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Medical Center Policy Manual



Chapter 0 : Table of Contents

Index

Table of Contents

Chapter I : Governance and Leadership

Section I : Governance and Leadership

0001 : Policy Development, Review and Approval

0005 : Medical Center Policy: Creating a Tobacco Free Environment at the Medical Center

0034 : Legal Inquiries

0049 : Management of Medical Center Public Space

0066 : Food and Drink Restrictions

0067 : Medical Center Space Allocation and Reallocation

0105 : Ethics and Patient Care Consultation

0132 : The Quality Reporting Process

0217 : Corporate Compliance Auditing and Monitoring Plan

0223 : Government and Regulatory Investigation Response

0235 : Compliance Code of Conduct

0255 : Mandatory Reporting of Healthcare Practitioners

0279 : Professional Practice Evaluations for Members of the Clinical Staff

0280 : Allied Health Professionals Practice Evaluations

0283 : Behavioral Code of Conduct

0291 : Code of Conduct for Providers Who Hold Clinical Privileges

0314 : Use of Electronic Cigarettes

0315 : Management of Observers

0320 : Participation In and Submission of Data to a Patient Safety Organization

Chapter II : External Relations

Section 1 : External Relations

0013 : Vendors, Sales and Service Representatives at the Medical Center

0050 : Patient Visitation

0058 : Medical Center Volunteers

Chapter III : Emergency Response

Section 1 : Emergency Response

0172 : Preventing and Responding to Violence in the Workplace

0187 : Medical Emergency Response

0265 : Emergency Response Training

Chapter IV : Safety, Security, and Environment of Care

Section 1 : Equipment Management

0019 : Alerts and Recalls of Products, Supplies, Tissues, Devices, Implants and Pharmaceuticals

0055 : Use of Non-UVA Medical Center Equipment

0076 : Management of Medical Devices Used in Patient Care

0139 : Cell Phones, Wireless Devices and Other Radio Frequency Producing Equipment

0165 : Medical Device Failures and Safe Medical Devices Act Reporting

0222 : Reprocessing and Reuse of Single-Use Devices

0254 : Clinical Alarm Management

0273 : Use of Medical Center Equipment for Non-Medical Center Functions

0289 : Environmental Management and Sustainability Practices

0319 : Medical Supply Expiration

0327 : Cardiac Monitoring Orders

Section 2 : General Safety

0054 : Hazardous Material Spill/Accident Notification

0188 : Laser Safety

0246 : Therapy Animal and Pet Visitation

0338 : Service Animals for Patients and Visitors

Section 3 : Infection Control

0091 : Infection Prevention and Control

0134 : Transmissible Bloodborne Pathogens

0290 : Hand Hygiene

Section 4 : Security Management

0174 : Regulation of Weapons, Fireworks and Explosives on University Property

0209 : Patients Requiring Enhanced Security

Chapter V : Finance and Business

Section 1 : Expenditure Management

0015 : Travel Reimbursement

0189 : Medical Center Procurement Guidelines

0238 : Local Funds

0260 : Medical Center Fleet Management Program

0288 : Reconciliation of Medical Center Accounting Records

Section 2 : Fundraising and Gifts - See Health System Policy Manual

Section 3 : Patient Accounting and Billing

0010 : Billing Deferments/Adjustments

0027 : Charge Control and Documentation

0059 : External Review Organizations On-site Payor Reviews

0064 : Cash Receipts

0068 : Patient Financial Requirements Prior to Scheduling an Inpatient Admission for Elective or Routine Medical Care

0249 : International Patients Billing/Collection

0335 : Use of Payment Cards at the Medical Center

Chapter VI : Human Resources

Section 1 : Human Resources

0117 : Testing for HIV and Hepatitis Viruses Following Certain Exposures to Blood or Body Fluids

0215 : Employee, Volunteer, and Vendor Background Screening

0242 : Clinicians' Wellness Program

0262 : Standards for Professional Behavior

0294 : The Aging Practitioner

Chapter VII : Information Management/HIPAA Security and Privacy

Section 1 : Information Services

0030 : The Use of Cameras and other Electronic Devices and Media

0193 : Electronic Mail (E-mail)

0244 : Electronic Medical Record Access Auditing

0266 : Records Management: Records/Document Retention and Disposition

Section 2 : Patient Information

0084 : Health Information Request for Non-Patient Care Usage

0092 : Release of Patients’ Protected Health Information

0201 : Patient Identification

0218 : Definition, Characteristics, Authentication and Maintenance of the Medical Record and Designated Record Set

0253 : Verification for Release of Patient Information

0256 : Accounting of Disclosures of Protected Health Information

0286 : Prevention, Detection, and Mitigation of the Theft of Patients' Identities

Chapter VIII : Provision of Care, Treatment, and Service

Section 1 : Admissions, Transfers and Discharges

0025 : Discharge Planning

0031 : Insurance Certification/Authorizaton Requirements for Planned and Urgent/Emergent Services

0039 : Reservation, Registration, and Admission Requirements for Procedures and Admissions

0063 : Internal Inpatient Transfers

0292 : Admissions from the Emergency Department

0301 : Orders for Patient Status

Section 2 : Consent

0024 : Informed Decision-making

0293 : Disclosure of Outcomes

Section 3 : Patient Rights

0023 : Loss, Damage or Theft of Patient, Employee or Medical Center/University Property

0070 : Patient Complaints and Grievances

0094 : Patient Care Documentation (Electronic Medical Record)

0142 : Advance Directives

0220 : Interactions with Law Enforcement Authorities

Section 4 : Special Circumstances of Patients

0046 : Discharge of Infants Placed for Adoption

0098 : Organ, Tissue and Eye Donation

0140 : Judicial Treatment Orders

0192 : Medical Treatment of Prisoners

0207 : Organ Procurement in Donors After Cardiac Death

0213 : Abuse, Neglect or Exploitation of Patients

0219 : Searching a Patient and/or a Patient's Belongings (Inpatient and Emergency Department)

0317 : Feeding Young Children: Newborns, Infants and Toddlers

0321 : Management of Patients Who Leave their Assigned Patient Care Areas

0337 : Medically and Ethically Inappropriate Treatment is Not Required

Section 5 : Support Services for Patients

0156 : Language, Interpretive, and Adaptive Aids for Persons with Disabilities or Limited English Proficiency

0269 : Provision and Documentation of Patient and Family Education

0336 : Local Transportation for Certain Medical Center Eligible Patients

Section 6 : Treatment of Patients

0079 : Code Status Orders and Associated Treatment Plans

0083 : Medical Laboratories Specimen Acceptance/Rejection Criteria

0090 : Consultations

0097 : Medical Center Bed Assignment

0102 : Discharges Against Medical Advice

0109 : Medical Orders for Patient Care

0115 : Procedures for the Determination of Death by Cardiorespiratory or Neurologic Criteria

0119 : Tissue Review by Pathology

0125 : Reporting of Critical Values and Findings

0126 : Placement of Admitted Patients Treated With Therapuetic Amounts of Radioactive Material

0146 : Blood Utilization and Administration

0153 : Procedural Sedation by Non-Anesthesiology Providers

0155 : Provision of Healthcare Services to Children

0159 : Restraint and Seclusion of Patients

0191 : Refusal of Treatment

0197 : Suicide Risk Assessment and Prevention

0203 : Point of Care Testing

0204 : Clinical Decision Tools

0214 : Medical Screening and Stabilizing Treatment For Emergency Medical Conditions

0221 : Board Certification Requirements for Medical Center Providers with Clinical Privileges

0224 : Provision of Non-Prescription Home Supplies after Discharge or Clinic Visit

0239 : Pain Assessment and Management (Adult & Pediatric Patients)

0250 : Universal Protocol for Preoperative/Pre-Procedure Verification

0270 : Death Certificates, Fetal Death Reports and Autopsy

0275 : Management of Surgically Removed Body Parts and/or Explants

0285 : Laboratory Testing for Patients Receiving Anticoagulant Therapy

0304 : Responsibilities of Attending Physicians on Inpatient Services

0322 : Counts on Invasive Procedures in Procedure Areas

0324 : Clinical Communication and Escalation of Care/Inpatient Services

0325 : Counts on Surgical/Invasive Procedures in All Operating Rooms and in Critical Care Units

0329 : Attending Presence During Surgery in an Operating Room

0330 : Attending Presence During Invasive Procedures in Procedure Rooms

0334 : Board Certification Requirements for Advanced Practice Providers

Section 7 : Medication Management

0171 : Use of a Patient's Own Medication

0212 : Closed Formulary System

0231 : Payments for Dispensed Prescription Medications

0259 : Medication Management

0267 : Administration of Intravenous Medications on Adult Acute and Intermediate Care Units

0268 : The Handling of Hazardous Drugs

0299 : Controlled Substances

0300 : Medication Reconciliation

0303 : Pyxis Medication Management

0306 : Management and Documentation of Allergies in Patient Care

0307 : Patient Weights

0309 : Public Health Services Pharmaceuticals

0311 : Clinical Pharmacokinetics/Pharmacodynamics Consult Service

0326 : Medication Management - Chemotherapy

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