Download Dear Student, We are pleased that you have chosen to complete a

Dear Student,
We are pleased that you have chosen to complete a clinical rotation at Baylor University Medical Center (BUMC).
The Department of Medical Education strives to facilitate the highest quality experience for all learners, and we look
forward to welcoming you upon arrival.
To ensure a smooth start on your first day, please make certain that you comply with the following requirements
and submit required documents no later than two weeks before your rotation start date. Signed and/or required
documents should be emailed to [email protected] or faxed to 214-820-7272.
A. Forms that need to be reviewed, completed, signed and returned:
o Student information form
o Badge photo form
o Motor vehicle registration form
o Confidentiality form
o Guide to your care form and signature page
o Unapproved abbreviation sheet with signature form
o HIPPA privacy overview with test
o Select ISP Form (PM&R Rotators only)
B. Ensure that copies of the following have either been uploaded to VSAS, faxed in, or home school (i.e.
TAMHSC) has provided attestation of:
o Proof of current immunizations including proof of influenza vaccine for rotations beginning in
September
o Proof of BLS/ACLS training
o Proof of personal health insurance
o Proof of malpractice insurance
o Proof of any OSHA, infection prevention and sterile technique training
C. Online Baylor EHR training
a. All new and returning students must complete courses no later than 72 hours prior to arrival.
o Link: http://BaylorEHR.interactyx.com
o Alternate Link: www.myBaylorEMR.com , click the ‘EHR Resources’ tab
o New Users must register. Registration Info: Organization = Dallas Campus; Code = DCDR
o See FAQ attachment for screenshot assistance or call Helpdesk at 214-820-4646.
b. Six courses that must be completed:
o EHR 101: Basics, EHR 201: Physician Documentation, EHR 202: Fundamentals of Order Entry
EHR 301: Order Reconciliation Manager, EHR 302: Discharging a Patient, EHR 303: Entering
Complex Orders
CI. Reporting Information and Orientation
I understand that I will Park in Garage 7 and report to the Office of Medical Education located on the 1st
floor of the Roberts Hospital, Suite 1013 at 8:15 a.m. on Day 1 of rotation for orientation. During which we
will arrange for your ID badge, campus parking, computer access and EHR competency check-off.
Directions: Enter main entrance of Roberts Hospital. Follow left hallway between gift shop and café and pass
through wooden double doors labeled, “Powell Center for Medical Education”. Office is second door of the
left, Suite 1013. Map attached.
**** I have read this document and have complied with sections A,B,C and D.
Signature _____________________________________
Date: ____________
Printed Name: _____________________________________
If you have additional questions, please contact Lisa Hammond at [email protected] or 214-818-6499.
STUDENT INFORMATION
Form Status: CONFIDENTIAL
1.
2.
3.
4.
All students must check in with the Medical Education Department upon arrival for elective.
All students must check out with the Medical Education Department upon completion of elective.
All students must complete a confidential evaluation form in the Medical Education Department when checking out.
If assigned a call room, there is a $25 replacement fee if the call room key is lost.
Today's Date
Name
First
Middle
Date of Birth
Last
Social Security # XXX-XX-
Address
Street
Apt. #
Email address:
City
State
Zip
Telephone #
Beeper #
Have you rotated here before? No
When?
Elective
Name of your Medical School
Current Status: MS IV
Expected Graduation Date
Elective Other
From
To
Baylor Clinical )DFXOW\Sponsor
Person to notify in case of emergency
Phone
Relationship
Medical Education Department
Baylor University Medical Center
3500 Gaston Avenue
Dallas, TX 75246
Phone 214.820.2361 Fax 214.820.7272
BUMC Parking
Call Room
Security
Beeper
Supervisor
Student Information
Date:
Name ___________________________________________________________________________
Address __________________________________________________________________________
City __________________ State/Province ________________ Zip/Postal Code ____________
Home Phone ______________ Cell Phone ______________ Alternate Phone ________________
Pager
Spouse Name ___________________________________________________________________
Employer ______________________________________________________________________
Cell Phone _____________________ Work Phone __________________
Emergency Contacts
1st Contact ____________________________________________ Relationship__________________
Address _________________________________________________________________________
City __________________ State/Province ________________ Zip/Postal Code ____________
Home Phone _______________ Cell Phone _________________ Alternate Phone _________________
2nd Contact________________________________________ Relationship______________________
Address _________________________________________________________________________
City __________________ State/Province ________________ Zip/Postal Code ____________
Home Phone ______________
Cell Phone __________________ Alternate Phone ________________
Baylor Health Care System
PHOTO ID/ACCESS CONTROL AUTHORIZATION
Non-Baylor Employee _ ✔
Baylor Employee
Date
Name to appear on badge:
Social Security #: [[[[[ Program Name: 0HGLFDO(GXFDWLRQ
Badge Expiration Date:
Credentials: 06
Specific Badge Access: __0HGLFDO6WXGHQW________________________(completed by coordinator)
Responsible department: Medical Education
Name of BHCS Department Director: Jennifer Olvera
Authorized by:
| Access Card #
(Authorized representative) Jennifer 2OYHUD, Christina Gutierrez, Donna McCullin, 6\OYLD6QRZor /LVD+DPPRQG
THIS SECTION TO BE COMPLETED BY PERSON RECEIVING PHOTO ID BADGE/ACCESS CARD:
I acknowledge the following:
1. I have received a photo identification badge/access card issued by the Baylor Health Care System
Department of Public Safety, Parking and Transportation Services Division, in accordance with
BHCS policies and procedures.
2. I agree to pay a $25 replacement fee to BHCS if my badge is lost or stolen. I understand it is my
responsibility to report my badge lost or stolen as soon as possible after becoming aware of the
loss.
3. I understand this badge is the property of BHCS, and I agree to return the badge to the
Department of Medical Education upon completion of my rotation.
4. I understand this badge is not to be used, worn or carried by anyone other than myself. I also
understand that unauthorized use or transfer of my badge could result in disciplinary action.
PRINT LAST NAME
FIRST NAME
MI
SIGNATURE
DATE
Parking Services: 214-820-7275
New Assignment
Process Level:
Update
Deposit Amount:
MOTOR VEHICLE REGISTRATION
Baylor Health Care System
All Saints
Grapevine
Check One:
Bryan Tower
Irving
Dallas
McKinney
Plano
Lot Number
Garland
Waxahachie
Baylor Employee________ Contract Employee________ Faculty________ Intern________ Medco Employee________
Resident/Fellow________ Student________ Volunteer________ Physician________ Physician Office/Tenant Employee________
Please indicate shift worked:
LAST NAME
Days ____
FIRST NAME
HOME STREET ADDRESS
CITY
DATE OF HIRE
SHIFT HOURS
EDUCATIONAL PROGRAM
COMPLETION DATE
Evenings ____
Nights ____ Weekends ____ PRN ____ TDA ____
MI
EMPLOYEE #
SOCIAL SECURITY - Last 4#
STATE
WORK LOCATION
MARQUIS RESIDENT
ZIP
HOME PHONE NUMBER
SUITE #
WORK PHONE NUMBER
EMAIL ADDRESS
Vehicle 3
Vehicle 2
Vehicle 1
VEHICLE INFORMATION
ADD
DROP
TEMP
PERMIT #
LICENSE PLATE #
ADD
DROP
TEMP
PERMIT #
LICENSE PLATE #
ADD
DROP
TEMP
PERMIT #
LICENSE PLATE #
VEH YEAR
VEH YEAR
VEH YEAR
STATE MAKE
COLOR
MODEL
TEMP EXPIRATION DATE
STATE MAKE
COLOR
MODEL
TEMP EXPIRATION DATE
STATE MAKE
COLOR
TEMP/HANGTAG #
TEMP/HANGTAG #
MODEL
TEMP EXPIRATION DATE
TEMP/HANGTAG #
PARKING REGULATIONS ACKNOWLEDGMENT
I acknowledge the following:
1. I have been advised to go to Parking and Transportation Services on mybaylor.com to read the Parking and Traffic Regulations for my work
campus, and I agree to read and follow the regulations in their entirety.
2. Hangtags must be properly displayed from rearview mirror with the number visible from outside of the vehicle. Decals must be affixed to
vehicle, on the outside of the rear window in the lower left corner. If the back window is obstructed the decal is to be placed in the upper left
corner of the front window.
3. I agree to contact Parking and Transportation Services within seven (7) days from the date that I receive the regulations with any
questions. If I do not contact Parking and Transportation Services within seven (7) days regarding any questions, it will be assumed that
I fully understand the regulations.
4. Baylor Health Care System does not agree to safeguard your vehicle or assume care, custody, or control of your vehicle or its contents.
5. Baylor Health Care System is not responsible for fire, theft, damage, or loss to your vehicle or its contents.
6. In the event that a lawsuit is filed for any casualty to your vehicle, or its contents, you agree to defend and indemnify Baylor Health Care
System for any other type of loss including reasonable attorney fees.
7. I agree to pay all applicable card/permit replacement fees, according to the procedures stated in the regulations, and authorize Parking and
Transportation Services to deduct any unpaid fees from my final paycheck upon termination of my employment with Baylor.
8. Employee and/or Vendor agree to report any damage caused by the Employee and/or Vendor's vehicle.
9. I agree to abide by the regulations in their entirety at all times and fully understand that there are penalties for failure to do so.
X
/
Name (signature)
/
Date
Entered By
/
/
Date
CONFIDENTIALITY AGREEMENT
This Confidentiality Agreement (hereinafter referred to as “Agreement”) is entered into by and between
____,
(Name of Rotator [Student/Resident/Fellow])
(hereinafter referred to as “Education Participant”), and _____Baylor University Medical Center___ (hereinafter referred to as “Baylor”), collectively referred to as
“the Parties.”
Education Participant, a student or faculty member of
, in providing patient care at
(Students: Name of medical school Residents: Name of Institution)
Baylor as part of a designated course of study to obtain clinical educational experience will have access to and review confidential patient information maintained
in electronic and/or paper form by Baylor.
Education Participant agrees not to access, use, disclose, or reproduce any confidential patient information for any other purpose, except as specifically permitted
pursuant to my Student/Faculty duties. Education Participant further agrees to use appropriate safeguards to prevent access, use, disclosure, or reproduction of
confidential patient information other than as provided herein. Upon completion of his/her clinical educational experience with Baylor, Education Participant
agrees to return any confidential patient information or reproductions thereof in Education Participant’s possession.
Education Participant acknowledges that he/she has reviewed the Baylor Health Care System’s Data Policy and agrees to abide by it as adopted and amended from
time to time.
Education Participant acknowledges and understands that unauthorized access, use, disclosure, or reproduction of any patient information in violation of the
Baylor Health Care System’s Data Policy or in violation of this Agreement will authorize Baylor to prohibit Education Participant from providing any patient care
on Baylor’s premises. Education Participant further understands that certain unauthorized disclosure of patient information is punishable by fines and penalties
imposed by Federal and State law(s).
Education Participant acknowledges and understands that if Education Participant is granted specific computer system(s) access based on the nature and scope of
Education Participant’s assignment, Education Participant is prohibited from accessing or attempting to access any computer system(s) in a manner that violates the
Baylor Health Care System’s Data Policy or is not consistent with Education Participant’s specifically assigned user rights.
Education Participant further agrees to indemnify and hold harmless Baylor for any liability, expense or loss, including damages, exemplary damages and
reasonable attorneys fees which may be sustained by Baylor as a result of any unauthorized disclosure of confidential patient information to any third party by
Education Participant.
Upon request, Education Participant agrees to make available Education Participant’s internal practices, books, and records relating to use and disclosure of
protected health information to the Secretary or an employee of the Department of Health and Human Services.
Education Participant agrees that in the event any amendments or corrections are made to the patient’s protected health information such amendments or
corrections will be incorporated into such records in Education Participant’s possession.
I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.
____________________________
5HSUHVHQDWLYHRI%D\ORU
__________________
Date
_______________________________
Education Participant’s Signature
__________________
Date
-1Revised 8-2011
A Guide to Your Care
Important information about medical and ethical issues
For example, you have the right to:
•information about your condition, treatment
options and test results
If you are reading this guide, you are probably in
the hospital or preparing to be in the hospital. Our
goal while you are a patient in our hospital is to
help you experience the best possible outcome from
your stay here. For this to happen, everyone—you,
your family and your health care team—must
all work together and communicate clearly. This
guide is provided to help you understand how you
and your family can work with your health care
team toward the goal of achieving the best possible
outcome, as well as to help you understand what
your rights and responsibilities are while you are a
patient here.
•information about outcomes that may be
different from what you and your family expected
•treatment for pain and suffering
•information about hospital ethics policies
•participate in your treatment decisions, including
ethical decisions about treatment
•refuse or accept treatment or research that is
offered to you. This includes the right to refuse
treatments that can potentially help prolong your
life, such as mechanical breathing machines,
dialysis, artificial nutrition/hydration or
attempted cardiopulmonary resuscitation (CPR)
We know that a hospital can be a confusing place.
You may have many different doctors who visit
when your family isn’t nearby. Physicians and
nurses may use words you don’t understand. You
may have questions about hospital rules or your
rights as a patient. You may be very sick and hard
choices may need to be made about your treatment.
Making those decisions can be difficult and
emotions may be strong. We hope the information
you find in this guide will ease your mind, make
you feel comfortable communicating with your
health care team about your treatment or any other
issues, and enhance the experience of both you and your family.
•complete advance directives such as a living will
or medical power of attorney. These forms can
be obtained from your nurse, chaplain, social
worker, or physician
•privacy, confidentiality, security and culturally
respectful communication
•have a language interpreter to assist you with
conversations about your health throughout your
visit free of charge
•have access to items and/or devices to assist you
with conversations about your health throughout
your visit free of charge
•decide who may visit you during your hospital stay
Your rights and responsibilities as a patient
•choose a primary support person to stay with you
during your hospital stay
As a patient, you have certain rights and
responsibilities. As a hospital, it is our responsibility
under federal law and hospital accreditation
standards to make sure you are informed about
those rights and responsibilities. •be informed if family or guest visitation must be restricted
•freedom from mental, physical, sexual or verbal
abuse or neglect
1
MOD-11037. 6/2011 44043
With your rights come certain responsibilities.
Your responsibilities, among others, include:
•your diagnosis
•the responsibility to give your health care team
honest and accurate information about your
medical history
•the types of treatment appropriate to meet those goals
•goals of your treatment
•the benefits, burdens, and risks of treatment as well as the probability of success
•the responsibility to follow treatment directions
and cooperate with your health care team
•the responsibility to treat other patients, visitors,
your health care team and hospital property with respect
It is important that you discuss your goals and the
types of treatment with your physicians, nurses
and your family while you are able to speak for
yourself. How do you want to be treated if you
have an accident or an illness and become so sick
you can’t speak for yourself? Who should speak for
you and what should they say?
Who is on my health care team?
Throughout this guide we refer often to your
health care team. Depending on many factors,
your health care team may be made up of any
number of individuals who will provide your care.
Every team member brings special expertise to
your plan of care. These individuals will identify
themselves, their professional status if applicable,
their relationship to others on the team, and their
role in your treatment and care.
The importance of advance care planning
The process of thinking about who should speak
for you if you can no longer speak for yourself
and considering the goals and intensity of your
treatment is called advance care planning. When
thinking about who should speak for you, consider
how trustworthy that person is and how available
they are. Think about what you would want them
to say on your behalf. This is easy if you are only
temporarily unable to speak for yourself and
recovery is expected.
Goals and types of treatment
The most basic goal of medicine is to fix or cure
your health problem. If a complete cure is not
possible, the goal of the health care team is to try
to slow down the problem or make it go away for
a while (remission). Perhaps the most important
goal is to provide you with comfort and relief of
suffering at all times. You will receive medically
appropriate treatment to meet these goals and we
hope that you will do well.
But what if you become so sick that you can
no longer communicate and cure is no longer
possible? If you make these decisions in advance,
you will be relieving your family and loved ones
from making these decisions for you. You should
think about these questions:
Communicating with your health care team
•What physical, mental or financial burdens
would you be willing to accept to temporarily
stay alive longer (or prolong dying) in that
circumstance?
Good communication is essential to every part of
medical treatment. It is important when things are
going well. It may be even more important when
things are not going well and the outcome you and
your family expected is not being achieved. Either
way, it is vital that you, your family and your
health care team communicate clearly. You should
feel free to discuss any topic associated with your
care and treatment with members of your health
care team. For example, you may want to discuss:
•What quality of life would you want to have to
make staying on a breathing machine or dialysis
worth while?
•Would you be willing to live confined to a bed in
a nursing home, unable to care for yourself?
2
•How important is pain control to you—not only
physical, but mental and spiritual?
• Common Questions and Answers About
Palliative Care
•What if you were permanently unconscious and
could not feel pain, hunger, thirst, happiness,
love or joy, but could be kept alive with a tube
in the stomach to provide artificial nutrition and
hydration?
• Common Questions and Answers About Severe
Brain Injury
• Information About Serious Illness
• Official State of Texas forms for a: Living Will
(Directive to Physicians and Family or Surrogates),
Medical Power of Attorney, Notice of Declaration
and Declaration for Mental Health
These are hard questions and they often have
deeply personal answers. Whatever your answers
are, the best way to communicate them is by
completing an advance directive such as a Living
Will and/or a Medical Power of Attorney.
• Out-of-Hospital Do-Not-Resuscitate Order
• Simplified Advance Care Plan and Living Will
(Optional)
Advance directives have been clearly shown to
improve patient care in the setting of serious illness
and to lessen family stress. If you do not have an
advance directive at the time of admission, we
hope you will complete one prior to discharge. It
is never too late to do so, and a copy can be placed
in your medical record. You are not required to
complete an advance directive. Whether or not
you choose to complete an advance directive, your
care, treatment and services that you receive will
not be affected, nor will your decision result in any
discrimination against you.
If I complete an advance directive, can I
change my mind?
Yes, you may cancel any advance directive simply
by destroying the document, signing and dating a
written statement that states your desire to cancel
the directive, or telling your doctor or nurse. You
may also review and revise your advance directive.
If you choose to change an advance directive, you
must execute a new one.
Where else can I get help?
In addition to your personal physician, all Baylor
Health Care System hospitals have specially trained
social workers, nurses, and chaplains who can help
you with advance care planning concerns. You
may also have ethical concerns as you consider
potentially serious issues. All Baylor Health Care
System hospitals have access to ethics committees
and ethics consultants who may offer counsel
and assist in resolving ethical issues that might
arise. These services are provided free of charge.
You, your family or health care decision maker,
your physician or any member of your health
care team may request guidance from a Baylor
Health Care System hospital ethics committee. For
further information, your physician, nurse, social
worker or chaplain can help you reach the ethics
committee at your facility or you may call one of
the phone numbers at the end of this handout.
You may also wish to consult your personal or
To help you face questions you may have about
advance directives and to complete an advance
directive, you may request the following additional
resources from your nurse, social worker, chaplain
or physician, or you may access all of the following
documents online at www.BaylorHealth.com/
PatientInformation.
• Advance Care Planning
• A Guide to Your Care
• Common Questions and Answers About
Artificial Nutrition and Hydration
• Common Questions and Answers About Autopsies
• Common Questions and Answers About
Cardiopulmonary Resuscitation (CPR)
• Common Questions and Answers About Hospice
• Common Questions and Answers About Pain in
the Setting of Serious Illness
3
family lawyer if you have questions about advance
care planning.
positive and negative. If you have any complaints,
we hope you will:
What if there is disagreement about
ethical issues?
• First report your complaint to the clinical
manager for the unit or facility involved. The bedside nurse will help you identify the
clinical manager.
On rare occasions there may be ethical disagreements
between you, your family and/or health care
providers. We believe good communication can
prevent most ethical disagreements. It is also worth
remembering the following:
• You may also contact hospital administration at
the number listed in the Contact Information
contained in this document.
•We will make every reasonable attempt to honor
your treatment preferences within the mission,
philosophy and capabilities of Baylor Health
Care System hospitals and the accepted standards
of medical practice. This includes those expressed
by an advance directive or by others on your
behalf if you lack an advance directive and are
unable to make decisions.
We will investigate your complaint through our
formal complaint process and we will give you a
response.
Although we encourage you to bring your concerns
directly to us, you always have the right to take any
complaint to the Texas Department of State Health
Services and/or the Joint Commission by e-mail,
fax, letter or phone at the contact numbers and
addresses listed below.
•We respect your right to reject treatments offered.
•We do not recognize an unlimited right to receive
treatments that are medically inappropriate.
Grievance Process Information
•Texas law, specifically Chapter 166 of the Texas
Health & Safety Code, provides a process for
resolving ethical disagreements between you,
your family, and/or health care providers in those
rare cases where further communication does
not resolve the disagreement. This process relies
on ethics consultants and ethics committees
available at each Baylor Health Care System
hospital to help as needed.
THE JOINT COMMISSION:
• E-mail: [email protected]
• Telephone: (800) 994-6610 weekdays 8:30 a.m. to 5 p.m., Central Time
• Fax: (630) 792-5636 Office of Quality Monitoring
• U.S. Mail:
Office of Quality Monitoring
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
At some point, you may be asked to make hard
choices about treatment when cure of your
illness is no longer possible and emotions may
be strong. We have provided this information
in hopes of helping you better understand your
rights, responsibilities and ethical issues associated
with being in the hospital. We hope a better
understanding will improve communication,
treatment and lessen stress for all.
TEXAS DEPARTMENT OF STATE HEALTH SERVICES:
If you have any complaints concerning the
information on advance directives that we have
provided in this document, you may contact the
Texas Department of State Health Services at
(888) 973-0022 (toll free number).
1100 W. 49th Street
Austin, TX 78756-3199
Complaints
We welcome your feedback at all times, both
4
Baylor Health Care System:
BAYLOR MEDICAL CENTER AT SOUTHWEST FORT WORTH
Administration: (817) 346-5674
Pastoral Care/Chaplain: (817) 346-4056
Guest Representative: (817) 346-4032
Public Safety: (817) 922-1911
PATIENT PRIVACY OR CONFIDENTIALITY
COMPLAINTS:
If you have concerns about patient privacy or
confidentiality, you may call (866) 245-0815 (toll-free number).
BAYLOR MEDICAL CENTER AT WAXAHACHIE
Administration: (972) 923-7020
Pastoral Care/Chaplain: (972) 923-7343
Public Safety: (972) 923-7000
BILLING CONCERNS:
(214) 820-3151 or (800) 725-0024
Baylor Health Care System Facility
Contact Information:
BAYLOR REGIONAL MEDICAL CENTER AT
GRAPEVINE
Administration: (817) 329-2500
Pastoral Care/Chaplain: (817) 329-2520
Public Safety: (817) 424-4587
BAYLOR ALL SAINTS MEDICAL CENTER
Administration: (817) 926-2544
Pastoral Care/Chaplain Office: (817) 927-6150
Guest Representative: (817) 922-2777
Public Safety: (817) 922-1911
BAYLOR REGIONAL MEDICAL CENTER AT PLANO
Administration: (469) 814-2100
Pastoral Care/Chaplain: (469) 814-2700
Guest Representative: (469) 814-2028
Public Safety: (469) 814-4444
BAYLOR JACK AND JANE HAMILTON HEART AND VASCULAR HOSPITAL
Administration: (214) 820-0695
Pastoral Care/Chaplain: (214) 820-2542
Guest Representative: (214) 820-0629
Public Safety: (214) 820-4444
BAYLOR SPECIALTY HOSPITAL
Administration: (214) 820-9756
Pastoral Care/Chaplain: (214) 820-2542
Guest Representative: (214) 820-9756
Public Safety: (214) 820-4444
BAYLOR INSTITUTE FOR REHABILITATION
Administration: (214) 820-9386
Pastoral Care/Chaplain: (214) 820-2542
Public Safety: (214) 820-4444
BAYLOR UNIVERSITY MEDICAL CENTER AT DALLAS
Nursing Administration: (214) 820-7727
Pastoral Care/Chaplain: (214) 820-2542
Guest Representative: 3-SERV or (214) 818-7378
Public Safety: (214) 820-4444
Dial-a-Prayer Line: (214) 820-2333
BAYLOR MEDICAL CENTER AT CARROLLTON
Administration: (972) 394-2255
Pastoral Care/Chaplain: (972) 492-1010
Guest Relations: (972) 512-7530
Public Safety: (972) 394-2228
OUR CHILDREN’S HOUSE AT BAYLOR IN DALLAS
Administration: (214) 820-9838
Patoral Care/Chaplain: (214) 820-2542
Guest Representative: (214) 820-9838
Public Safety: (214) 820-4444
BAYLOR MEDICAL CENTER AT GARLAND
Administration: (972) 487-5232
Pastoral Care/Chaplain: (972) 487-5454
Public Safety: (972) 487-5122
BAYLOR MEDICAL CENTER AT IRVING
Administration: (972) 579-8113
Pastoral Care/Chaplain: (972) 579-8178
Public Safety: (972) 579-8772
THE HEART HOSPITAL BAYLOR PLANO
Administration: (469) 814-3278
Pastoral Care/Chaplain Office: (469) 814-2700
Guest Relations: (469) 814-2028
Public Safety: (469) 814-4444
5
A GUIDE TO YOUR CARE
I have received the Guide to Your Care pamphlet and I am responsible
for reading it.
Name – Printed
Signature
Date
Baylor University Medical Center’s
Unapproved Abbreviation Listing
As a result of the 2003 JCAHO National Patient Safety Goals, the following list of abbreviations,
acronyms, and symbols applies to ALL clinicians that document on any type of documentation that goes
in the medical records. BUMC’s Unapproved Abbreviation Listing was created to promote best practice
and help prevent patient injury.
Unapproved abbreviations: Abbreviations that have been recognized within the industry as having
potential for misinterpretation that could negatively impact patient care/safety.
Unapproved
Abbreviation
> and <
µg
Any drug name
abbreviation.
Cc
IU
Intended Meaning
Misinterpretation
Correction
Greater than and Less than
Mistakenly used opposite
of intended
Mistaken for “mg”
milligram when
handwritten
Can be misinterpreted as
a different medication
(e.g. DPT-Demerol,
Phenergran, Thorazine as
Diphtheria, PertussisTetanus
Misread at “U” units
Mistaken for IV
(intravenous) or the 10
(ten)
Mistaken for magnesium
sulfate. Mistaken for
morphine sulfate.
Period after the Q can be
mistaken for an “I” and
the “O”
Mistaken for the number
“55”
Mistaken for “SL”
Use “greater than” or“less
than”
Spell out “microgram”
microgram
ARA-C, ARA-A, AZT, CPZ,
DPT, HCI, HCT, HCTZ, MTX,
TAC
Cubic centimeter = mL
International Unit
MS, MS04, MgS04
Morphine Sulfate or
Magnesium Sulfate
q.d. or QD or QOD
Every day or Every other
day
ss
Sliding Scale (insulin) or ½
(apothecary)
Subcutaneous
SQ or SC
T.I.W. or t.i.w.
Three times a week
Mistaken for three times a
day or twice a week.
U or u
Unit
Zero after decimal point
(1.0mg)
1 mg
Read as a zero (0) or a (4)
causing a 10 fold overdose
or greater (4U seen as 40
or 4u seen as 44)
Misread as 10mg if the
decimal point is not seen.
Zero not placed in front
of decimal (.5mg)
.5mg = 0.5mg
Misread as 5mg if the zero
is not present.
Please use complete
generic name spelling for
all drug names.
Write “mL”
Write “International Unit”
Write “Morphine Sulfate”
or “Magnesium Sulfate”
Write “Daily” or “Every
other day”
Spell out “sliding scale”.
Use “one-half” or “1/2”
Write “subcutaneous” or
“Sub Q”
Write “three times a
week” . Suggest giving
specific days of the week.
Unit has no acceptable
abbreviation. Write “unit”
Do not use terminal zeros
for doses expressed in
whole numbers.
Always use zero before a
decimal when the dose is
less than a whole unit
Acknowledgment-Medical Education Department
Unapproved Abbreviations in Medication Orders
September 1, 2003 – Department of Pharmacy Policy/Procedure
Section Drug Use Policies – Policy #04.015
I have received the Unapproved Abbreviations in Medication Orders Drug
Use Policy/Procedures. I understand that I am responsible for reading
the document and adhering to it in order to promote best practices and
help prevent patient injury. I am aware that I am not to use the
unapproved abbreviations in medication orders or in handwritten chart
documentation. I am further aware that I may be subject to disciplinary
action if I use unapproved abbreviations in violation of this
Policy/Procedure.
______________________________
Print Name
_____________________________
Signature
______________________________
Date
Medical Students:
Medical
Students:
BUMC utilizes
an Electronic
Health Record (EHR) as a
tool to deliver patient care. To be successful in patient
care, complete the steps below:
Step 1: Register as a New User
At http://BaylorEHR.interactyx.com, click
. Complete required fields.
* Type in Dallas Campus for organization and DCDR
for code.
Step 2: Register for courses
Register for these courses: EHR 101, 200, 201, 202,
203, 301, and 302. Click Launch to begin lessons. As
each one is complete, close the video and click
refresh to make the next lesson available. Complete
all lessons in registered courses, recommended and
optional.
*For any e-Learning questions, email
[email protected].
Step 3: Complete check off and preferences
Email [email protected] with your
name and phone number to schedule a check off and
preference setting session. All e-learning courses
must be completed prior to scheduling.
*For any further questions, please email
[email protected]
HIPAA
Basic Privacy Overview
Lesson Objectives
•
At the end of this module, you will be able to:
1.
Understand the Federal Law about HIPAA
2.
Give two examples of Protected Health Information
(PHI)
3.
Recall three key patient rights
4.
Differentiate between “use” and “disclosure”
5.
Define the concept of “minimum necessary”
6.
Realize when to report a breach of PHI
7.
List two safeguards to protect PHI
8.
State the penalties and fines for non-compliance with
Federal and State Privacy laws
9.
Define physical and electronic security
10. Secure documents and manage records
2 Tuesday, November 02, 2004
Federal Privacy Law
Health
Insurance
Portability and
Accountability
Act of 1996
HIPAA is spelled with two A’s
HIPAA is a federal law that prohibits the
violation of patient privacy and establishes
standards for the privacy and security of
individually identifiable health information
3 Tuesday, November 02, 2004
State of Texas Law
• In addition to HIPAA, the Texas Medical
Records Privacy Act or “Texas Privacy Rule”
also mandates protection of the privacy of
patients’ health care information
4 Tuesday, November 02, 2004
Examples of PHI
• Protected Health Information (PHI) is:
ALL individually identifiable health information
held or transmitted by Baylor or its Business
Associates in any form, including:
•
•
•
•
•
•
•
Health Claims
Billing Information
Satisfaction Surveys
Admission and Discharge Summaries
Client Reports
Remittance Advice
Medical Records
PHI is confidential !!
5 Tuesday, November 02, 2004
What is Confidential?
• All information about patients is considered
private or “confidential” if it is:
– written on paper
– saved on a computer
– spoken aloud
6 Tuesday, November 02, 2004
What is Confidential?
(continued)
• Individually identifiable data or data that
identifies an individual patient must be
carefully protected if it includes:
– Name, address, Social Security number,
age, phone number, driver’s license
number, date of birth, etc.
– Illness, treatments, medications, test
results, notes, etc.
7 Tuesday, November 02, 2004
Three Key Patient Rights
•
HIPAA’s focus is on the rights of patients and
confidentiality of his/her information
•
Under HIPAA, patients have the right to several key
issues:
1. May request restrictions on uses and/or
disclosures of PHI, such as:
a. Uses and/or disclosures to persons (family
member/close friend) involved in the patient’s
care, and for notification purposes, provided
the patient has been provided an opportunity
to agree or object to such disclosures
b. May request that his or her PHI not be
disclosed to a family member or to a particular
member of Baylor's staff
c.
8 Tuesday, November 02, 2004
Requests to be a “No Information” patient
d. May request no information be given to
anyone but the patient
Patient Rights (continued)
2. May request to receive communications
of PHI from Baylor by alternative means
or at alternative locations. For example:
a. An individual may ask that all
communications by Baylor be
disclosed to the individual at his or her
work location rather than at home
b. A request that no messages be left on
the individual's home answering
machine
3. Patients may complain to Baylor if they
believe their privacy rights have been
violated
9 Tuesday, November 02, 2004
Use and Disclosure of PHI
• HIPAA refers to the
– USE (information circulated within Baylor) and/or
– DISCLOSURE (information released outside of Baylor) of
PHI for the purposes of:
• Treatment – the provision of health care
• Payment – insurance companies working to
facilitate reimbursement or managing the bill
• Operations – normal business activities
(reporting, data collection & eligibility checks,
etc.)
Only the minimum necessary PHI must be used and/or
disclosed to perform the job or meet the request
Note: Consent for Use and/or Disclosure is different than
Consent for Treatment
10 Tuesday, November 02, 2004
Minimum Necessary:
Use/Access – “Getting” PHI
• Minimum necessary means limiting information
uses, disclosures and requests only to those
necessary
• Give only the minimum necessary access to
PHI to perform the job function
• Before obtaining patient information, ask
yourself one simple question:
“Do I need to know this to do my job?”
11 Tuesday, November 02, 2004
Minimum Necessary:
Disclosure/Sharing - “Giving” PHI
• Share only the minimum necessary PHI
• Know your role in Baylor
• Know the roles of your co-workers
• Limit your own exposure of PHI to only what is
needed to perform your job or meet the
request
• Before sharing PHI, ask yourself:
“Does this person need this PHI to treat the
patient, receive payment or conduct
eligibility?”
12 Tuesday, November 02, 2004
Incidental Disclosures
• HIPAA recognizes there will be times when
your conversation may be overheard (for
example, calling out a patient’s name in the
waiting room)
• These “incidental disclosures” are permissible
only if “reasonable safeguards” are taken (for
example, lower your voice, go to a family
room, etc.)
13 Tuesday, November 02, 2004
Incidental Disclosures
(continued)
• Never discuss patient information:
– With the patient in the waiting room where
there is a risk that other patients can
overhear
– In public areas such as elevators, dining
areas, hallways, nursing units, parking lots,
bathrooms, etc.
– Outside Baylor with friends, family,
neighbors, etc.
14 Tuesday, November 02, 2004
When to Report a Breach of
PHI
• Report a breach of PHI to your supervisor if
you know PHI has been given out and the
information is not needed for Treatment,
Payment or Operations
– Example: A patient states to a nurse that
she does not want her sister to know her
current diagnosis, but the sister finds out
because the request was not
communicated to a second nurse who
unintentionally shared this information with
the sister
This is an “unintentional disclosure” and
should be reported to your supervisor and
the Baylor Privacy Officer
15 Tuesday, November 02, 2004
Safeguards
• Sign-in list: Patient information such as names
on a waiting list, surgery schedule, or patient
white board should only have the minimum
amount of information displayed
• Computer: Make sure computer screens are
not visible by other patients or unauthorized
individuals to prevent anyone from viewing PHI
16 Tuesday, November 02, 2004
Safeguards (continued)
• Fax: Make sure that you are dialing the correct
fax number and use the approved Baylor fax
cover sheet with the confidentiality disclosure
• Copiers and printers: All documents should be
removed from printers and copiers immediately
if the document contains PHI. Printers and
copiers should be located only in protected
areas not accessible to the public
17 Tuesday, November 02, 2004
Safeguards (continued)
• Medical records binders:
– Place the binders in a physical location not
easily accessible by unauthorized
individuals (do not leave it on a desk and
never leave unattended)
– Make sure the HIPAA Consent Form
(#46002) is signed and in the binder
– If you are working on a physical chart and
you have to step away, close the chart and
return it to its appropriate storage place
18 Tuesday, November 02, 2004
Sanctions
• Baylor may impose disciplinary actions, up to
and including immediate separation from
employment of those who breach patient
confidentiality
• The severity of the disciplinary action will be
based on the nature of the violation
19 Tuesday, November 02, 2004
Penalties and Fines
• Federal:
– Unintentional Disclosure
• Up to $50,000 and/or one year in prison
– Disclosure under False Pretenses
• Up to $100,000 and/or 5 years in prison
– Disclosure with Intent to Sell or Use
• Up to $250,000 and/or 10 years in
prison
20 Tuesday, November 02, 2004
• State of Texas:
– Texas has a “private right to sue” law, so
violations against the HIPAA privacy rule
can also bring about civil legal action
against Baylor and against the individual(s)
involved
Complaints
• Patients, visitors, volunteers, students, interns,
residents, physicians, staff and employees
have the right to make a complaint
• Complaints relating to our “Notice of Health
Information Practices” document that is given
to each patient upon check-in, may be
communicated to anyone within Baylor
• All privacy complaints must be directed to the
Baylor Compliance EthicsLine at 1-866-2450815, staffed 24-hours a day, 7 days a week
(complaints may be filed anonymously)
• EthicsLine posters must be posted in locations
visible to all employees, patients and visitors in
English and Spanish
21 Tuesday, November 02, 2004
Contracts
• Certain vendors, drug representatives,
computer/equipment repair technicians,
contractors, and consultants that perform a
function on behalf of Baylor are considered
“Business Associates” and must have a signed
Business Associate Agreement
• Volunteers, interns, residents, and students
(nursing and medical) are NOT Business
Associates but they MUST sign confidentiality
agreements
22 Tuesday, November 02, 2004
Physical Security
• Only authorized individuals should be allowed
in areas where PHI is present
• Challenge individuals you do not recognize or
may not necessarily have the authority to be in
a work area
• Visitors are not allowed at an employee's work
station where PHI can be seen
23 Tuesday, November 02, 2004
Physical Security (continued)
• Vendors, drug representatives,
computer/equipment repair technicians, etc.
must have proper identification and have
signed a confidentiality agreement to be in a
work area where PHI is present
• You are responsible for taking precautions to
protect PHI from being seen at your
workstation
24 Tuesday, November 02, 2004
Electronic (Computer) Security
• Protect the confidentiality, integrity, and
availability of electronic PHI
• Protect systems from improper access or
alteration by not sharing passwords, etc.
• Prevent public access to medical records
If working on a computer and you need to step
away for some reason, either log off of the
system, or use a screen-saver password.
Do NOT leave the computer unattended
25 Tuesday, November 02, 2004
Electronic (Computer) Security
(continued)
• Do NOT use another person’s password to
gain access to a computer system
• DO change your password on a regular basis
• Each person must have and use his/her own
unique user ID and NOT share it with anyone
for any reason
• You may NOT check the computer system if
you are interested in the current status of a
patient that you previously cared for if you are
no longer caring for that patient
26 Tuesday, November 02, 2004
Document and Records
Management
• Lock bins, drawers and files when not in use
• Keep work areas free of exposed PHI when
you are not present
• Faxes, printouts, and reports should only be
accessed by authorized persons
27 Tuesday, November 02, 2004
Document and Records
Management (continued)
• Use trash can to:
– Dispose of documents that do NOT contain
patient information
• Use shredding bin to:
– Destroy documents, paper or computer
CD’s with patient information
• Use biohazard bin to:
– Dispose of biohazard material (for example,
IV bags) labeled with patient information
28 Tuesday, November 02, 2004
Summary
• Compliance with Federal and State Privacy
laws is mandatory
• You are required to safeguard individuals'
health information
• Hopefully you now recognize the value of
having processes and procedures that comply
with HIPAA requirements
• If you do not follow policies and procedures,
you could risk disciplinary actions for violations
of privacy policies as well as be personally
fined and/or sentenced to prison time
29 Tuesday, November 02, 2004
BHCS HIPAA Basic Privacy Overview
Test
Circle the correct answer. Passing grade is 100%.
Note to sponsor: The individual may NOT take these questions with
them. After they have taken the test, place this test in their file with
their answers circled and score clearly marked.
Print Name: ___________________________________________ Date:________________ Score: ______
1. The Federal Privacy Law is called the
A. Health Information Privacy and Protection Act of 1996
B. Healthcare Identification Privacy and Assurance Act of 1996
C. Healthcare Interstate Portability and Accuracy Act of 1996
D. Health Insurance Portability and Accountability Act of 1996
2. Which example below contains two elements of PHI?
A. Driver's license, religion
B. Test results, date of birth
C. Medical records, marital status
D. Social Security number, race
3. What are three key patient rights?
1. Request restrictions on uses or disclosures of PHI
2. Request to receive communications of PHI from Baylor by
alternative means or at alternative locations
3. Patient may complain to Baylor if they believe their privacy rights
have been violated
4. Patient may remove his/her entire medical record and make copies
and bring it back a week later
A. 1, 2, and 4
B. 2, 3, and 4
C. 1, 2, and 3
D. None of the above
4. USE is information released outside of Baylor and DISCLOSURE is
information circulated within Baylor
A. True
B. False
5. Which option best defines the concept of “minimum necessary?”
A. Give only the minimum necessary access to PHI to perform the job
function
B. Before looking at patient information, ask yourself one simple
question: “Do I need to know this to do my job?”
C. Before sharing PHI, ask yourself: “Does this person need this PHI
to treat the patient, receive payment or conduct eligibility?”
D. All of the above
6. A breach of PHI must be reported when (select the best answer)
A. Your co-worker is on the telephone discussing a diagnosis issue.
You inadvertently overhear PHI about a patient that you do not need
to know
B. Your co-worker checks the computer system because she/he is
interested in the current status of a patient that she/he previously
treated, but who has since been transferred to another unit, and is no
longer caring for that patient
C. You see someone throwing documents containing PHI in the
shredding bin
D. None of the above
7. List two safeguards to protect PHI
1. Put the waiting list and surgery schedule out on the counter so
anyone can come up and view it
2. Move the medical records binder away from a counter top or desk
to a more secure location not accessible by unauthorized individuals
3. Before dialing the fax number, call the person, verify the fax
number, then carefully dial the fax number
4. To promote patient satisfaction, turn the computer screen so the
patient and/or their family can see the list of all the patients being
treated
A. 1 and 2
B. 2 and 3
C. 3 and 4
D. 1 and 4
8. The ___________ has a “private right to sue” law, so violations against
the HIPAA privacy rule can also bring about civil legal action against
Baylor and against the individual(s) involved
A. State of Texas
B. Federal Government
C. Dallas/Fort Worth Hospital Council
D. Healthcare Privacy Compliance Commission
9. Which of the following statements about physical and electronic security
is NOT true?
A. Physical and electronic security is important in areas where PHI is
present
B. Only management is responsible for taking precautions to protect
PHI from being seen at your workstation
C. Vendors, drug representatives, computer/equipment repair
technicians, etc. must have proper ID and have signed a
confidentiality agreement
D. Password sharing is not allowed
10. Documents, paper or computer CD’s with PHI should be discarded in a
A. Trash can
B. Shredding bin
C. Biohazard bin
D. Recycle bin
A
For PM&R rotations ONLY
Policies and Procedures
Title: Information Security Policy
Date: June 17, 2009
Issued by: Security Department
Supersedes: July 1, 2008
Approved by: James Talalai, EVP & CIO
I. Purpose
Select Medical Corporation and its subsidiaries, affiliates, and joint venture entities controlled by Select
Medical Corporation are concerned about the security of the information processed and maintained on any
of the various computing devices used throughout the Corporation. Information is a critical corporate asset
and as such must be protected from misuse, improper access, and delays in processing. It is imperative
that the following policy be implemented and enforced.
Select Medical information must be protected in a manner commensurate with its sensitivity, value and
critical nature. Security measures must be employed regardless of the medium on which information is
stored (paper, PCs, CDs, tapes, etc.), the systems which process it (PCs, networks, voice mail systems,
etc.), or the methods by which it is moved (electronic mail, face-to-face conversation, etc.). Such
protection includes restricting access to information based on the need to know.
II. Scope
This document applies to Select Medical Corporation, its subsidiaries and affiliated companies
(Corporation) and all personnel accessing Select’s network. In this document the term “employee” applies
to employees, contractors, temporaries, vendors, consultants, physicians, etc.
III. Responsibility
Supervisors and managers are responsible for keeping all employees informed of this policy. All
employees will be informed of this policy Compliance Orientation and will be required to sign and abide by
the policy.
IV. Definitions
The following terms have the meanings specified below and are used throughout this Acknowledgement.
Please be sure to refer back to this section as you read through this document in order to fully understand
the policies expressed in this Acknowledgement.
A. “Corporation” – Select Medical Corporation and its subsidiaries, affiliates, and joint venture entities
controlled by Select Medical Corporation.
B.
“UserID” – the unique identifier, protected by a changeable password, which identifies each computer
user.
C.
“Password” – a control word consisting of a minimum of 5 alphanumeric characters with an expiration
interval of at least 90 days, known only to the owner of a userID. The password is used to restrict the
use of the userID to a specific individual or, in a number of limited cases, a number of individuals. A
password can also be referred as a “passphrase.”
D. “Information” – data stored and processed on any type of Corporation computing device, raw input
data that will be entered into a computer, and processed output data in any form.
E. “Owner of Information” – the person who has a vested interest in the information, who has been given
the authority to allow access to the information, and who has the responsibility of maintaining the
integrity of the information.
F. “Hardware” – any equipment, machinery, tapes, diskettes, or other tangible objects used in the
storage, processing, retrieval, printing, or transmission of data, including, but not limited to, terminals,
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Policies and Procedures
personal computers, tape or disk drives, monitors, printers, modems or other peripheral equipment,
and disks, diskettes, or tapes.
G. “Software” - any computer programs, operating systems, languages, commands, utilities or other
intangible forms of information used in the storage processing, retrieval, printing, or transmission of
data.
H. “Data” - any information stored, processed, retrieved, printed, or transmitted mechanically or
electronically by means of hardware or software.
I.
“Employee” - any director, officer, employee, or contractor of the Corporation. That is, any person who
has been given authorization to use any of the Corporation's hardware or software, in any manner
whatsoever.
J.
“Corporate Property” - all right, title and interest in or to the hardware, software, or data owned, leased,
or licensed by the Corporation.
K. "Corporate Confidentiality Statement" (must be used verbatim) - Note: The information contained in
this message may be privileged and confidential and protected from disclosure. If the reader of this
message is not the intended recipient, or an employee or agent responsible for delivering this
message to the intended recipient, you are hereby notified that any dissemination, distribution or
copying of this communication is strictly prohibited. If you have received this communication in error,
please notify us immediately by replying to the message and deleting it from your computer. Thank
you.
V. Statement of Policies and Regulations
It is the policy of the Corporation that:
A. All information and programs that process the information (which include programs making up
operating systems) are the property of the Corporation. The Corporation forbids either the information
or the programs to be given to or viewed by anyone not employed by the Corporation. Exceptions can
be made if the operating manager of the department responsible for the information or programs gives
prior approval.
B. No data or software shall be downloaded, transferred or otherwise made available to any person who
is not an Employee or to any entity which is not affiliated with the Corporation, without the prior
permission of the Employee's immediate supervisor.
C. At the very least, the following steps shall be taken to protect Corporation information:
1. Control and limit to a minimum and only to essential personnel, physical access to areas
containing information and/or data processing resources.
2. Provide only the access necessary (READ, UPDATE, DELETE) to those employees with the need
to use the information.
3. Provide necessary procedures to ensure a transferring or terminating individual's access changes
in accordance with their changed status.
4. Provide necessary computerized tools to monitor and enforce security procedures.
5. Implement and maintain documented procedures to impede or prevent employees of the
Corporation or third parties from tampering with or misusing information.
D. All Corporate property shall remain the property of the Corporation, regardless of its origin, including,
but not limited to, any software or data developed by Employees on Corporation's time or using
Corporate property. The Employee hereby assigns to the Corporation the entire right, title, and
interest in and to any software or data developed by the Employee, and shall execute any
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Policies and Procedures
assignments or other documents necessary to effect such assignments. The Employee agrees that
any software or data developed by the Employee on Corporation's time or using Corporate property
shall be deemed a "work made for hire".
E. The Employee shall not load or otherwise transfer any software or data to any Corporate property
without prior permission from the Chief Information Officer through their Supervisor. This includes
downloads of software or programs from the internet.
F. No terminal or personal computer connected to Corporate property, including dial-up, VPN, or SSL
connections from remote locations, shall be left unattended while signed on (unless password
protected). Each employee must log off his or her personal computer prior to leaving the facility for a
lengthy period of time. (i.e., when leaving the facility for the day or to attend an off-site meeting). All
connections should require the user to key a password to gain access, and should not make use of
any type of feature that would bypass this requirement.
G. Remote and/or local area network layer connections to the Corporate network are only permitted from
hardware owned by the Corporation, unless authorized by the Information Security Department. No
Corporate software is to be installed on any hardware not owned by the Corporation, unless
authorized by the Chief Information Officer.
H. The Employee shall not use or install any personal locks on any hardware, safes, or storage cabinets
for software, or on any adjacent office equipment. The Corporation reserves the right to inspect the
Employee’s work area and to remove, by any means, any personal locks found to be installed in
violation of this policy.
I.
The Employee shall be solely responsible for any computer activity conducted under the Employee's
UserID, and shall not disclose his/her UserID and associated password to any Employee or nonEmployee, unless authorized beforehand by a member of the Information Security Department. The
Employee shall not in any way attempt to discover the password of any other Employee.
J.
The Employee shall not use any Corporate property, in whole or in part, for personal reasons, unless
authorized by the Employee’s immediate supervisor. The Employee shall use Corporate property to
facilitate company business, and only highly limited, reasonable personal use is permitted.
K. The Employee shall use any software purchased, leased, or licensed from third party vendors strictly
in accordance with the license agreement and copyright statements for such software. The Employee
shall not copy, download or upload any such software without the prior approval of the Chief
Information Officer, and shall not under any circumstances modify any such software.
L. The Employee acknowledges that any action taken by the Employee in violation of this policy may
subject both the Employee and the Corporation to criminal and civil liability. In the event that any suit,
claim, or demand is asserted against the Corporation which arises out of the Employee's actions in
violation of this policy, the Employee shall indemnify, defend, and hold harmless the Corporation from
and against all liability, cost, or expense, including attorney's fees. The indemnity contained herein
shall survive the expiration or termination of the Employee's employment by the Corporation.
M. The Employee shall not use any Corporate property to gain access to any software or data, whether
the property of the Corporation or a third party, unless the Employee has prior authorization to do so.
N. The Employee shall not unduly influence or attempt to influence the Corporation to purchase, lease, or
license any hardware, software, or data from a third party vendor with which the Employee has had
prior dealings.
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Policies and Procedures
O. All compensation paid to the Employee during the term of his/her employment by Corporation shall be
deemed to be salary and not royalties or similar compensation for development of software or data.
P. The Employee acknowledges that any violation of the above rules and procedures may subject the
Employee to disciplinary action, including, but not limited to, termination of the Employee's
employment; and subject to civil and criminal proceedings. In the event that the Employee's
employment is terminated, the Corporation shall retain all legal or equitable remedies against the
Employee, and such remedies shall be cumulative and not exclusive.
Q. The environment containing the information and the data processing resources shall be adequately
protected by using appropriate procedures and technology. Some examples of these would be locked
doors or cabinets, fire alarms and suppression devices, and emergency power supplies and switches.
R. All departments that process and maintain Corporation information shall ensure that a documented
contingency plan is developed to enable the continued availability of important or critical information in
the event of an extended emergency.
S. The Employees should not expect privacy with respect to any of their activities using the companyprovided Internet access or services. The company reserves the right and has the legal authority to
review any files, messages, or communications sent, received, or stored on the company’s computer
system.
T. Unless it has specifically been designated as public, all Select Medical internal information must be
protected from disclosure to third parties. Third parties may be given access to Select Medical internal
information only when demonstrable need-to-know exists, when a Select Medical contractual
agreement has been signed, and when such a disclosure has been expressly authorized by the
relevant Select Medical information owner. If sensitive information is lost, or disclosed to unauthorized
parties, or is suspected of being lost or disclosed to unauthorized parties, the information owner and
Information Services must both be notified immediately.
U. All Employees who secure files, folders or disks with passwords or encryption shall turn over the
passwords or decryption keys to the Information Security Department upon separation from the
company.
V. Removable devices that are able to store data need to follow the safeguarding guidelines of Select
Medical. Generally, Select Medical does not promote the use of removable media and usage should
be limited to the minimum necessary for legitimate business purposes.
W. Wireless Devices connected to the Corporate WAN must be approved by the Information Services
Department and follow the Corporate standards for security and configuration. Wireless devices
without any connectivity to Select Medical networks do not fall under the purview of this policy.
X. If remote access to date is granted, the employee must maintain a work environment that meets
security and confidentiality requirements for PHI, financial information, and any proprietary company
information as defined by Select Medical’s policies and procedures as well as established law.
Employees will not compromise the confidentiality or security of information due to remote computer
access. Users must ensure that confidential information in any form cannot be accessed and/or
viewed by any unauthorized person. It is the employee’s responsibility to be aware of their
surroundings when viewing sensitive data in possible public areas. Breaches in the use and handling
of PHI or technology, whether intended or unintended, will be subject to disciplinary action up to and
including termination, in accordance with Select Medical’s Human Resource’s policies and procedures
and Code of Conduct.
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Policies and Procedures
Select Medical Corporation Electronic Communication/Internet Policy
I. Purpose
With the increased capabilities available for electronic forms of communications, Select Medical
Corporation must ensure that all employees, contract consultants, and other agents of the Corporation are
knowledgeable about these capabilities and understand the circumstances in which these forms of
communication are appropriate and permitted. Therefore, this Electronic Communication/Internet Policy
has been formulated to inform Select Medical Corporation employees of the proper use of the electronic
communication network.
This policy applies to all Select Medical Corporation employees and any other individuals with authorized
access to the Corporate network, and applies to all forms of electronic communications, including, but not
limited to, the web browsing, file transfers (FTP), file sharing, fax, telnet, instant messaging and e-mail.
This policy applies to any electronic communication that is:
• Accessed on or from company premises
• Accessed using company computer equipment or via company-paid access methods; and/or
• Used in a manner that identifies the user with the company.
II. Implementation and Responsibility
For interpreting this policy, approving exceptions and recommending changes:
Corporate Information Services Department
Corporate Legal Department
Corporate Human Resources Department
For monitoring compliance with this policy:
All supervisory and management personnel
Corporate Information Services Department
Corporate Compliance Committee
III. Statement of Policies and Regulations
It is the policy of the Corporation that all forms of electronic communications be utilized only by employees
who have been properly authorized. Internet access and email are Corporate property and their primary
purpose is to facilitate company business. Every user has a responsibility to maintain and enhance the
company’s public image and to use company email and access to the internet in a productive manner. All
outbound email must include the Corporate Confidentiality Statement.
Select Medical Corporation will hold employees accountable for their individual behavior associated with
the Select Medical Corporation name and all their activity conducted with Select Medical Corporate
information assets. Electronic communications reside on Corporate resources. Therefore, this information
is the property of Select Medical Corporation and is to be used for valid business reasons only.
It is the responsibility of all managers to determine the forms of electronic communications and types of
services that their staff requires to fulfill their job responsibilities, and to supervise their staff to assure that
they are utilizing these services in accordance with the guidelines of this policy.
It is the responsibility of all employees to utilize only those types of services for which they have been
authorized. Employees using electronic communications must safeguard Corporate information assets by
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Policies and Procedures
understanding and complying with this policy and the related guidelines, as well as other existing policies
of the Corporation. Additionally, employees are responsible for reporting breaches of this policy to the
Corporate IS Department or to their managers or supervisors, whichever is appropriate.
A violation of this Policy or of the standards, procedures or guidelines established in support of this Policy
may result in denial of access to the electronic communications network and the Internet and may be
considered grounds for disciplinary actions up to and including termination of employment.
While the primary focus of this policy is on the use of the Internet, the policy covers all types of electronic
communications applicable to Select Medical Corporation and all its divisions, subsidiaries and affiliated
companies. The regulations cannot be all-inclusive and are intended to illustrate appropriate and improper
use. The Corporation reserves the right to interpret electronic communication use in a manner it deems
appropriate to protect the interest of the Corporation.
The following items represent a set of minimum guidelines that must be observed during any use of
electronic communications, and specifically the Internet connection.
A. Every effort must be made to protect the Corporation's information assets and resources. Employees
must comply with all existing policies when utilizing electronic communications. This includes, but is
not limited to, Select Medical Corporation’s Information Security Policy and the Code of Conduct.
B. All email and internet users must have the Corporation’s standard anti-virus utility properly installed
and running on their PCs. Employees are prohibited from disabling or removing any virus protection
software from Corporate computers. Internet email is also a frequent source of misinformation about
supposed viruses, sometimes called hoax viruses. To inquire about a virus warning’s authenticity,
consult the IS department. Do not forward suspect messages to anyone.
C. Dedicated connections into the Select Medical Corporation corporate network must be through a
firewall and/or secured environment.
D. To assure effective control and monitoring of remote communications (including dial-up, VPN, or SSL
connections), access will be allowed only via approved software and modems or approved remote
access solutions.
E. Confidential or proprietary information must be sent via electronic mail or over the Internet only when it
fulfills a valid business purpose. Confidential information should be labeled as such and its distribution
tightly controlled. No patient information shall be sent via electronic means without first being properly
secured following guidelines within this policy.
F. Company software, documentation and all other types of internal information must not be sold or
otherwise transferred to any non company party for any purposes other than business purposes
expressly authorized by management.
G. The Employee shall not download or otherwise transfer any software or programs from the internet
onto Corporate computers without the prior permission of the Chief Information Officer through their
Supervisor.
H. Security systems are in place (or may be in place in the future) that will monitor and record Employee
usage, including web-site activity, email, and file transfers into and out of the network. This
information will be periodically reviewed by the Corporate IS Department for possible misuse of
Corporate resources and unauthorized access.
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Policies and Procedures
I.
Select Medical Corporation reserves the right to examine email, directories, files, and other information
stored on Company resources or on the network. The examinations will be done to assure compliance
with policies, support the performance of internal investigations, and assist with the management of
Select Medical information systems. Attempts by employees to read, delete, copy, or modify the
electronic communications of other employees are not allowed unless approval has been given by the
Chief Information Officer.
Information Services Department routinely monitors usage patterns for its electronic communications.
The reasons for this monitoring are many, including cost analysis/allocation, management of the
company’s gateway to the Internet, and compliance monitoring. All messages created, sent, or
retrieved over the company’s Internet/e-mail are the property of Select Medical and are considered
Select Medical property. Select Medical designated security personnel have the right to access and
monitor all messages and files on Select Medical systems. Security personnel conduct investigations
of this nature only on an ‘as needed” basis when possible violations and/or security concerns exist. As
a result, employees should therefore not assume electronic communications are private.
J.
Testing of security systems is prohibited without approval of the Chief Information Officer. Disclosing,
capturing, altering, or destroying information that relates to or creates security exposures is prohibited.
All security exposures must be disclosed to the Chief Information Officer immediately or as soon as
possible. Additionally, users are prohibited from disclosing, changing, or disabling any audit features
without the approval of the Corporate I.S. Department.
K. Select Medical Corporation supports strict adherence to software vendor's licensing agreements.
When using Corporate computing and/or network resources, copying of software that violates the
vendor's license agreement is prohibited. Participation in pirated software bulletin boards and similar
activities is prohibited. Reproductions of writings posted or otherwise available over the Internet must
be done only with the permission of the author/owner.
L. Electronic communication must be in compliance with applicable federal, state and local laws and
regulations. Use of Select Medical Corporation’s computing resources for criminal purposes is
prohibited, (i.e., materials that are of a fraudulent, defamatory, harassing, obscene, abusive, or
threatening nature, or to solicit or exchange copies of copyrighted software).
M. Employees must refrain from expressing personal opinions when using Corporate resources, except in
a business context relating to trade associations and other professional activities.
N. All costs incurred for paid subscriptions on the Internet are the responsibility of the department or
employee utilizing such services.
O. Connections to the Internet will not be left unattended.
P. Only Corporate approved electronic mail systems will be used to conduct business.
Q. The Corporation has the right to access and disclose the contents of any employee’s e-mail messages
as required for legal and audit purposes, and for legitimate Corporate operational purposes.
R. In an effort to protect Select Medical users from unwanted or malicious e-mail or internet traffic, e-mail
messages containing various types of attachments and content are filtered and not allowed to be
received by the end user.
S. Objectionable internet access, e-mail and instant messaging usage using Select Medical Corporation
resources includes, but is not limited to:
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7
Policies and Procedures
1. Excessive or inappropriate personal use (e.g. conducting side business, playing games,
solicitation to employment opportunities, electronic snooping or eavesdropping, gossiping via mail
systems).
2. Allowing another person to utilize your UserID and password to gain access or using another
person’s UserID and password to gain access.
3. Representing yourself as someone else.
4. Subscribing another person to a bulletin board or discussion group.
5. Accessing or distributing information with illegal, racist, sexist, sexually-oriented, obscene,
harassing, or other potentially objectionable content.
6. Disclosing inappropriate or confidential information regarding the Corporation.
7. Furthering any kind of conduct that is inappropriate or prohibited in the workplace.
8. Soliciting or distributing computer viruses.
9. Distributing or storing chain letters, jokes, solicitations, offers to buy or sell goods, or other nonbusiness material of a trivial or frivolous nature.
10. Maligning any other person or company.
11. Sending harassing messages or unauthorized mail (e.g., chain letters).
12. Entering chat rooms for unauthorized or non-business purposes.
13. Providing information about the Corporation’s employees to others.
14. Incurring excessive, unnecessary, or unauthorized expenses.
15. Interfering with the operation of the Internet gateway.
16. Any other use that is not valid company business.
17. Engaging in illegal, fraudulent, or malicious conduct.
18. Monitoring or intercepting the files or electronic communications of employees or third parties.
19. Obtaining unauthorized access to any computer system.
20. Attempting to test, circumvent, or defeat security or auditing systems of the company or any other
organization without prior authorization.
21. Spamming e-mail accounts from Select Medical e-mail services or company machines.
22. Improper usage or downloading of material protected under copyright laws.
T. It is the policy of the Corporation that you regularly delete your e-mail messages in order to conserve
space on the e-mail system. Failure to do so will result in an automatically generated message
reminding you to clean up your files before the system does it for you. This includes your Inbox,
Outbox, Deleted Items, and Sent Items.
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8
Policies and Procedures
Select Medical Corporation
Information Security Policy
Electronic Communication/Internet Policy
Please sign and return this page to the Corporate Information Security Department (fax 800-767-9682).
The undersigned Employee acknowledges that he or she has read and understands the above Information
Security Policy and Electronic Communication/Internet Policy, and shall at all times act in strict accordance
with them.
__________________________________________________________ _______________________
EMPLOYEE’S SIGNATURE
DATE
__________________________________________________________
EMPLOYEE’S NAME (PRINTED)
______________________
EMPLOYEE NUMBER
__________________________________________________________________________________
FACILITY/LOCATION
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9
Baylor Dallas
Campus Map
DART
STATION
• Baylor Department of
Public Safety –Safety Escorts
and Motorist Assistance (214) 820-4444
• Parking Services (214) 820-7275
• If you are disabled or require special
assistance, call (214) 820-2833
Pick-up Discharged Patients
1-800-4BAYLOR
BaylorHealth.com
©2009 Baylor Health Care System CE-BUMCM&PR 7.090REV
Discharge – Assistance,
Parking and Pick-up
A member of the hospital staff will escort you to the
appropriate entrance and help you into your vehicle
when it is time to leave.
Pick-up
All Baylor University Medical Center at Dallas
inpatients should be picked up through Jonsson
Hospital’s underground parking Garage 30 (accessible
from Junius Street).
From Parking Lot 9 (facing Truett Hospital):
• Upon exiting parking lot, turn left onto Hall St.
• At the first light, turn left onto Gaston Ave.
• At the second light, turn right onto Washington Ave.
• At the first light, turn right onto Junius St.
• On the right, turn into underground lot marked
“Patient Admitting/Discharge-Garage 30.”
From Parking Lot 4 or Garage 5 (facing Worth St.):
• Upon exiting the parking lot, turn left onto Worth St.
• At the first light, turn left onto Washington St.
• At the first light, turn left onto Junius St.
• Pass Jonsson Hospital (past red sculpture)
• On the right, turn into underground lot marked
“Patient Admitting/Discharge-Garage 30.”
From Parking Lot 2 (facing Emergency
Department):
• Upon exiting parking lot, turn right onto Worth St.
• At the first light, turn left onto Washington Ave.
• At the first light, turn left onto Junius St.
• On the right, turn into underground lot marked
“Patient Admitting/Discharge-Garage 30.”
From Parking Lot 3 (Collins Hospital underground
parking)
• Upon exiting parking lot, turn left onto Worth St.
• At the first light, turn left onto Washington St.
• At the first light, turn left onto Junius St.
Driving Directions
FROM THE NORTH
Carrollton, Denton, Frisco, Plano, Grapevine
US Highway 75 (Central Expressway) • Travel south
on US Hwy 75. Take exit 1B: Haskell-BlackburnFitzhugh. Turn left on Haskell and continue to Gaston
Ave. Turn right on Gaston to the Baylor campus.
Dallas North Tollway • Travel south on the Dallas
Tollway and merge onto Interstate 35E (after last
toll booth). Follow I-35E to Interstate 30 eastbound.
Continue on I-30 and exit at Carroll-Peak-Haskell.
Turn left on Peak and continue to Worth St. Turn left on
Worth to the Baylor campus.
Texas Highway 114 • Travel east on Hwy 114 and
merge with Texas Highway 183. Merge again with
Interstate 35E and travel south to Interstate 30
eastbound. Follow I-30 eastbound to Carroll-PeakHaskell exit. Turn left on Peak and continue to Worth
St. Turn left on Worth to the Baylor campus.
FROM THE SOUTH
DeSoto, Duncanville, Lancaster, Red Oak, Waxahachie
Interstate 35E • Travel north on I-35E, take I-30
eastbound then exit at Carroll-Peak-Haskell. Turn left
on Peak continuing to Worth St. Turn left on Worth to
the Baylor campus.
US Highway 67 • Travel north on Hwy. 67 to I-35E.
Follow directions (above) from I-35E.
Interstate 45-(Becomes US Hwy 75)•Travel north on
I-45 to I-30 eastbound, exit at Carroll-Peak-Haskell.
Turn left on Peak continuing to Worth St. Turn left
on Worth to the Baylor campus.
FROM THE EAST
Commerce, Garland, Greenville, Mesquite,
Rockwall, Terrell
Interstate 20 • Travel west on I-20 to US Highway
80. Continue on Hwy 80 to Interstate 30 westbound.
Follow I-30 westbound to Carroll-Peak-Haskell exit.
Turn right on Peak and continue to Worth St. Turn left
on Worth to the Baylor campus.
FROM THE WEST
Arlington, Fort Worth, Grand Prairie, Irving,
Midcities
Interstate 30 • Travel east on I-30, exit at CarrollPeak-Haskell. Turn left on Peak continuing to Worth St.
Turn left on Worth to the Baylor campus.
Texas Hwy 183 • Travel east on Highway 183 and
merge to Interstate 35-E. Continue on I-35E and take
I-30 eastbound, then exit Carroll-Peak-Haskell. Turn
left on Peak, continuing to Worth. Turn left onto Worth
St. to the Baylor campus.
Interstate 20 • Travel east on I-20 and take US Hwy
67 north to merge with Interstate 35E. Continue on
I-35E until exit for I-30 eastbound. Exit Carroll-PeakHaskell. Turn left on Peak continuing to Worth St. Turn
left on Worth to the Baylor campus.
Baylor Dallas
Campus Map and
Driving Directions
Key Phone Numbers
Making Calls For dialing assistance or general
information, dial the hospital operator at 0.
In-hospital Calls
• If number begins with (214) 820-####, dial 2 + ####
• If number begins with (214) 818-####, dial 3 + ####
Local Calls Dial 9 + (area code) + (7-digit number).
Long Distance Calls
Dial 9 + 0 + (area code) + (7-digit number).
Key Telephone Extensions A full list of Baylor
Dallas numbers is at the back of this Patient
Services Guide Binder.
• Operator/Main Hospital 0 or 2-0111
• Administration 2-4140
• Admitting/Registration 2-2264
• Business Services 2-6600
• Baylor Public Safety - police 2-4444
• Chaplaincy Program 2-2542
• Patient and Family Services 2-3515
• Guest Relations, Interpreter, International
Services, Concierge desks 2-2833
• Baylor Plaza Hotel 2-7000
1-800-4BAYLOR
BaylorHealth.com