Policy Manual

POLICY MANUAL

Administration | Clinical | Clinical Finance | Clinical Operation Compliance
Human Resources | Information Management

Administration

	A1-	Physician Director
	A2-	Medical Staff Coverage
	A3-	Access to Care Standards
	A4-	New Appointment Availability
	A5-	Distribution of Provider Schedules in ID Scheduling
	A6-	Edit to Provider Schedules
	A7-	Provider Cancellations
		Clinic Schedule Change Form
	A8-	Missed Appointments
	A9-	Patient Late Arrival Policy
	A10-	Habitual or Excessive No Show Patients
	A11-	Method of Informing Patient of Responsible Physician
	A12-	Variance Reporting
		Variance Report Form
	A13-	Receipt, Review and Resolution of Patient Comments/Concerns
		Patient Comment/Concern Form
	A14-	Confidentiality/Disclosure of Health Information
	A15-	Clinical Information for Patients
	A16-	Referral Module in Logician Policy
	A17-	Transfer of Patients Within ECU Physicians
		Addendum A- Physician Initiated Letter of Termination
		Addendum B- Patient Initiated Letter of Termination
		Addendum AC- Termination of Care
	A18-	Patient Dismissal
	A19-	Patients' Valuables and Personal Property
	A20-	Abandoned Patients
		Addendum- Assessment
	A21-	Patient Transportation Within ECU Physicians
	A22-	Prisoner Security and Transportation
	A23-	Smoke Free Environment
	A24-	Utility Outages
	A25-	Adverse Weather Plan
	A26-	Sales/Vendor Representative Policy
	A27-	Managed Care Contract Evaluation
	A28-	Hazard Notices and Product Recalls
		Addendum- Product Recall Notice
	A29-	Professional Courtesy & Discretionary Write-off Practices
	A30-	Research Related Injuries
	A31-	Student Training and Professional Visitor
		Attestation 1 - Universal Affiliation Agreement
		Attachment 2 - Visitor Encounter Application
		Attachment 3 - Short Term Visitor Health Questionnaire
		Attachment 4 - Long Term Visitor Immunization History
		Attachment 5 - Visitor Encounter Agreement and Release and Waiver From Liability
		Attachment 6 - Visiting Medical Student Application
		Attachment 7 - BSOM Code of Conduct Attestation Form and BSOM Code of Conduct
	A32-	Responding to Media Requests for Patient Information
	A33-	Responsibility for Assignment of Space
	A34-	ECU Physicians Answering Service Procedures
	A35-	Prospective Health Review of Facility Construction/Renovations/Acquisition

Clinical

C1-	Patient Rights and Responsibilities
C1.1-	Consent
C2-	Noncompliance with ECU Physicians Policy
C3-	Code Blue
	Addendum 1 - ECU Physicians Code Blue Record
C4-	Defibrillator and Emergency Cart Checklist
C5-	Controlled Drug Policies and Procedures
C6-	Conscious Sedation
	Addendum - Pre-Sedation Assessment
	Addendum - Conscious Sedation Work Sheet
C7-	Hazardous Drugs
	Addendum - Hazardous Drug Safety and Health Plan
	PCMH Attachments
C8-	Chemotherapy Administration
C9-	Intravenous Medication Administration
C10-	Reporting of Adverse Drug Safety and Health Plan
C11-	Food and Drug Interactions
C12-	Sample Drugs
	Addendum 1 - Sample Medication Log
	Appendix 2
C13-	Standing Orders
C14-	Verbal and Telephone Orders
C15-	Monitoring of Patients Receiving Medication
C16-	Risk Screening and Patient Assessment
C17-	Infection Control
C18-	Patients Presenting with a Communicable Disease
C19-	Tuberculosis and Other Respiratory Illness Screening
C20-	Reporting Suspected Nosocomial Infections
C21-	Documentation and Follow-up of Diagnostic Studies
C22-	Release Against Medical Advise (AMA)
	Addendum - Release Against Advice Form
C23-	ECU Physicians Home Health Referrals
C24-	Location, Storage, & Procurement of Medicine & Supplies
C25-	*"RESERVED FOR FUTURE USE"*
C26-	Do Not Resuscitate (DNR)
C27-	Nursing Resource Manual Statement
C28-	Domestic Violence Identification and Referral
C29-	Suspected Victims of Abuse and/or Neglect
C30-	Prescribing Medication - Patient Contact
C31-	Advance Care Planning
C32-	ABN - Medical Necessity
C33-	Examination of Patients Under Anesthesia by Medical Students

Clinical Finance

CF1-	Completion of Health Forms
	Addendum
CF2-	POS Collections Policy
CF3-	GPA ECU CARE - (UNDER REVIEW)
CF4-	Managed Care Contract Termination
CF5-	Monthly Payment Plans for Low Income Patients
CF6-	Delegation of Authority for Case Rate Negotiations

Clinical Operation Compliance

COC1	*"RESERVED FOR FUTURE USE"*
COC2-	MTNC Standard Revision
COC3-	Comprehensive Error Rate Testing (CERT)

Human Resources

HR1-	ECU Physicians Provider Credentialing Information
HR2-	Physician License Renewal
	Addendum 1 - License Renewal Letter
	Addendum 2 - Second Request Letter
HR3-	DEA Registration and Renewal - (combined with HR4)
	Addendum 1 - Renewal Reminder Letter with additional instructions
HR4-	*"RESERVED FOR FUTURE USE"*
HR5-	Departing Physicians
	Attachment 1 - Clinical Faculty Resignation Memorandum
	Attachment 2 - Sample Notification letter to Patient from Physician Leaving ECU Physicians
	Attachment 3 - Departing ECU Physician/Clinical Provider Checklist
HR6-	Scope of Practice for RN or LPN
HR7-	New Employee Orientation Policy
HR8-	Scope of Patient Care Tasks by Unlicensed Personnel
HR9-	Licensure Verification for Professional & Unlicensed Practical Nurses
HR10-	Midlevel Provider and Licensed Staff License Renewal and Reimbursement
	Addendum - License Renewal Failure Letter
HR11-	Evaluation of Clinical Competency
HR12-	Staff Education
	Addendum - Staff Education Record
HR13-	Medication Administration and Dispensing
HR14-	Medication Calculation Competency
HR15-	Minimal Standards for Dress and Appearance
HR16-	Dress Code of Group Practice Administration
HR17-	Dress Code for Faculty and Staff Providing Direct Patient Care
HR18-	Liability Coverage for Volunteering
	Volunteer Services Request Form
HR19-	Health and Dental Care for Residents, Medical and Graduate Students and Dependents
HR20-	Expert Witness Service
HR21-	Patient Care Staffing
HR22-	*"RESERVED FOR FUTURE USE"*
HR23-	Acceptance of Vendor Representative Courtesies



	* HR22, 24, 26, 27, 28 were removed - please refer to the HR CSS policies located on the HR website at http://www.ecu.edu/cs-admin/hr/upload/ECU%20Human%20Resources%20Policy%20Manual.htm

Information Management

IM1-	Official Medical Record
IM2-	Multiple Record Volumes
IM3-	Data Retention
IM4-	Problem List
IM5-	Medication List
IM6-	Allergies
IM7-	Progress Note
IM8-	Documentation Standards
IM9-	Electronic Signatures
IM10-	Entering Authorizations in IDX
IM11-	Verbal Orders
IM12-	Medical Record Review
	Addendum
IM13-	HIV Testing
IM14-	Sensitive Information
IM15-	Unapproved Abbreviations
	Addendum - Abbreviations