management & Governance
    • 2. Incident Reporting & Event Management