Ambulatory Services Environment of Care Manual
Ambulatory Services Environment of Care Manual
About this Manual
Ambulatory Services Environment of Care Manual is a manual containing many of our policy and procedure templates for the medical office, hospital, and other healthcare organizations. The policies cover: Joint Commission (JCAHO or TJC) • CMS • HIPAA • CDC • AAAHC and more.Want access to all our manuals? Click here
SECTION 01 - SAFETY
Safety Management Program
1001 - Safety Management Plan1002 - Responsibilities of the Safety/Environment of Care Committee1003 - Your Facility's Organizational Chart1004 - Policy Statement - Safety Management1005 - Authority1006 - Letter of Safety Officer Appointment1007 - Environment of Care Criteria1008 - Snow Removal1009 - Safe Delivery of Surgical and Anesthesia Services1010 - Safe Delivery of Radiology Services1011 - Library Policy1012 - Risk Assessment Program1013 - Risk Assessment - Interim Life Safety Hazard Analysis Worksheet
Performance Improvement/Safety/Environment of Care Committee
1101 - Incident Report Protocol1102 - Visitor Fall Incident Investigation Report Form1103 - Employee Safety Incident Reports - Illness or Injury1104 - Work-Related Back Injury1105 - Accident Investigation and Analysis1106 - Monitoring Activities Summary Format1107 - Safety/Environment of Care Committee PI Monitoring and Evaluation Plan1108 - Safety/Environment of Care Committee PI Trending Sheet1109 - Safety/Environment of Care Committee Meetings1110 - Sample Safety/Environment of Care Committee Agenda1111 - Safety/Environment of Care Committee Minutes (Example)1112 - Safety/Environment of Care Committee Meeting Minutes Form (Blank)1113 - Safety/Environment of Care Committee Reporting1114 - Report to Safety/Environment of Care Committee Form1115 - Employee Health Report Form to Safety/Environment of Care Committee1116 - Bimonthly Summary of Patient Incidence Form1117 - Safety/Environment of Care Committee Report Form1118 - Quarterly Safety/Environment of Care Committee Report Form1119 - Quarterly Safety/Environment Of Care Committee Report Sample Form1120 - Safety/Environment of Care Committee Recommendations Form1121 - Safety/Environment of Care Committee Departmental Action Report Form1122 - Incident Reporting Staff Questionnaire Form1123 - Annual Evaluation of the Effectiveness of the Safety Management Plan/Program
Hazard Surveillance Detection
1201 - Safety Hazard Surveillance1202 - Hazard Surveillance Detection Survey - Ambulatory Surgery1203 - Hazard Surveillance Detection Survey - Business Office1204 - Hazard Surveillance Detection Survey - Clinical Laboratory1205 - Hazard Surveillance Detection Survey - Engineering Department1206 - Hazard Surveillance Detection Survey - Environmental Services1207 - Hazard Surveillance Detection Survey - Imaging Services1208 - Hazard Surveillance Detection Survey - Nursing Services1209 - Hazard Surveillance Detection Survey - Urgent Care Services1210 - Departmental Hazards1211 - Hazard Detection Inspection Reports - Corrective Actions Form1212 - OSHA Safety Checklist
Staff Safety Education
1301 - Safety Orientation1302 - Safety Orientation Special Training1303 - Safety Continuing Education1304 - Employee Safety Education Report Form1305 - Staff Safety Questionnaire Form1306 - Body Mechanics Training1307 - Body Mechanics - Staff Education Handout1308 - Employee Safety Information1309 - Ergonomics Program
Patient/Visitor Safety
Department Safety
1501 - Administrative and Business Office Safety1502 - Ambulatory Surgery Department Safety1503 - Clinical Laboratory Safety1504 - Engineering Department Safety1505 - Environmental Services Safety1506 - Nursing Services Safety1507 - Department Safety/Environment of Care Meeting Form1508 - Department Safety/Environment of Care Communication Form
SECTION 02 - SECURITY
2001 - Security Management Plan2002 - Security Authority2003 - Security Risk Assessment and Vulnerability Analysis2004 - Security Risk Assessment and Vulnerability Analysis Form2005 - Security Risk Assessment and Vulnerability Analysis - Corrective Actions Form2006 - Crime Risk Prevention Patrol2007 - Security Code2008 - Key Control2009 - Removing Facility Property From Premises2010 - Security Measures Involving VIP(s)2011 - Checking Valuables2012 - Patient Property Inventory Form2013 - Missing Property Form2014 - Lost and Found Items2015 - Lost and Found Form2016 - Violence Communication Policy2017 - Workplace Violence Prevention Plan2018 - Workplace Violence Training Outline2019 - Employee Workplace Violence Assessment Checklist2020 - Recognizing Inappropriate Behavior2021 - Conduct to Minimize Violence2022 - Violence Intervention and De-escalation2023 - Violence Incident Report Policy2024 - Violence Incident Report Form2025 - Departmental Security Risk Assessment Form2026 - Cashier Violence2027 - Cashier Violence Prevention Checklist2028 - Outpatient Pharmacy Violence Prevention Checklist2029 - Pharmacy Security2030 - Pharmacy Drug Storage and Preparation Area2031 - Automated Dispensing Machines - Controlled Substances2032 - Urgent Care Security2033 - Urgent Care Security/Threat Assessment2034 - Drug Recalls2035 - Manufacturer Recalls and Hazardous Device Notices2036 - Medical Device Recall Notification2037 - Notice of Recall/Warning Form2038 - Recall/Warning Status Report Form2039 - Disposing of Recalls2040 - Quarterly Report of Security Incidents2041 - Annual Evaluation of the Effectiveness of the Security Management Plan/Program
SECTION 03 - HAZARDOUS MATERIALS AND WASTE
3001 - Hazardous Materials and Waste Management Plan3002 - Hazardous Materials and Waste Management Responsibilities3003 - Hazardous Materials and Waste - Departmental Management3004 - Hazardous Materials and Waste - Ordering and Receiving3005 - Hazardous Materials and Waste - Receiving MSDS3006 - Hazardous Materials and Waste - Notebook3007 - How to Read Safety Data Sheets (SDS)3008 - Hazardous Materials and Waste - Storage3009 - Hazardous Materials and Waste - Waste Disposal3011 - Radioactive Waste Disposal3011 - Insert Facility Floor Plan3012 - Hazardous Materials Identification and Labeling3013 - Hazardous Materials and Waste - Spills3014 - Hazardous Materials and Waste - Employee Injury3015 - Hazardous Chemical Communication Program3016 - Outside Contractors - Hazardous Chemical Communication Program3017 - Hazardous Materials and Waste - Training3018 - New Employee Chemical Inservice Sample Memo3019 - Chemical Training Record Form3020 - Hazard Communication Employee Training Record Form3021 - Hazard Communication Employee Information and Training Schedule/Log3022 - Hazardous Materials and Waste - Departmental Reporting Form3023 - Sharps Injury Protection Plan3024 - Disposal of Sharps3025 - Sharps Injury Log Form3026 - Hazardous Materials and Waste - Nursing Services3027 - MRI Patient Safety3028 - Radiation Safety3029 - Hazardous Materials and Waste - Pharmacy3030 - Compressed Gas and Oxygen Use3031 - Ethylene Oxide Monitoring - Employee Training and Emergency Response3032 - Formaldehyde Precautions3033 - Glutaraldehyde Precautions3034 - Mercury Handling3035 - Waste Anesthetic Gases3036 - OSHA Hazard Communication Checklist3037 - Annual Evaluation of the Effectiveness of the Hazardous Materials and Waste Management Plan/Program
SECTION 04 - FIRE SAFETY
4001 - Life Safety Management Plan4002 - Life Safety Code Compliance4003 - Fire Safety Chain of Command - Key Personnel4004 - Fire Safety - Responsibilities of Department Managers and Supervisors4005 - Fire Safety - Staff Responsibilities for General Fire Prevention4006 - Fire Safety - Hazards4007 - Fire Safety - Smoking Policy4008 - Fire Safety - Evacuation of Patients4009 - Materials or Equipment Purchases4010 - Life Safety - Construction Suitability4011 - Life Safety - New Construction4012 - Interim Life Safety Measures (ILSMs)4013 - Life Safety Summaries4014 - Fire Drill Policy4015 - Fire Drill Evaluation Form4016 - Summary of Fire Drills Form4017 - Fire Alarm System Testing and Inspection4018 - Fire Alarm System Check Form4019 - Fire Alarm Monitor Test Form4020 - Pull Station Test Form4021 - Fire and Smoke Dampers Inspection4022 - Smoke Detector Test Form4023 - Fire Extinguishing System Check Form4024 - Fire Door Inspection4025 - Fire Door Inspection Form4026 - Sprinkler Drop Test4027 - Sprinkler Drop Test Form4028 - Fire Control Valves4029 - Fire Sprinkler System Repair4030 - Sprinkler Heads4031 - Types of Fire Extinguishers4032 - Use of a Fire Extinguisher4033 - Fire Extinguisher Check4034 - Fire Extinguisher Log4035 - Fire Safety - Admitting4036 - Fire Safety - Registry Staff4037 - Fire Safety - Ambulatory Surgery4038 - Fire Safety - Anesthetizing Locations4039 - Fire Safety - Business Office4040 - Fire Safety - Clinical Laboratory Services4041 - Fire Safety - Engineering Department4042 - Fire Safety - Environmental Services4043 - Fire Safety - Health Information Management4044 - Fire Safety - Imaging Services4045 - Fire Safety - Materials Management4046 - Fire Safety - Nursing Department/Services4047 - Fire Safety - Operator4048 - Fire Safety - Pharmacy Department4049 - Fire Safety - Physical Therapy Services4050 - Fire Safety - Urgent Care4051 - Fire Safety - Volunteers, Non-Staff Personnel4052 - Annual Evaluation of the Effectiveness of the Life Safety/Fire Safety Plan/Program
SECTION 05 - MANAGEMENT OF MEDICAL EQUIPMENT
General Electrical Safety
Medical Equipment
5101 - Medical Equipment Management Plan5102 - Biomedical Equipment Management5103 - Selection and Acquisition of Equipment5104 - Inventory and Inspection of New Equipment5105 - Medical Equipment Management Inventory5106 - Medical Equipment Inventory Sheet5107 - Medical Equipment Management Inventory List5108 - Additions to Medical Equipment Management Inventory5109 - Deletions From Medical Equipment Management Inventory5110 - Equipment Acceptance Checklist5111 - Definitions of Medical Equipment Maintenance Strategies5112 - Equipment Management Code System5113 - Medical Equipment User/Maintainer Training Program5114 - Medical Equipment Management - Orientation/Education5115 - Employee Medical Equipment Training and Competency Form5116 - Medical Equipment Failure/User Error Follow-up Report Form5117 - Quarterly Report to Safety/Environment of Care Committee - Medical Equipment Management Incidence5118 - Reprocessing of Single-Use Devices5119 - Safe Medical Devices5120 - Medical Device Recall Notification5121 - Disposition of Recalled Supplies or Equipment5122 - Personal Electrical Equipment5123 - Use of Electrical Equipment in Oxygen Enriched Environment5124 - Recommendations for Laser Safety5125 - Equipment Decontamination5126 - Contract Service5127 - Equipment Loan/Rental Policy5128 - Reusable Medical Devices5129 - Outside Contractors Working in the Facility5130 - Preventive Maintenance Policy - Medical Equipment5131 - New Medical Equipment Testing Log5132 - Biomedical Equipment Maintenance Action Report Form5133 - Annual Evaluation of the Effectiveness of the Medical Equipment Management Plan/Program
Preventive Maintenance
5201 - Air Compressor5202 - Anesthesia Unit5203 - Apnea Monitor5204 - Arthroscope5205 - Automated Chemistry System5206 - Automated Hematology Analyzer5207 - Bedside Monitoring Devices5208 - Bilirubinometer5209 - Biological Refrigerator5210 - Blood Bank Refrigerator5211 - Blood Gas Analyzer5212 - Bulk Steam Sterilizer5213 - BUN Analyzer5214 - Carbon Dioxide Analyzer5215 - Cataract Extraction Unit5216 - Ceiling Mounted Surgical Light5217 - Centrifuge5218 - Chloride/CO2 Analyzer5219 - Clinical Lab Freezer5220 - Clinical Laboratory Incubator5221 - Clinical Laboratory Optical Microscope5222 - CO Oximeter5223 - Coagulation Analyzer5224 - Contrast Media Injector5225 - Cryosurgical Unit5226 - Defibrillator5227 - Dialyzer5228 - Water Quality Testing for Renal Dialysis Equipment5229 - Doppler5230 - Electric Beds5231 - Electroencephalograph (EEG)5232 - Electrolyte Analyzer5233 - Electromyograph (EMG)5234 - Electronic Thermometer5235 - Electrophoresis Equipment5236 - Electrosurgical Unit5237 - Esophagoscope (Flexible/Rigid)5238 - Examination Table5239 - Fiberoptic Light Source5240 - Fibrometer5241 - Fluoroscopic Imaging Room5242 - Glucose Analyzer5243 - Head Light5244 - Hemodialysis Machine5245 - Hydrotherapy Bath5246 - Ice Dispenser5247 - Imaging Room5248 - Irrigation Pump5249 - Irrigation Solution Warmer5250 - Laminar Airflow Hood5251 - Light Source5252 - Line Isolation Monitor5253 - Mass Spectrometer5254 - Microscope5255 - Moist Steam Cabinet5256 - Moist Therapy Pack Conditioner5257 - Nebulizer5258 - Nebulizer Mist Humidifier5259 - Nitrogen Analyzer5260 - Nitrous Oxide System5261 - Nitrous Oxide Trace Gas Leak Test5262 - Noninvasive Blood Pressure Monitor5263 - Operating Room Table5264 - Ophthalmic Surgical Laser5265 - Ophthalmoscope5266 - Oscilloscope5267 - Otoscope5268 - Oximeter5269 - Oxygen Analyzer/Monitor5270 - pH Meter5271 - Pulmonary Function Analyzer5272 - Radiation Monitor5273 - Radiographic View Box5274 - Refractometer5275 - Scintillation Counter5276 - Slit Lamps5277 - Spectrophotometer5278 - Spirometer5279 - Surgical Laser5280 - Surgical Lavage5281 - Surgical Light5282 - Surgical Microscope5283 - Surgical Video System5284 - Table Top Steam Sterilizer5285 - Treadmill/Exerciser5286 - Ultrasonic Cleaner5287 - Ultrasonic Diathermy5288 - Ultrasonic Nebulizer5289 - Ultraviolet Light5290 - Urine Analyzer5291 - Wall Suction5292 - Xenon Gas System
SECTION 06 - UTILITIES MANAGEMENT
6001 - Utility Systems Management Plan6002 - Definitions of Utility Systems Maintenance Strategies6003 - Utility Systems Management - Program Inventory6004 - Inventory of Utility Systems6005 - Utility Systems Management Inventory List6006 - Additions to Utility Systems Management Inventory6007 - Deletions from Utility Systems Management Inventory6008 - Utility Systems Management - Emergency Power6009 - Utility Systems Management - Emergency Power Maintenance6010 - Emergency Power Supply System and Stored Emergency Power Supply Systems6011 - Testing of Emergency Generators6012 - Generator Test Log6013 - Battery Power Backup6014 - Emergency Lighting and Power - Annual Inspections6015 - Guidelines and Procedure for Failure of Essential Equipment6016 - Definition of Utility Failure6017 - Outside Vendor Assistance6018 - Management of Utility System Failure - Electrical Power6019 - Blood Bank Refrigerator(s) - Failure6020 - Communication System(s) - Failure6021 - Elevator Failure - Passenger Evacuation6022 - Ethylene Oxide Leakage6023 - Fire Alarm System - Failure6024 - Emergency Generator Failure6025 - HVAC System - Failure6026 - Medical Air System/Vacuum - Failure6027 - Medical Gas Oxygen System - Failure6028 - Bulk Oxygen System - Failure6029 - Medical Gas System (Nitrous Oxide) - Failure6030 - Natural Gas Supply - Failure6031 - Plumbing System and Flooding Procedure - Failure6032 - Pneumatic Tube System - Failure6033 - Steam Delivery Boilers - Failure6034 - Water Distribution System - Failure6035 - Safety Testing and Maintenance of Utility Systems6036 - Preventive Maintenance Policy - Utilities6037 - Utility System Specific Maintenance Strategies6038 - Maintenance - Boiler and Steam System6039 - Maintenance - Electrical Distribution System and Generator6040 - Electrical Distribution Annual Check6041 - Condition of Electrical Receptacles6042 - Filter System Log Policy6043 - Maintenance - HVAC System6044 - Air-Handling and Ventilation Systems6045 - Indoor Air Quality Program6046 - Maintenance - Medical/Surgical Air and Vacuum System6047 - Piped Medical Gas System Testing6048 - Maintenance - Medical Gas System6049 - Torn Media Inspection Policy6050 - Torn Media Inspection Form6051 - Maintenance - Water Distribution and Plumbing System6052 - Maintenance and Monitoring of Water Systems6053 - Cooling-Tower Inspection Form6054 - Water Conditioning6055 - Water Treatment Test Form6056 - Utility Systems Management - User/Maintainer Training6057 - Engineering Department Training Log6058 - Engineering Department Training Log (Blank)6059 - Utility Systems Management - Continuing Education6060 - User Training for Utility Systems Log6061 - Sample Training Outline - General Facility Knowledge6062 - Sample Training Outline - Communication Systems6063 - Sample Training Outline - Facility Electrical Distribution System6064 - Sample Training Outline - Safe Use of Electrical Equipment6065 - Sample Training Outline - Emergency Generator6066 - Sample Training Outline - HVAC System User6067 - Sample Training Outline - Medical Gas6068 - Sample Training Outline - Use of Medical Gas Delivery System6069 - Sample Training Outline - Handling, Storage and Transport of Compressed Gas Cylinders6070 - Sample Training Outline - Medical Gas Alarms Test6071 - Sample Training Outline - Breached Medical Gas Lines6072 - Sample Training Outline - Use of Pumps and Motors6073 - Sample Training Outline - Steam Boiler6074 - Sample Training Outline - Use of Water Delivery System6075 - Utility Systems Shutdown6076 - Utility Systems Record Drawings6077 - Electrical Distribution System Shutdown6078 - Electrical System Shutdown Switches Form6079 - HVAC System Shutdown6080 - Emergency Shutoff of HVAC System Form6081 - Valve Shut-Off Locations - Oxygen Supply6082 - Valve Shut-Off Locations - High Pressure Nitrous Oxide6083 - Utility Systems Management - Emergency Shut-Off Labels6084 - Shut-off Labels for Medical Air, Oxygen, Natural Gas and Steam6085 - Utility Systems Management - Problems, Failures and User Errors6086 - Utility System Failure/User Error Report Form6087 - Utility System Failure/User Error Log6088 - Utility Systems Management - Identified Problems6089 - Utility Systems Management - Problem Resolution Log6090 - Quarterly Report to Safety/Environment of Care Committee Utility Systems Incidence6091 - Annual Evaluation of the Effectiveness of the Utility Systems Management Plan/Program
SECTION 07 - EMERGENCY MANAGEMENT
Emergency Management Program and Plan
7001 - Emergency Management Program7002 - Hazard Vulnerability Analysis (HVA)7003 - Facility Command Center7004 - General Staff Training7005 - Emergency Management Plan (EMP)7006 - Insert your Facility Resource Directory7007 - Staff Call-Back Tree7008 - Equipment and Supplies7009 - Emergency Water Supply7010 - Security7011 - Insert Facility Floor Plans7012 - Emergency Management - Responsibilities7013 - Labor Pool7014 - Emergency Management - Medical Staff Assignments7015 - Ambulatory Surgery - Emergency Management7016 - Business Office, Data Processing - Emergency Management7017 - Clinical Laboratory - Emergency Management7018 - Engineering Department - Emergency Management7019 - Environmental Services - Emergency Management7020 - Health Information Management - Emergency Management7021 - Human Resources Department - Emergency Management7022 - Imaging Services - Emergency Management7023 - Materials Management - Emergency Management7024 - Pharmacy Department - Emergency Management7025 - Physical Therapy Services - Emergency Management7026 - Urgent Care - Emergency Management7027 - Utilities - Emergency Management7028 - Emergency Procedures for Utility System Failure/Disruption7029 - Disruption of Facility Services Notification7030 - Disruption of Services - Electrical7031 - Disruption of Services - Medical Gas7032 - Disruption of Services - Natural Gas7033 - Disruption of Services - Sewage7034 - Disruption of Services - Water7035 - Air Conditioning System - Failure7036 - Operating Room Air Conditioning - Failure7037 - High Pressure Boilers - Failure7038 - Elevators - Failure7039 - Telephone System - Failure7040 - Piped Vacuum System and Compressed Air - Failure7041 - Emergency Management Locations Form7042 - Patient Medical Record and Victim/Patient Tracking7043 - Evacuation7044 - Emergency Management Plan Activation - Evaluation Form7045 - Annual Evaluation of the Effectiveness of the Emergency Management Program
Addenda to the Emergency Management Plan
7101 - Bomb Threat7102 - Bomb Threat Room Search7103 - Bomb Threat Report Form7104 - Riot or Civil Disturbance Response Plan
Severe Weather
Radiation Incidents