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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, Last updated 6/17/2009 BRR 1 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 Last updated 6/17/2009 BRR 2 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. Last updated 6/17/2009 BRR 3 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. Last updated 6/17/2009 BRR 4 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 Last updated 6/17/2009 BRR 5 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. Last updated 6/17/2009 BRR 6 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: Last updated 6/17/2009 BRR 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. Last updated 6/17/2009 BRR 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 Last updated 6/17/2009 BRR 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