Download Woman`s Hospital Facility Documents File

Non-Employee Service Provider Orientation
Purpose
To provide information concerning resources and the organizational environment to identified
individuals who are permitted by law and by Woman’s Hospital to provide care and services,
within the scope of the individual’s license and consistent with individual granted clinical
privileges or contracts.
Instructions
 Read the enclosed information thoroughly. This information is yours to keep.
 Sign and date the two agreement statements.
 Detach the agreement statements and return them to Human Resources.
CONTENTS
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TOPIC
Management Philosophy/Being Part of Our Team
Abuse and Neglect
Corporate Compliance Plan
Cultural Diversity and Sensitivity
Emergency Codes/Numbers
Ethics Committee
Harassment Free Workplace
Hazard Communication
Confidentiality Policy 275
Protected Health Information (PHI)
Electronic Protected Health Information (EPHI)
Permitted Uses and Disclosures
Patient Rights
Facility Directory Restrictions
Involvement in the Individuals Care
and Notification Purpose
Verification
Workstation Use and Security Policy
Password Management
Proper Use of Email and Fax
Protection from Malicious Software
Log-In Monitoring
Safeguards
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16-21
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Disposal of Patient Information
Photographs
Auditing Access
Breach of Protected Health Information
Breach Requiring Notification to Patient
Consequences for not complying with the law
Reporting Violations
Security Incident
Infant Security
Infection Control and Prevention
Life Safety
Lines of Communication
Medical Equipment
Organ Procurement
Pain Management
Patient Safety Program
Performance Improvement
Requests to be excluded from Patient Care
Restraints and Seclusion
Systems Failures
Unusual Clinical Event
Population-Specific Patient Care
Non Employee Service Provider Agreement
Non Employee Confidentiality Agreement
1
Management Philosophy/Being a part of the Woman’s Hospital Team
Womans Hospital will achieve its mission through a management philosophy which values
and supports:
 respecting each employee and recognizing his/her contributions as a valued asset
to our team;
 continuously promoting the personal and professional development of each staff
member;
 developing and supporting management practices that encourage individual
initiative, sense of ownership, mutual respect, courtesy, and loyalty;
 recognizing the importance of our patients to our success;
 accepting and treating all patients with respect, courtesy, friendliness, and
honesty;
 recognizing the significant contributions and loyalty of our physicians;
 respecting and treating our physicians as vital members of our service team;
 recognizing each volunteer and his/her contributions to our patients, visitors,
physicians, and staff;
 presenting ourselves in the most professional manner at all times;
 building upon, not resting upon, our reputation;
 establishing and maintaining policies and practices, which support and ensure a
safe and healthy environment;
 maintaining our commitment to community service through education,
voluntarism, and goodwill;
 pursuing the highest levels of quality service while maintaining financial
responsibility;
 continuously seeking to improve each individual’s performance;
 striving to utilize the most effective technology and management tools and
techniques; and
 striving to develop leadership and teamwork throughout the organization.
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Abuse and Neglect
If you see signs/symptoms or suspect abuse and/or neglect of a patient, notify the area
manager or his/her designee immediately. If you think the patient may be in immediate
danger, report to the nurse in charge of the patient.
For all age groups, the following list of signs and symptoms are objective indicators of abuse
or neglect:
 injuries in areas usually covered by clothing;
 injuries that don’t match history given;
 cuts, bumps, bruises, or scratches indicating the use of force;
 changed or fearful behavior around partner;
 partner hovers and doesn’t want patient to be alone with healthcare provider;
 patient seems frightened, disoriented or depressed over a minor injury or
minimizes the importance of a major injury.
Corporate Compliance Plan
It is the intention of Woman’s Hospital to comply with all applicable laws and regulations.
Woman’s wants to ensure that patients are billed for services rendered, that these services
meet patients’ medical needs, and that these services are properly documented. Any activity
believed to be illegal, dishonest or jeopardizing to quality of care should be reported to
Woman’s anonymous compliance hotline at (225) 924-8757. No retaliatory action will be
taken for reporting such concerns. Concerns about safety of quality of care may be reported
to Joint Commission at 1-800-994-6610 or complaint@jointcommission.
Cultural Sensitivity & Diversity
Woman’s Hospital maintains a practice of non-discrimination toward patients and their
families, employees, students, volunteers, contract workers, and all other individuals;
prohibiting discrimination because of age, race, color, creed, sex, national origin or handicap.
Emergency Numbers/Codes
The emergency assistance phone number is 8499. An example of an emergency would be
cardiac or respiratory arrest of a patient, suspicion of infant abduction, or discovery of a fire.
Various overhead page codes have been designated to identify specific hospital and/or
community events. In the event of a paged code, you should complete the procedure you
are performing and wait for specific direction from the area manager or his/her designee.
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Ethics Committee
Woman’s Hospital supports the right of the patient or her family to participate in the
treatment plan/care decisions. If the patient or family disagrees with the proposed plan of
care, she may contact her nurse, physician, social services, or pastoral services. The patient
or family may request their case be presented to the Ethics Committee, which is available as
needed to discuss ethical issues involving patient care (i.e., administration or cessation of lifesustaining procedures or issues related to the conception of life, reproductive technology,
and ensuring legal and regulatory compliance related to the ethical issues). Questions or
concerns about ethical issues involving a patient’s care should be discussed with the area
manager or his/her designee.
Harassment Free Workplace
Woman’s Hospital provides a productive work environment free from verbal, written, or
physical conduct that harasses and/or creates an intimidating, discriminating, or offensive
hospital work environment. No person will be retaliated against for expressing a concern of
harassment. Questions or concerns regarding harassment should be discussed with the area
manager or his/her designee or can be reported to the Human Resources Department at 225
924-8655.
Hazard Communication
A Hazardous material is any chemical that may cause physical or health hazards. See area
manager or designee for list of hazardous substances you may come into contact with in each
specific work area. See area manager or designee for proper protective equipment you must
use when working with specific substances. Use the specific equipment needed to perform
the task.
Confidentiality Policy 275
Information concerning employees, physicians, patients or hospital business shall be
protected during its collection, use, disclosure, storage and destruction in accordance with
the provisions of state and federal regulations.
Information concerning employees, physicians, patients or hospital business may not be
accessed, used, or released by unauthorized individuals; or discussed with anyone without
written authorization.
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The Health Insurance Portability and Accountability Act, (HIPAA) Privacy Rule sets national
standards for the protection of patient information. The Privacy rule covers ALL forms of
protected health information… oral, written and electronic. The HIPAA Security Rule sets
standards for electronic patient information and ensures the confidentiality, integrity, and
availability of all electronic protected health information (EPHI) the hospital creates, receives,
maintains, or transmits.
The Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009
strengthens the federal privacy and security rules, increases enforcement and penalties for
HIPAA violations, requires the patient be notified when there is a breach of unsecured
patient information and extends HIPAA security requirements to Business Associates.
Protected Health Information (PHI)
PHI is any individually identifiable health information (IIHI). Any of the following information
can be used to identify a patient: name, address, date, telephone or fax number, social
security number, medical record number, patient account number, insurance plan number,
vehicle information, certificate/license number, medical equipment number, photograph,
fingerprint, e-mail address, internet address, web universal resource locator (URL), and any
other unique code, characteristic or identifier.
Students, clinical instructors, and school representatives while at Woman’s Hospital for a
clinical rotation or clinical experience as per an affiliation agreement in place with Woman’s
Hospital understand the following:
1. Students shall not disclose PHI to teachers or other school officials who do not
otherwise have the right to access such data.
2. The foregoing does not prevent disclosure of properly de-identified health information
when and to the extent necessary in connection the student’s education or training.
3. Teachers and other officials may access PHI or receive PHI from students when they are:
a. Providing healthcare in association with the student
b. Are a member of Woman’s workforce
c. Are a business associate of Woman’s, or a member of the workforce of such
business associate, and the disclosure is consistent with the business associate’s
functions on behalf of Woman’s.
4. Student’s shall be trained on this policy and on the information to be eliminated to
meet the de-identification standard.
5. Students, clinical instructors, and school representatives should consult Woman’s
Privacy Officer about questions or for assistance in implementing this policy.
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Electronic Protected Health Information (EPHI)
EPHI is individually identifiable health information that is transmitted by electronic media or
maintained in electronic media. All information that can identify a patient must be protected.
Permitted Uses and Disclosures
Only authorized employees may disclose patient information. Non-employees (i.e. students,
contractors, volunteers, advisory council members, etc.) providing services to Woman’s
Hospital are not authorized to disclose patient information.
HIPAA allows for the provider of care to use and disclose health information for Treatment,
Payment and Operations (TPO). Other permitted uses and disclosures allowed include
disclosures required by law, disclosures for public health purposes, etc. Patients must sign an
authorization for the use of their health information for non-TPO or other permitted uses
and disclosures. Woman’s Hospital has approved authorization forms.
Under the Minimum Necessary Rule members of the workforce should only have access to
the information they need to fulfill their assigned duties. (Workforce includes students,
contractors, volunteers, advisory council members, as well as, anyone under the direct
control of the health care provider, whether or not they are paid.)
The hospital must make reasonable efforts to limit PHI to the minimum necessary when
using, disclosing or requesting information. Minimum necessary does not apply when
disclosing or requesting information for treatment.
Patient Rights
Patients have a right to know how their health information may be used or disclosed, and
that they have certain privacy rights. These rights are communicated to our patients through
a document called Notice of Privacy Practices (NPP). Our Notice of Privacy Practices is
distributed upon registration and a signed acknowledgement is obtained.
Patients have a right to know the names of their care providers. Wear your identification
badge with your photo and name showing at all times.
Patient rights allow patients to access and obtain a copy of their medical record, request to
amend their medical record, obtain a list of who the hospital has disclosed their PHI to for up
to the past six years, request communications of health information by alternative means
and request restrictions on the use of their PHI.
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Facility Directory Restrictions
Patients must be given the opportunity to agree or object to be included in the facility
directory (master patient index of patients treated at the hospital).
If the patient chooses to be included in the directory, the location (room number or unit)
may be given to individuals who ask for the patient by name. Religious affiliation of the
patient can only be given to clergy.
If the patient chooses not to be included in the directory, the patient’s name is marked as
confidential (“CONF”) in the information system. Persons calling or visiting should be told,
“I’m sorry, I don’t have any information for that name.”
Involvement in the Individuals Care and Notification Purpose
Patients must be provided the opportunity to agree to, prohibit or restrict the disclosure of
protected health information (PHI) for involvement in their care and for notification
purposes.
Protected health information may be disclosed to a family member, close personal friend, or
any other person named by the patient, if the information is relevant to that person’s
involvement with the patient’s care or payment of the patient’s health care services.
A family member, close personal friend, or any other person named by the patient may be
notified of the patient’s location, general condition, or death, provided:
 the patient agrees to the disclosure(s);
 the patient has had the opportunity to object to the disclosure, and the patient did
not express an objection; or
 the health care provider reasonably infers from the circumstances, using professional
judgment, that the patient does not object to the disclosure.
If the hospital suspects that a patient is a victim of domestic violence or abuse, the hospital
should not disclose information if there is reason to believe that the information could cause
harm to the patient.
In the event that the patient does not have the opportunity to agree or object to the
disclosure, the information can be disclosed using professional judgment, determining
whether the disclosure is in the best interest of the patient and, if so, disclose only the PHI
that is relevant to the person’s involvement with the patient’s health care
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Verification
Workforce members, who are authorized to disclose PHI, must verify the identity and
authority of the person(s) requesting PHI if the identity is not known.
Workstation Use and Security Policy
All health information, no matter where it is, must be kept secure. This includes information
stored on computers. Everyone who uses a computer has a duty to keep health information
secure. Workstation Use Policy also applies to laptops, notebooks, hand-held devices, or
other computers.
Portable/Home computers
 Must not be left unattended unless they are In a secure area
 Must be placed in proper carrying cases when transporting
Users of portable/home computers:
 Must immediately report any lost, damaged, malfunctioning or stolen equipment to
the Security and Privacy Officers.
 Are responsible for securing the unit, associated equipment and data within their
homes, cars and other locations
 May not permit anyone else to use the computer for any purpose, including family
Workforce members must protect all patient information on computers by signing-on with
individual IDs and passwords, signing-off of computers, protecting computer screens from
unwanted viewing and never leaving printers unattended when printing confidential
information.
Password Management
Woman’s Hospital Password Management policy requires logging on to systems only with
valid user IDs passwords. Passwords must not be shared with any other person. Use of
another person’s login ID or password is prohibited. Passwords must be changed whenever
there is any indication of possible password compromise. New passwords may be requested
from IS Help Desk or System Administrator. Passwords must be not be written down unless
the paper the password is written on can be stored securely.
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Proper Use of Email
Woman’s Hospital email policy prohibits transmission of patient information in an e-mail
message outside of the organization. Patient name is prohibited in the transmission of
internal e-mails.
Proper Use of Fax
Faxing of patient information is only permitted in emergency situations. The Woman’s
Hospital cover sheet should always be used.
Protection from Malicious Software
All information systems must have installation and regular updating of anti-virus software. If
a virus or worm is suspected, the Information Security Officer should be notified by
telephone, 8352 or e-mail.
Log-In Monitoring
The number of unsuccessful login attempts is limited. Unsuccessful login attempts may be
recorded and monitored.
Safeguards
Documents, faxes, photocopies, reports, schedules, charts, patient boards, etc. must be
hidden from unauthorized viewers. File rooms should never be left unattended or unlocked.
Disposal of Patient Information
Patient information must be disposed off carefully, such as using the “Shred-it” container
instead of throwing patient information away. Patient information should never be disposed
of in an open area trash bin.
Photographs
Photographing patients or visitors by hospital employees, students, contractors, volunteers,
advisory council members, etc. without a valid, written authorization is prohibited.
Auditing Access
Most hospital computer systems have “audit trails” that identify specific computer
transactions. Audit trails document the date, time, and the name of a user accessing a
specific patient. Audit logs are reviewed on a routine basis. Access that appears to be
inappropriate is investigated and sanctions are applied when violations are identified.
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Breach of Protected Health Information
Breach means the acquisition, access, use or disclosure of PHI in a manner not permitted
under the HIPAA Privacy Rule.
Breach Requiring Notification to Patient
Breaches requiring notification by the Privacy Officer are those breaches determined
after risk assessment that the security and or privacy of PHI is compromised (poses a
significant risk of financial, reputational, or other harm to the patient). The patient must be
notified by first class mail, without unreasonable delay and no later than sixty days after
discovery of the breach.
Examples of breaches:
 Employee accesses PHI of a friend, coworker, or neighbor in computer out of curiosity
and without a business-related purpose.
 Stolen laptop, PDA, or flash drive with unencrypted PHI
 Employee posting patient photo or other PHI on Facebook or MySpace
 Misdirected fax containing patient information
 Sending, bills, records, etc. to the wrong person
 Nurse takes photo of baby with cell phone and transmits to friends
 Discussing patient information with others outside the hospital or without a need to
know to perform their job
Consequences for not Complying with the Law
A breach of privacy may result in the cancellation of contract(s), loss of privileges, removal
from committee(s), legal action and/or disciplinary action up to and including termination of
employment.
It has always been against hospital policy to improperly use, disclose, share, or dispose of
patient information in the wrong way. Under HIPAA, there are fines and penalties for this.
Wrongful and willful disclosure of health information can result in fines from $100 up to $1.5
million for multiple violations of an identical requirement during the calendar year. Criminal
penalties for “wrongful disclosure” could result in jail sentences up to ten years and fines up
to $1.5 million.
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Reporting Violations
It is EVERYONE’s responsibility to report violations. Any individual receiving an allegation of a
breach or having knowledge or a reasonable belief that a breach of confidentiality of PHI may
have occurred shall report it immediately.
If complaints are from patient during visit, refer to the supervisor. If patient wants to file
formal grievance, refer to Patient Relations Coordinator, Kathleen Bosch, 924-8380.
If a former patient calls to file complaint, refer to Patient Relations Coordinator. All other
allegations and suspected breaches, Refer to Director of Health Information
Management/Privacy Officer, Danielle Berthelot, 924-8322
Security Incident
An information security incident is defined as “the attempted or successful unauthorized
access, use, disclosure, modification, or destruction of information or interference with
systems operations in an information system.”
An information security incident may be reported in one of the following ways:
 Submit an Information Systems Helpdesk ticket via the intranet
 If the Intranet is down or inoperable, call the IS Help Desk between the hours of
7:00am and 6:00pm, Monday through Friday
 If you do not reach an IS technician, call the IS on-call pager number at 934-2822
 Call or email the Information Security Officer, Rhett Roy
 Visit the Information Systems office.
Infant Security
Infants are transported internally only in portable bassinets or in Mother’s arms, and
escorted by hospital personnel.
When Mother and baby are leaving the hospital, hospital personnel will escort them through
the admitting entrance.
To report any suspicious person or activity to Security, dial 8473. Report missing scrubs,
uniforms, lab coats, name badges, etc to the area manager or his/her designee. Nursery staff
abides by the Infant Security Badge Procedure. Be aware: a disturbance may be created as a
diversion.
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Infection Control and Prevention
Hand washing is the single most effective measure to reduce spread of infection. Always
wash your hands when there is contact with patients, before and after wearing gloves,
between procedures on the same patient, after using the restroom, before and after eating,
after contact with a patient’s intact/non-intact skin, before invasive procedures, and after
contact with inanimate objects, including medical equipment, in the immediate vicinity of the
patient.
Artificial nails and long natural nails are prohibited for any worker assigned to patient care
activities.
Standard precautions are used on all patients when handling blood, body fluids and
secretion/excretion (except sweat).
Sharps:
 Do not recap needles.
 Place sharps only in sharps-specific containers found in each patient care area.
 Notify the area manager or his/her designee when the sharps container is ¾ full.
Medical waste is separated into two types:
 Waste that has been contaminated (grossly soiled) with blood or body fluids, and is
placed only in RED colored bags.
 Waste that is not contaminated with blood or body fluids is placed in the regular
trash.
All dirty linen is placed in BLUE colored bags. You should obtain the appropriate colored bag
from the area manager or designee as needed. Close all bags securely. Leave the closed bag
in the patient care area and notify the area manager or designee of its location and contents.
The Exposure Control Plan is found in the Infection Control Manual via the intranet and on
each patient floor. If you have questions, contact the Infection Control Coordinator by dialing
8962 or 8466. If you have an actual exposure, immediately contact the Employee Health
Nurse by dialing 8144 or 8299. After 3 p.m. and on weekends, call the Operator, who will
contact the Administrative Supervisor for instructions.
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Transmission-based precautions (airborne, droplet, or contact) are added when infection or
colonization with transmissible pathogens is known or suspected. Woman’s Hospital is
identified by the Centers for Disease Control protocol as a low risk facility. Isolation rooms
are located in the Assessment Center, 2nd floor rooms 2201, 2236, 2311 and 2512, 3rd floor
rooms 3336, 3515, 3534 and 3566, 4th floor room 4436 and 5th floor room 5536. Always check
with the area manager, his/her designee, or with the Infection Control Coordinator (x8862)
before entering any area that is labeled as having Isolation or Transmission-based
Precautions in effect.
Life Safety
Smoking is prohibited on Woman’s Hospital property at all times.
If you become aware of, or suspect a fire, report it immediately to the nearest employee and
wait for instructions. If no employee is present, pull the nearest fire alarm pull station
(located at each stairwell entrance).
If a fire is paged overhead (“Code Red”) and is identified as being in a location other than that
in which you are working, continue with the procedure you are performing. Remain in your
assigned area until the overhead paging announces an “all clear,” or you are directed to
leave.
If a fire is paged overhead and is identified as being in the same location of the hospital as
that in which you are working, finish the procedure as quickly as possible and wait for
direction from the employee in charge. In the event of evacuation, follow the directions of
the employee in charge
Lines of Communication
The first line of communication for clinical information concerning a patient is the area
manager or his/her designee. The first line of communication for hospital administrative
information is the administrative supervisor, who may be reached by dialing 8399 from the
phone in the patient’s room or from any house phone, or by dialing “0” for the Operator and
asking him/her to page the administrative supervisor.
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Medical Equipment
Medical equipment is fixed or portable equipment used for the diagnosis, treatment,
monitoring and care of patients. Contact the area manager or designee for information about
the location and operation of the equipment you will use. If there is a problem with the
equipment, notify the area manager or his/her designee. It is your responsibility to:
 identify the equipment you will use;
 know how to properly operate the equipment you will use; and/or
 know the location of the equipment you will use.
Organ Procurement
Woman’s Hospital provides all families of potential donors with the option of
organ/tissue/eye donation upon the death of a suitable candidate. Woman’s Hospital
contacts the Louisiana Organ Procurement Agency to evaluate every death for potential
organ and tissue donation. Medical criteria for organ and tissue donation are available on
every nursing unit.
Pain Management
Pain management is a collaborative interdisciplinary approach to eliminate or minimize pain.
This process will begin prior to or upon admission and will continue while the patient is
receiving services at Woman’s Hospital. Assessment and reassessment of the patient’s pain
should be documented utilizing the appropriate pain scale and at the intervals identified by
organizational policy. Clinical care providers will receive more specific information from their
clinical area manager or designee. You should immediately report any unexpected complaint
of pain or any unusual clinical event or incident to the area manager or designee.
Patient Safety Program
Woman’s Hospital’s Patient Safety program is organization-wide and is based on
interdisciplinary team action, promoting open communication of all occurrences or near
misses. Reported occurrences will be handled without threat of punitive action. In any
adverse event, your first responsibility is to minimize harm to the patient or visitor. Following
this initial response, you should report any incident to the area manager or his/her designee.
Everyone has a responsibility to report any situation that seems potentially unsafe to the
area manager or his/her designee.
Performance Improvement
Woman’s Hospital is committed and dedicated to using a systematic approach to continuous
learning and improvement in the processes, services, and functions that influence the
provision of exceptional care and a culture of safety. The Quality and Patient Safety Program
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involves every department and every individual throughout the continuum of care and
extends to all subsidiaries of Woman’s. Working in a safe, fair, and just culture means every
individual shares a deep commitment to providing quality care and making safety a priority.
Requests to Be Excluded From Patient Care
It is the policy of Woman’s Hospital to consider your request to not participate in an aspect
of patient care when the request is based on your cultural values, ethics, or religious beliefs.
Further, it is our policy that no patient’s care will be compromised as a result of your request
for exclusion of some aspect of patient care. Any request for exclusion in an aspect of patient
care should be directed to the area manager or designee.
Restraints and Seclusion
Restraints are used only when other alternatives have been tried and are unsuccessful.
Seclusion is not to be used. Questions or concerns about the use of restraints should be
discussed with the area manager or designee.
Systems Failures
Notify the area manager or designee immediately if any of the following systems fail to
operate:
 Telephone system: there will be no dial tone on most phones;
 Normal power: emergency generators will automatically begin to provide power for
essential lighting and selected electrical outlets in the event of hospital-wide outage;
 Steam system: no building heat, inoperative sterilizers, no hot water;
 Medical gasses/vacuum systems: no oxygen or medical air; no vacuum and alarm;
and/or
 Communications system: no nurse call button.
Unusual Clinical Event
An unusual clinical event or incident is defined as an unexpected or unplanned physical
response noted in the patient. You should report any unusual clinical event or incident to the
area manager or designee.
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Population-Specific Patient Care
You should demonstrate appropriate behaviors based on a patient’s age-specific
characteristics, needs, and challenges. Review the following information on populationspecific patient care for the patients you serve.
NEONATAL: BIRTH TO 28 DAYS
 General Appearance: hands fisted, random grasp; weak, mewing cry associated with extreme
prematurity.
 General Information: internal and external world are not differentiated - all are experienced as a
part of self.
POPULATION-SPECIFIC CHARACTERISTIC
The neonate will develop a sense of trust
and security when his needs are met
consistently and with predictability by
parents and/or primary care givers.
BEHAVIORS
Encourage caregivers and parents to respond to physical
needs consistently
Involve parents in procedures and in education and
training
Encourage parents to cuddle/interact with neonate.
Touch and stroke the infant as permitted by physical
condition
The neonate is unable to communicate
their needs.
Recognize that a furrowed brow, tightly shut eyes and a
deepened nasolabial furrow are signs of pain
The neonate’s skin is very fragile and at
risk for injury and infection.
Handle neonate gently
Because of body system immaturity, the
neonate startles easily and loses body
heat quickly.
Avoid loud noises and bright lights
Speak in a soothing voice
Keep neonate wrapped for warmth.
The neonate is unable to support his
head.
Support infant’s head and neck when holding or moving
him.
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INFANCY: 29 DAYS TO ONE YEAR
 General Appearance: gains weight/height rapidly; doubles weight/length by 50% in 6 months;
anterior fontanel closes at 12-18 months, posterior fontanel closes at 2 months; regular bowel
and bladder patterns develops; should have approximately 8 teeth by end of first year; primitive
reflexes (grasp, moro, rooting, sucking) diminish.
 General Information: recognizes bright objects and progresses to recognizing familiar objects and
persons.
POPULATION-SPECIFIC CHARACTERISTIC
The infant will develop a sense of trust
and security when his needs are met
consistently and with predictability by
parents and/or primary care givers.
Sudden loud noises and bright lights
startle infants
Towards middle of the year, infant
learns to raise head, turn, roll over, and
brings hand to mouth.
Towards end of the year, infant learns to
crawl, stand alone, walk with assistance
and grasps strongly.
Towards end of the year, infant learns to
speak two words, mimic sounds, obey
simple commands and understand
meaning of several words.
Infants develop fear of strangers and
become anxious when away from
parents.
BEHAVIORS
Encourage caregivers and parents to respond to physical
needs consistently
Involve parents in procedures, education and training
Encourage parents to cuddle/interact with neonate.
Touch and stroke the infant as permitted by condition
Avoid loud noises and bright lights
Speak in a soothing voice
Provide safe/protective environment
Keep crib rails up at all times
Make sure toys do not have removable parts and check
for safety approval
Give soft blocks and squeaky toys
Do not leave unattended
Use simple, familiar words and commands
Use imitation to encourage desired response
Limit number of strangers caring for infant
Encourage parents to assist/stay in infant’s line of vision
Allow infant to have unlimited access to “lovey”
TODDLER: 1 - 3 YEARS
 General Appearance: all 20 deciduous teeth present by 2 1/2 to 3 years; abdomen protrudes;
grows 2-2 1/2 inches and 4-6 lbs yearly.
 General Information: knows own gender and differences of gender.
POPULATION-SPECIFIC CHARACTERISTIC
May cry and become anxious when
parents are not present.
Revised 3/2015
BEHAVIORS
Allow parents to stay with child at all times; Include
parents in all interactions
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Walks independently, progresses to
running, jumping, and climbing; loves to
explore.
Newly learned bowel and bladder
control may regress due to illness.
Constructing 3-4 word sentences and is
tying words to actions.
Understands ownership (what is mine);
sees things only from their point of view
(strong sense of will).
Maintain and provide for safety at all times
Do not leave unattended
Set limits
Allow for bathroom/”accident” interruptions
Has a short attention span; responds
better to pictures than words.
Give one direction at a time
Prepare the child shortly before a procedure
Use games, books, toys as distraction/communication
techniques.
Use simple directions and requests
Allow child control over security objects and toys
whenever possible
Allow choice when possible
Use firm, direct approach
Give permission to express feelings (“It’s all right to cry,
be sad)
SCHOOL AGE CHILD: 3 - 6 YEARS
 General Appearance: gains weight and grows in height 2-21/2 inches a year; becomes thinner
and taller.
 General Information: dresses/undresses independently; knows own phone number and address
; understands that the amount of something is the same regardless of shape or number of pieces
; prints first name; draws person with 6 major body parts; throws and catches a ball around 5
years; 5 year olds use sentences, knows colors, numbers, and alphabet.
POPULATION-SPECIFIC CHARACTERISTIC
Life centers around parents siblings, and
peers. He gets lonely and wants to play
with someone.
Is physically energetic.
BEHAVIORS
Encourage siblings and peers to visit when possible
Encourage parents to stay and hold child
Major cognitive skill is conversation; he
understands numbers and is able to
classify objects.
Encourage child to verbalize
Talk directly to child
Use counting and puzzles as distraction techniques
Revised 3/2015
Maintain safety at all times
Limit movement restrictions
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Beginning to assert his independence; he Allow child to have some control
likes to boast and tattle and may be
Give permission to express feelings
physically aggressive. His behavior may Make intentions clear to child before touching him
be changed by reward.
Praise for good behavior
Offer “badge of courage” - stickers, etc.
May have imaginary friend, has difficulty Use stories as distraction and/or teaching tool
distinguishing real from imaginary; likes
Listen to distinguish fact from fantasy
stories; uses imagination in play.
Do not deny imagination or imaginary friends
Is inquisitive, always questioning “why”; Explain procedures, unfamiliar objects
has a short attention span.
Demonstrate use of equipment
Focus on one thing at a time
SCHOOL AGE CHILD: 6 - 11 YEARS
 General Appearance: permanent teeth erupt; starts pubescent changes; growth is slow and
regular.
 General Information: starts to think abstractly and to reason; can handle and classify problems;
able to test hypothesis.
POPULATION-SPECIFIC CHARACTERISTIC
Belonging and gaining approval of peers
is important. Family and teachers are
also important.
Assume responsibility for own personal
care; takes care of pets and assists with
household chores.
Capable of logical operation with
concrete things; motor skills are
increasing and is able to follow
successive verbal directions.
Focus is on concrete processes and
operations; may view accident or illness
as punishment for previous misdeeds
and may have fear of body mutilation or
harm.
Behavior is controlled by expectations,
regulations and anticipation of praise or
blame.
Revised 3/2015
BEHAVIORS
Support visitation/phone calls from peers and siblings
Continue school/schoolwork if possible
Encourage self-help groups of peers for children with
chronic health problems
Allow the child to have some control
Reinforce accomplishments
Promote independence
Explain procedures and equipment
Allow the child to participate in care
Explain which body part will be affected and how
Give clear, simple, truthful explanations
Explain procedures by comparing them to other less
stressful procedures
Always explain the reasons for medication and/or
treatments
Use rewards to encourage compliance
Be concrete and specific
Clearly define and reinforce behavior limits
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ADOLESCENCE: 12 - 18 YEARS
 General Appearance: Awkward in gross motor activity; fine motor skills are improving.
 General Information: Beginning development of occupational identity (what I want to be);
achieves new and more mature relationships.
POPULATION-SPECIFIC CHARACTERISTIC
Belonging to peer group is important
and valued to the adolescent - may
prefer friends to family.
Because of the adolescent’s rapid
skeletal growth, he may fatigue easily.
Interested and confused by his own
physical development; is critical of own
features; concerned with physical
appearance; interested in opposite sex.
Has the ability to use abstract thought
and logic; to examine own thoughts and
feelings.
Wants to appear in control yet needs to
rely on adult/parent; accepts criticism or
advice reluctantly.
BEHAVIORS
Reinforce parental guidelines
Support visitation/phone calls from friends
Provide rest and sleep periods
Provide privacy
Encourage questions regarding fears
Consider adolescent’s choice of male or female caregiver
when possible.
Explain procedures to adolescent and parent using correct
terminology and giving rationale
Involve adolescent in decision making
Talk to the adolescent, not about him
Allow adolescent to make treatment decisions as much as
possible
Respond in non-defensive manner when adolescent
resists therapy
GERIATRICS: 65 YEARS AND OLDER
 General Appearance: bone mass begins to decrease; loss of skeletal height, atrophy of
reproductive organs, thinning of hair; changes in skin pigmentation.
 General Information: atrophy of reproductive organs, decreased muscle strength, endurance
declines; retirement; pursuing second career, interest, hobbies, community activities, leisure
activities.
POPULATION-SPECIFIC CHARACTERISTIC
Decline in health and function often
necessitates changes in physical living
arrangements.
Skin and skeletal structures are fragile.
The patient may experience decreased
mobility and balance.
Revised 3/2015
BEHAVIORS
Include family and individual in decision-making
Assess resources for discharge
Provide protective environment; maintain safety at all
times.
Use tape sparingly; remove Band-Aids carefully
Handle body with the palms of your hands rather than
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Decreased tolerance to heat and cold.
Decreased peripheral circulation causes
the patient to feel colder than may be
expected.
May be experiencing significant life
changes such as death of spouse and
friends and retirement.
Experiences decreases in hearing, vision,
memory, and mental function
Revised 3/2015
with fingers
Use caution when serving hot food and beverages and
when using heat for treatments
Be aware of the need for warmed environment (extra
blankets, higher thermostat)
Support feelings of value by encouraging individual to
share experiences and wisdom
Explore individual support system; involve support system
in plan of care
Emphasize relationships with children and grandchildren
Speak distinctly and slowly
Instruct about one item at a time
Provide needed time to make decisions
Repeat information frequently
Provide adequate lighting and larger print
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Non Employee Service Provider Agreement
Printed Name: _______________________________________________________________
Position or type of service:_______________________________________________________
Organization: ________________________________________________________________
(affiliation/school/ company/and hospital department)
Supervisor’s Name: ____________________________________________________________
I have thoroughly read and understand the attached information.
I understand that I have a responsibility to request the proper protective equipment to
perform my tasks safely.
I understand that I have a responsibility to be aware of the location and the proper
operation for all medical equipment I will use.
I understand there is someone available to assist me and will request assistance when
necessary.
I understand that I have a responsibility to inform the area manager (or his/her
designee) should a situation arise in which it is outside the scope of my ability/license
to perform/participate.
I have been provided information on Woman’s Hospital Health Information Privacy
and Security policies and procedures (pages 6-10) and understand the contents.
________________________________________________
Signature
Revised 3/2015
___________________
Date
22
Non Employee Confidentiality Agreement
Printed Name: ________________________________________________________________
Position: _____________________________________________________________________
Organization: _________________________________________________________________
(affiliation/school/ company/and hospital department)
Supervisor’s Name: ____________________________________________________________
I understand that my association, duties or educational assignments with the above named
organization may entail access to information from Woman’s Hospital that is not generally available
or known to the public. Such information includes but is not limited to patient, customer, member,
provider, group, physician, employee, financial, and proprietary information, whether oral or
recorded in any form or medium.
Woman’s Hospital has a legal and ethical responsibility to safeguard the privacy of all patients and
to protect the confidentiality of their health information. In the course of my organization’s business
relationship with Woman’s Hospital, I may access or be exposed to confidential patient information,
even though it may not be directly involved with the services/assignments I am performing.
In consideration of, and as a condition to, my organization’s business relationship with Woman’s
Hospital, I will hold any and all information (“confidential information”) in strictest confidence. I
hereby agree that such information is confidential and belongs to Woman’s Hospital. I further agree
that information developed by me, alone or with others that uses information from Woman’s
Hospital may also be considered confidential information that belongs to Woman’s Hospital.
As an employee, student, agent, vendor, contractor, committee member, volunteer or visitor of the
above named organization, I hereby agree that I will not access confidential information from
Woman’s Hospital except when legitimately required in the performance of my assigned duties.
No confidential information shall be disclosed except to the individual of the above named
organization who needs to know to fulfill their obligations to Woman’s Hospital or to authorized
representatives of Woman’s Hospital. I will not sell, share, discuss, assign, transfer, or otherwise
disclose any confidential information outlined above with any other individuals or business entities
during or beyond my affiliation with Woman’s Hospital. I will not use the confidential information for
any purpose other than providing the mutually agreed upon services.
I understand that any breach of confidentiality may result in disciplinary action, including immediate
discontinuation of my use of the system or access to restricted areas, and termination of my
engagement as an external resource at Woman’s Hospital and possible legal action.
________________________________________________
Signature
___________________
Date
_______________________________________________
Witness
___________________
Date
Revised 3/2015
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