Cardiac Cath Laboratory Policy and Procedure Manual
Cardiac Cath Laboratory Policy and Procedure Manual
About this Manual
Cardiac Cath Laboratory Policy and Procedure 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 - EMERGENCY MANAGEMENT
SECTION 02 - ENVIRONMENT OF CARE
2001 - Department Safety - Cardiac Cath Lab2002 - Body Mechanics Training2003 - Patient Safety in the Cardiac Cath Lab2004 - How to Read Safety Data Sheets (SDS)2005 - Hazardous Materials and Waste - Training2006 - Chemical Training Record Form2007 - Radiation Protection and Safety2008 - Monthly Radiation Exposure Monitoring (Dosimeter)2009 - Fluoroscopy Safety2010 - Lead Apron Testing2011 - Lead Apron Quality Control Form2012 - Compressed Gas and Oxygen Use2013 - Fire Safety - Cardiac Cath Lab2014 - Fire Safety in an Oxygen Rich Environment - Operating Room2015 - Electrical Equipment Safety2016 - Equipment Maintenance2017 - Equipment Service Call Form2018 - Required Life Support Equipment2019 - Line Isolation Monitor System2020 - Electrosurgical Unit Safety2021 - Laser Surgery - Practice and Safety2022 - Safe Medical Devices2023 - Medical Device Recall Notification2024 - Supplies and Equipment - Borrowing and Lending2025 - Loaning/Borrowing Equipment/Supplies - Documentation2026 - Loaning Equipment/Supplies Log Form2027 - Borrowed Equipment/Supplies Log Form2028 - Purchase Orders
SECTION 03 - HUMAN RESOURCES
3001 - Position Description/Performance Evaluation - Cardiac Cath Lab Director3002 - Performance Evaluation - Age-Related Competency - Cardiac Cath Lab Director3003 - Annual Competency Clinical Skills Assessment - Cardiac Cath Lab Director3004 - Position Description/Performance Evaluation - Cardiac Cath Lab Nurse Manager3005 - Performance Evaluation - Age-Related Competency - Cardiac Cath Lab Nurse Manager3006 - Annual Competency Clinical Skills Assessment - Cardiac Cath Lab Nurse Manager3007 - Position Description/Performance Evaluation - Cardiac Cath Lab Registered Nurse3008 - Performance Evaluation - Age-Related Competency - Cardiac Cath Lab Registered Nurse3009 - Annual Competency Clinical Skills Assessment - Cardiac Cath Lab Registered Nurse3010 - Position Description/Performance Evaluation - Cardiac Cath Lab LPN/LVN3011 - Performance Evaluation - Age-Related Competency - Cardiac Cath Lab LPN/LVN3012 - Annual Competency Clinical Skills Assessment - Cardiac Cath Lab LPN/LVN3013 - Position Description/Performance Evaluation - Cardiac Cath Lab Scrub Technician3014 - Performance Evaluation - Age-Related Competency - Cardiac Cath Lab Scrub Technician3015 - Annual Competency Clinical Skills Assessment - Cardiac Cath Lab Scrub Technician3016 - Position Description/Performance Evaluation - Cardiac Cath Lab Chief Certified Cardiovascular Technician3017 - Performance Evaluation - Age-Related Competency - Cardiac Cath Lab Chief Certified Cardiovascular Technician3018 - Annual Competency Clinical Skills Assessment - Cardiac Cath Lab Chief Certified Cardiovascular Technician3019 - Position Description/Performance Evaluation - Cardiac Cath Lab Certified Cardiovascular Technician3020 - Performance Evaluation - Age-Related Competency - Cardiac Cath Lab Certified Cardiovascular Technician3021 - Annual Competency Clinical Skills Assessment - Cardiac Cath Lab Certified Cardiovascular Technician3022 - Position Description/Performance Evaluation - Cardiac Cath Lab Radiology Technologist3023 - Performance Evaluation - Age-Related Competency - Cardiac Cath Lab Radiology Technologist3024 - Annual Competency Clinical Skills Assessment - Cardiac Cath Lab Radiology Technologist3025 - Position Description/Performance Evaluation - Cardiac Cath Lab Secretary3026 - Performance Evaluation - Age-Related Competency - Cardiac Cath Lab Secretary3027 - Annual Competency Skills Assessment - Cardiac Cath Lab Secretary3028 - Position Description/Performance Evaluation - Cardiac Cath Lab Medical Transcriptionist3029 - Annual Competency Skills Assessment - Cardiac Cath Lab Medical Transcriptionist3030 - Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol3031 - BCLS/ACLS Resuscitation Certification3032 - New Employee Orientation3033 - New Employee Orientation to Cardiac Cath Lab3034 - Orientation Checklist - Cardiac Cath Lab3035 - Staff Education and Training3036 - Education Profiles3037 - Performance Evaluations3038 - Student Role/Preceptorships in the Cardiac Cath Lab3039 - Employee Communication Notebook3040 - Pre-Placement Physicals3041 - Annual Health Screening3042 - On-The-Job (Workers' Compensation) Injured Employee Processing3043 - Return to Work After Illness/Injury Policy3044 - Physician's Certification of Illness Form (Sample)3045 - Attendance and Tardiness3046 - Disciplinary Action3047 - Dress Code3048 - Employee Photo Identification Badge3049 - Employee Requests for Time Off3050 - Harassment, Sexual (Either Sex)3051 - Holiday Policy3052 - Meal Periods and Rest Breaks3053 - Personal Telephone Calls To/From Employees3054 - Sick Leave Policy3055 - Vacation Policy
SECTION 04 - INFECTION PREVENTION AND CONTROL
4001 - Infection Prevention and Control Measures for the Cardiac Cath Lab4002 - Standard Precautions4003 - Transmission-Based Precautions (Isolation Precautions)4004 - Hand Hygiene - CDC Guidelines4005 - Management of Patients with Methicillin Resistant Staphylococcus Aureus (MRSA)4006 - Attire in the Cardiac Cath Lab4007 - Surgical Hand Scrub4008 - Gowning and Gloving Technique4009 - Closed Gowning and Gloving Technique4010 - Asepsis4011 - Exposure Control Plan4012 - Sharps Injury Protection Plan4013 - Disposal of Sharps4014 - Sharps Injury Log Form4015 - Management of Accidental Blood or Body Fluid Exposure/Contamination4016 - Event-Related Shelf Life - Sterile Storage4017 - Flash Sterilization4018 - Housekeeping Procedures4019 - Processing of Instruments/Items4020 - Protection Stations4021 - Refrigerators4022 - Selection of Barrier Materials for Cardiac Cath Lab Procedures4023 - Visitor Control4024 - Definition of Biohazardous Waste4025 - Handling of Biohazardous Waste
SECTION 05 - LEADERSHIP
5001 - Mission and Goals5002 - Vision Statement5003 - Focus Statement5004 - Scope of Services5005 - Staffing Patterns5006 - On-Call Staffing5007 - Types of Operative and Invasive Procedures Performed5008 - Scope of Responsibility - Chairperson of Cardiac Services Committee5009 - Committee Representation by Cardiac Cath Lab Staff5010 - Perioperative Nursing Practice5011 - Perioperative Nursing Standards and Process5012 - Patient Safety Plan5013 - Sentinel Event
SECTION 06 - MEDICATION MANAGEMENT
6001 - Concentrated Electrolyte Solutions and Other Drug Concentrations6002 - Automated Dispensing Machines - Access to6003 - Automated Dispensing Machines - Removing Medications6004 - Automated Dispensing Machines - Stock Medication6005 - Automated Dispensing Machines - Controlled Substances6006 - Security of Medications - Anesthesia Carts6007 - Emergency Crash Carts6008 - Emergency Crash Cart Security and Accountability6009 - Defibrillator Check6010 - Sample Crash Cart and Defibrillator Checklist Signature Form6011 - Emergency Medications List6012 - Telephone, Verbal and Written Orders for Medication6013 - Medication Reconciliation/Verification6014 - Medication Reconciliation/Verification - When Medications Are Used Minimally6015 - Medication Reconciliation/Verification Form6016 - Medication Administration6017 - Dispensing IV Medication by Certified Cardiovascular Technician (C CVT)6018 - Pediatric Dosing - General Guidelines6019 - Medication and Solution Administration in the Cardiac Cath Lab6020 - Use of Multiple Dose Vials (MDVs)6021 - Contrast Media6022 - IV Lidocaine Administration6023 - Urokinase Administration6024 - Safe Medication Practices6025 - Decreasing Medication Errors6026 - Adverse Drug Reaction Reporting6027 - Adverse Drug Reaction Reporting Form (Internal)6028 - Medication Errors6029 - Medication Inadvertent Incident Report6030 - Medication Inadvertent Incident Report Form6031 - Performance Improvement Analysis - Medication Inadvertent Incident Form
SECTION 07 - PERFORMANCE IMPROVEMENT
7001 - Performance Improvement Plan7002 - Incident Reporting7003 - Procedure/Surgical Complications Reporting7004 - Performance Improvement Indications and Notification Form7005 - Incident Follow-Up Form7006 - Performance Improvement Operative/Invasive Procedure Review Form7007 - Cardiac Cath Lab Operative and Invasive Procedure Review PI Monitoring and Evaluation Plan7008 - Cardiac Cath Lab Operative and Invasive Procedure Review PI Trending Sheet7009 - Performance Measure Summary Form7010 - Performance Improvement Quarterly Report Form
SECTION 08 - PROVISION OF CARE, TREATMENT AND SERVICES
Patient Assessment and Patient Care
8001 - Criteria for Cardiac Cath Lab Outpatients8002 - Conditions of Admission8003 - Outpatient Pre-Admission8004 - Outpatient Pre-Admission Instructions8005 - Outpatient Preprocedure Instructions Form8006 - Patient Identification for Clinical Care and Treatment8007 - Preoperative Tests8008 - History and Physical - Cardiac Cath Lab8009 - Preoperative Nursing Care8010 - Transporting of Patients8011 - Assessment and Reassessment - Cardiac Cath Lab Patient8012 - Skin Assessment8013 - Assessing/Grading of Peripheral Pulses8014 - Care of the Latex Sensitive Patient8015 - Latex Allergy Assessment Form8016 - Latex and Non-Latex Alternatives8017 - Pain Assessment, Reassessment and Management8018 - Pain Assessment in Children8019 - Pain Scale, Admission Pain History8020 - Behavioral-Physiological Pain Scale for Nonverbal or Preverbal Patients8021 - Pain Scale Examples8022 - Anesthesia Assessment8023 - Pre and Post Anesthesia Evaluation Policy8024 - Pre and Post Anesthesia Evaluation Form8025 - Sedation8026 - Sedation Monitoring Form8027 - Cardiac Cath Lab Checklist and Preprocedure Nursing Record8028 - Collection of Health Status Data for Nursing Diagnosis8029 - Formulation of Nursing Diagnosis Derived from Health Status Data8030 - Nursing Diagnosis8031 - Cardiac Cath Lab Plan of Care8032 - Implementation of Cardiac Cath Lab Plan of Care8033 - Evaluation of Cardiac Cath Lab Plan of Care8034 - Revision of Cardiac Cath Lab Plan of Care8035 - Cardiac Cath Lab Nursing Plan of Care Form8036 - Invasive Procedure Site Identification (Outside of the OR)8037 - Invasive/Surgical Procedure Verification/Time Out Checklist8038 - Intraoperative Patient Monitoring8039 - Cardiac Cath Lab Nursing Record Form8040 - Procedure Log/Flow Sheet Policy8041 - Procedure Log/Flow Sheet Form8042 - Patient Recovery - Invasive Procedures8043 - Outpatient Recovery - Non-Invasive Procedures8044 - Cardiac Cath Lab Recovery Record Form8045 - Discharge Criteria - Cardiac Cath Lab Patients8046 - Cardiac Cath Lab Discharge Form8047 - Cardiac Cath Lab Discharge Form - Cardioversions, Tilt Table, Tee8048 - Discharge Criteria from Cardiac Cath Lab to Patient Care Unit8049 - Admission of Cardiac Cath Lab Outpatient to Hospital8050 - Transfer to Operating Room8051 - Transfer of Patients from an Outside Facility8052 - Hand-Off Communication in the Cardiac Cath Lab8053 - Education of Patient and Family8054 - Outpatient Post Catheterization Instructions8055 - Outpatient Post Catheterization Instructions Form8056 - Outpatient Post-Procedure Instructions and Physician's Orders Form8057 - Accountability for Sponges, Sharps and Instruments8058 - ACIST Injection System8059 - Blood Transfusions in the Cardiac Cath Lab8060 - Cardioversion8061 - Cardiopulmonary Resuscitation in the Cardiac Cath Lab8062 - Defibrillation8063 - Catheter and Introducer Removal8064 - Coronary Stent Placement8065 - Draping8066 - Electrophysiology (EPS)8067 - Electrophysiology Study Flow Sheet Form8068 - Endomyocardial Biopsy8069 - Implantable Devices8070 - Insertion of Central Venous Lines and PICC Lines - Bundle8071 - Central Venous Catheter and PICC Line Time Out Checklist8072 - Insertion of Swan-Ganz Catheter8073 - Insertion of Temporary Pacemaker8074 - Maintenance of Temporary Pacemaker8075 - Intra-Aortic Balloon Pump (IABP)8076 - Intravascular Ultrasound8077 - Intravascular Ultrasound Clinical Report Form8078 - Intravenous Therapy8079 - Left Heart Catheterization Procedure8080 - Medrad Injector8081 - Pathology Specimens8082 - Patient Positioning8083 - Percutaneous Balloon Aortic Valvuloplasty (PBAV)8084 - Percutaneous Transluminal Atherectomy - Peripheral (CSI Orbital Atherectomy System)8085 - Percutaneous Transluminal Rotational Atherectomy - Rotablator®8086 - Percutaneous Transluminal Coronary Angioplasty (PTCA) Procedure8087 - Percutaneous Transluminal Mitral Valvuloplasty8088 - Postmortem Care8089 - Pressure Manifold - Set-Up8090 - Pulmonary Angiogram8091 - Pulse Oximeter, CO-Oximeter8092 - Radial Approach for Catheterization8093 - Radiofrequency Catheter Ablation8094 - Removal of Intra-Aortic Balloon Pump Catheter8095 - Reporting of Critical Results of Tests and Diagnostic Procedures8096 - Right Heart Catheterization Procedure8097 - Sheath Removal During Anti-Coagulation8098 - Skin Preparation Protocol8099 - Thermodilution Cardiac Outputs8100 - Tilt Table Testing8101 - Tilt Table Test Form8102 - Transducer Calibration8103 - Transesophageal Echocardiography (TEE)8104 - Transeptal Catheterization8105 - Vagal Reaction Protocol8106 - VasoSeal®8107 - FemoStop® Compression Devices8108 - Wound Dressing
General Department Procedures
8201 - Outpatient Scheduling8202 - Registering Patients for Outpatient Cardiac Cath Lab Procedures8203 - Cardiac Cath Lab Schedule8204 - Procedure Delays8205 - Opening Procedure for Cardiac Cath Lab8206 - Room Preparation8207 - Daily Procedure Set-up8208 - Closing Procedure for Cardiac Cath Lab8209 - Supplies8210 - Answering Machine
Supply Lists
8301 - Physician's Equipment and Supplies Preference List8302 - Left Heart Catheterization Supply List8303 - Right Heart Catheterization Supply List8304 - Right and Left Heart Catheterization/Bicath Supply List8305 - Intra-Aortic Balloon Pump Insertion Supply List8306 - Percutaneous Transluminal Coronary Angioplasty (PTCA) Supply List8307 - Percutaneous Transluminal Rotational Atherectomy Supply List8308 - Permanent Pacemaker Supply List8309 - Temporary Pacemaker Supply List8310 - Radial Artery Catheterization Supply List8311 - Stent Supply List
SECTION 09 - RECORD OF CARE, TREATMENT AND SERVICES
9001 - Documentation Required for Cardiac Cath Lab Care9002 - Nursing Documentation9003 - Documentation of Operative and Other High-Risk Procedures9004 - Report Dictation9005 - Patient Files9006 - Legibility of Medical Record Documentation9007 - Unacceptable Abbreviation and Symbol List9008 - Release of Medical Information9009 - Release of Patient Information Consent Form9010 - Fax Transmittal Sheet9011 - Patient Statistics9012 - Patient Statistics Form
SECTION 10 - RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL
10001 - Patient Rights and Responsibilities10002 - Informed Consent10003 - Authorization for and Consent to Surgery or Special Diagnostic or Therapeutic Procedures Form10004 - Blood/Blood Component - Informed Consent10005 - Refusal of Blood/Blood Component Transfusion10006 - Blood/Blood Component Transfusion Consent Form10007 - Refusal to Permit Blood/Blood Component Transfusion Form10008 - Recordings, Films or Other Images of Patients10009 - Authorization and Consent Form - Recordings, Films or Other Images, and Publication10010 - Advance Directives10011 - Confidentiality of Information - General Issues10012 - Complaint Resolution Process10013 - Patient Complaint and Grievance Process