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Annual Policy Review Department: Medical (Providers) The following policies have been identified as critical to the routine work of those in the department indicated above. Please visit www.pathsinc.org/splash, select “Policies” and review the policies listed below. Read and sign the statement at the end of this document and return it to Terri Motley ([email protected]). Policy # 01-01-001 01-01-002 01-01-003 01-01-004 01-01-005 01-01-006 01-01-007 01-01-008 01-01-009 01-01-010 01-01-011 01-01-012 01-01-013 01-01-014 01-01-015 01-01-016 01-01-017 01-01-018 01-01-019 01-01-020 01-01-021 01-01-022 01-01-023 01-01-024 01-01-025 01-01-026 01-01-027 01-01-028 01-01-029 01-01-030 01-01-031 Title Accounting for Disclosure of PHI Administrative, Technical and Physical Safeguards Against Inappropriate and Unlawful Disclosure of PHI Confidentiality Distribution of Notice of Privacy Practices and Obtaining Written Acknowledgment De-Identification of Protected Health Information and Limited Data Sets Handling of Patient Complaints Minimum Necessary Standard Parental Viewing of a Minor’s Record Patient Confidentiality with Regards to Medical Record Information, It’s Use Patient Requests to View and Receive Copies of Own Record Patient Right to Access Health Information Handling Requests for Correction/Amendments Permitted Disclosures Not Requiring Authorization Request Restrictions on Use and Disclosures of Protected Health Information Requests for Patient Records Requesting Confidential Handling of Information HIPAA-Security Training Uses and Disclosures for Treatment, Payment and Healthcare Operations Destruction and Purging Patient Identifiers for Shred Box USB and Flash Drives Workstation Use Portable Computers Work at Home Health Information Disaster Plan Sanction Policy Internet Security Search Warrants Access Authorization HIPPA Security Termination Procedure Telemedicine Security 01-01-033 01-01-034 01-01-035 01-01-036 01-01-037 01-01-038 01-01-039 01-01-040 01-01-041 01-02-001 01-02-002 01-02-003 01-02-005 01-02-007 01-02-008 01-02-009 01-02-010 01-02-015 01-02-016 01-02-021 01-02-022 01-02-023 01-02-025 01-02-029 01-02-030 01-02-032 01-02-034 01-02-035 01-03-015 01-04-001 01-04-002 01-04-003 01-04-004 01-04-005 01-04-006 01-04-007 01-04-008 01-04-009 01-04-011 02-04-012 01-04-013 02-04-015 01-04-016 02-04-017 01-04-018 01-04-019 01-04-020 01-04-021 Personal Security Media Controls Internal Audit HIPAA or Security Breach Procedure Response Procedures Notice of Privacy Practices Fax Policy Company Cell Phone Policy Security Policy After Hours Coverage Advanced Directives Consent and Treatment of a Minor Ending the Patient-Provider Relationship Informed Consent Licensed Dependent Practitioners Medication Refills Practice Agreement for Patient Care Provided by a Physician’s Assistant Practice Agreement for Patient Care Provided by a Licensed Nurse Practitioner Privileging Providers Signing Death Certificates Patient Care Completed by Residents and Students Patient Care by PATHS for PATHS Employees Chart Completion Practice Agreement for Patient Care Conducted by a Pediatric Nurse Practitioner Hospital Follow-up Guidelines for Completion of Disability Forms PATHS Community Medical Center is a Patient Centered Medical Home Electronic Communication with Patient’s through eCW’s Patient Portal Use of Company Vehicles Continuing Education Routine Work in PATHS’ EHR E-mail Emergency Site Closings Professional Courtesy Internet Access and Usage Interpreters (Foreign Language) Interpreters (Hearing Impaired) Patient Complaints Immunization of Healthcare Workers CQI Plan Computer Equipment Damage Risk Management Plan Internal Event Reporting Standards of Conduct for Employees, Board Members and Consultants Tuition Reimbursement Pre-Employment Physicals Hours of Operation Minor’s in the Workplace 01-06-001 01-07-001 01-07-007 01-08-000 01-08-000A 01-08-001 01-08-002 01-08-003 01-08-004 01-08-005 01-08-006 01-08-007 01-08-008 01-08-009 01-08-010 01-08-011 01-08-012 01-08-013 01-08-014 01-08-015 01-08-016 01-08-017 01-08-018 01-08-019 01-09-001 01-09-002 01-09-003 01-09-004 01-09-005 01-09-006 01-09-007 01-09-008 01-09-009 01-09-010 01-09-011 01-09-012 01-09-013 01-09-014 01-09-015 01-09-016 01-09-017 01-09-018 01-09-019 01-09-020 01-09-021 01-09-022 01-09-023 01-09-024 01-09-025 Specialty Consult Xray Order & Referral Policy Sample Medication Handling Medication Changes for MEDAssist Intro to OSHA PATHS OSHA Template Bomb Threat Policy Competency Assessments Smoking in PATHS Facilities Disposal of Regulated Waste Equipment Lock-Out and Tag-Out Hazardous Materials, Spill & Accident Notification Hostage Incident PATHS Hazard Communication Policy Management of Staff who are Known to be Colonizing MRSA OSHA Posting Safety Violations Infection Control Exposure Control Plan Back Injury Prevention Incident Reporting Robbery at any PATHS Site TB Exposure Control Plan Fire Evacuation Procedures Workplace Injuries & Illnesses Acceptable Medical Abbreviations Patient Refusal of Care ECW Lab Protocol for Providers Narcotic Cross Coverage Prescribing Narcotic or Controlled Substance Medications Peer Review Leave Request for Clinical Staff Quality Health Measures Pain Assessment & Management Patients Requiring Immediate Medical Attention Guidance for Rapid Flu Testing Patient Notification Lab Designee Process for Abnormal Values Standing Orders for Patient Work-ups Standing Orders for Medication Refills Well Female Adult Protocol Well Male Adult Protocol Family Planning Protocol Do Not Resuscitate Orders Hypertension Guidelines Dyslipidemia Guidelines Provider Coverage Clinical Protocol for Cervical Cancer Screenings Diabetic Clinical Practice Guidelines Protocols for Well Child and Adolescent Visits 01-09-026 01-09-027 01-09-028 01-09-029 01-09-030 01-10-008 01-10-009 01-10-010 01-10-011 01-10-012 01-10-013 01-10-014 01-10-015 01-10-016 01-10-017 01-10-018 01-10-019 01-10-020 01-10-021 01-10-022 01-10-023 01-10-024 01-10-025 01-10-026 01-10-027 01-10-028 01-10-030 10-10-031 01-10-032 01-10-033 01-10-034 01-10-035 01-10-036 01-10-037 01-10-038 01-10-039 01-10-040 01-10-041 01-10-042 01-10-043 01-10-044 01-10-045 01-10-046 01-10-047 01-10-048 01-10-049 01-10-050 01-10-051 01-10-052 Colorectal Cancer Screening Policy Frequency of Patient Sampling Sample Medication Handling Outpatient Management of Acute Hyperglycemia without Evidence of DKA Tracking and Following of Abnormal PAP Tests Patient Preparation Ace Bandage Application Pelvic and Rectal Exams Excision of Lesions and Skin Tags Emergency Box and AED Foley Catheter Specimen Collection Latex Allergy Nail Removal U-Bag Application Reporting Animal Bites Reporting Diseases Skin and Staple Removal Suture Removal Transportation of Patients to Hospital from Site Urine Specimen Collection Vision Screening with Eye Chart Audiometry WA Electrocardiogram/Cardiograph Ear Lavage Hand Washing Frequency of Medication Sampling Intravenous Insertion Intravenous Infusion Procedure for Pediatric IV’s Medication Disposal Multi-dose Vials Sterile Saline Solution Maintenance Subcutaneous Injection Intradermal Injection PPD (Mantoux) Testing I.M. Injections Depo Provera Injections Z-Track Injections Observations After Injections Injections Given by Medical Assistants Sublingual Medications Adult Specimen Collection Instructions Ped Bagged Urine Collection Nebulizer Procedure Peak Flow Testing Vaccine Storage Pediatric Vaccine Administration Addult Vaccines Orthostatic Hypotension 01-10-053 01-10-054 Procedure for Vital Signs Pulse Oximetry The signatures below acknowledge orientation to the policies listed above. If questioned, the employee can either answer question directly, or be able to find the correct answer in PATHS’ policies. Furthermore, it is acknowledged that the employee must adhere to, and be accountable for, following these policies. Failure to adhere to these policies and procedures may lead to disciplinary action for all involved. This acknowledgement will be updated annually and it is management’s responsibility to ensure that employees remain knowledgeable and fluent in the expectations of job performance as they relate to PATHS’ policies and procedures. ________________________________________________ Employee Name (Printed) ________________________________________________ Employee Signature ___ / ___ / _____ Date ________________________________________________ Supervisor’s Signature ___ / ___ / _____ Date
