Labor and Delivery Policy and Procedure Manual

MCN’s Labor and Delivery Policy and Procedure Manual provides policies and procedures your L&D unit needs to be compliant with the latest regulatory standards. This comprehensive manual includes over 200 policies, procedures and forms in an easy-to-customize Word format that meet TJC and NIAHO standards. This manual addresses all of the frequently cited TJC requirements, including: patient rights, assessment, NPSGs, medication management, infection prevention and control, and staff competency.

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Table of Contents - TJC standardsTable of Contents - JCI standardsCopyrightDisclaimerApproval/Signature SheetIntroduction
SECTION 03 - HUMAN RESOURCES
3001 - Position Description/Performance Evaluation - Maternal Child Health Nurse Manager3002 - Performance Evaluation - Population-Specific/Age-Related Competency - Maternal Child Health Nurse Manager3003 - Annual Competency Clinical Skills Assessment - Maternal Child Health Nurse Manager3004 - Position Description/Performance Evaluation - Labor and Delivery RN3005 - Performance Evaluation - Population-Specific/Age-Related Competency - Labor and Delivery RN3006 - Annual Competency Clinical Skills Assessment - Labor and Delivery RN3007 - Position Description/Performance Evaluation - Labor and Delivery LPN/LVN3008 - Performance Evaluation - Population-Specific/Age-Related Competency - Labor and Delivery LPN/LVN3009 - Annual Competency Clinical Skills Assessment - Labor and Delivery LPN/LVN3010 - Position Description/Performance Evaluation - Maternal Child Health Unit Secretary3011 - Performance Evaluation - Population-Specific/Age-Related Competency - Maternal Child Health Unit Secretary3012 - Annual Competency Skills Assessment - Maternal Child Health Unit Secretary3013 - Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol3014 - Staff Qualifications and Competency3015 - New Employee Orientation3016 - Orientation/Skills Checklist - Labor and Delivery RN/LPN/LVN3017 - Orientation/Skills Checklist - Maternal Child Health Unit Secretary3018 - Competencies for Drug Administration3019 - Insertion of Intrauterine Pressure Catheter Performance Evaluation Form - Sample3020 - Peer Review Feedback Form3021 - Employee Preparation for Performance Review Form
SECTION 07 - MEDICATION MANAGEMENT
7001 - High Alert Medication Management7002 - Insert List of High-Risk/High Alert Medications for Your Facility7003 - Patient Medication Information/Reconciliation7004 - Patient Medication Information/Reconciliation Form7005 - Controlled Drug Management on Patient Care Units7006 - Narcotics7007 - Emergency Crash Carts7008 - Emergency Crash Cart Security and Accountability7009 - Emergency Medications7010 - Sample Crash Cart and Defibrillator Checklist Signature Form7011 - Resuscitation of Neonate - Supply and Equipment Checklist7012 - Prescribing/Ordering - General Practices7013 - Verbal and Written Orders - General7014 - Telephone, Verbal and Written Orders for Medications7015 - Medication Ordered STAT and at Specified Time Intervals7016 - Standing Orders7017 - Titrating Medications7018 - Range Orders for Medications7019 - Medication Administration7020 - Safe Medication Practices7021 - Medication and Solution Administration - Invasive Procedures7022 - Apresoline (Hydralazine Hydrochloride) Administration7023 - Betamethasone (Celestone) Administration7024 - Cervidil Administration for Pre-Induction Cervical Ripening and Labor Induction7025 - Eye Treatment of Newborn7026 - Magnesium Sulfate Administration7027 - Oxytocin Induction/Augmentation - Care of the Patient7028 - Rubella Vaccination7029 - Rubella Virus Vaccine Post Delivery - Consent to Administer Form - Sample7030 - Measles, Mumps and Rubella (MMR) Vaccines - What You Need to Know7031 - Terbutaline Tocolysis7032 - Decreasing Medication Errors7033 - Medication Errors7034 - Medication Inadvertent Incident Report Form7035 - Medication Error Analysis Tool
SECTION 09 - PROVISION OF CARE, TREATMENT AND SERVICES
Patient Care
9101 - Patient Identification for Clinical Care and Treatment9102 - "Hand-Off" Communication - Labor and Delivery9103 - Amnioinfusion9104 - Amniotomy9105 - Amniocentesis - Care of the Patient9106 - Antepartum Hemorrhage9107 - Apgar Scores9108 - Birth Out of Asepsis (BOA Delivery)9109 - Blood Alcohol9109A - Breastfeeding - Baby-Friendly Hospital Initiative9110 - Breast/Nipple Stimulation - Antepartum Testing9111 - Carboprost (Hemabate) - Management of Patient9112 - Care and Observation of the Patient in Labor9113 - Care of the Dying Patient9114 - Care Planning9115 - Catheterizing the Bladder During Labor9116 - Indwelling Urinary Catheter Insertion and Maintenance - Female Patient9117 - Cesarean Section - Preparation of the Patient9118 - Cesarean Deliveries in Labor and Delivery9119 - Cord Blood Banking for Donation or Private Banking9120 - Epidural Anesthesia - Care of the Patient9121 - Estimation of Blood Loss9122 - Fetal Fibronectin Testing9123 - Fetal Heart Rate (FHR) Abnormalities9124 - Fetal/Neonatal Demise9125 - Forceps Application for Assisted Vaginal Delivery - Care of the Patient9126 - Gestational Age Evaluation9127 - Induction of Labor9128 - Infusion Pumps - Equipment Inspection, Care and Maintenance9129 - Insulin Infusion During Labor and Delivery9130 - Invasive Procedure Site Identification (Outside of the OR)9131 - Invasive/Surgical Procedure Verification/Time Out Checklist9132 - Lithotomy Position9133 - Management of Patient with Malignant Hyperthermia (MH)9134 - Malignant Hyperthermia (MH) Cart9135 - Multiple Gestation Labor and Delivery9136 - Nonstress Test (NST) - Antepartum Testing9137 - Oxygen, Free-Flow, in Emergency Situations9138 - Placement of a Fetal Scalp Electrode by a Registered Nurse9139 - Placenta Examination9140 - Positions During Labor9141 - Postpartum Hemorrhage9142 - Precipitous Birth9143 - Pre-eclampsia (Pregnancy-Induced Hypertension)9144 - Rapid Response Team9145 - Neonatal Resuscitation Team9146 - Resolving Conflicting Interpretations of Fetal and/or Maternal Data9147 - Rh Sensitization9148 - Ruptured Membranes - Care of the Patient9149 - Sedation9150 - Sedation Monitoring Form9151 - Sterile Speculum Examination by a Registered Nurse9152 - Umbilical Cord Blood Gas9153 - Umbilical Cord Prolapse9154 - Use of Clinical Alarms on Medical Equipment9155 - Vacuum Extraction for Assisted Vaginal Delivery - Care of the Patient9156 - Vaginal Birth After Cesarean (VBAC)9157 - Vaginal Delivery9158 - Version - External Cephalic9159 - Vital Signs9160 - Waived Testing9161 - Urine Dipstick Testing9162 - Scheduling Elective Labor Inductions and Cesarean Sections9163 - Cesarean Section Scheduling Classification