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Labor and Delivery Policy and Procedure Manual

Labor and Delivery Policy and Procedure Manual

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Labor and Delivery 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.
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Changes

Labor & Delivery.4.changes Labor & Delivery.4.1.changes Most current changes

Table of Contents - TJC standards Table of Contents - JCI standards Copyright Disclaimer Approval/Signature Sheet Introduction

SECTION 01 - EMERGENCY MANAGEMENT

Emergency Management - Maternal Child Health Nurse Manager

SECTION 02 - ENVIRONMENT OF CARE

Safety Visitation on Labor and Delivery Unit Body Mechanics Training Identification of Infants Infant Security Plan Infant/Child Abduction Response Plan Hazardous Materials and Waste - Nursing Services How to Read Safety Data Sheets (SDS)Fire Safety - Labor and Delivery Electrical Safety Use of Electrical Equipment in Oxygen Enriched Environment

SECTION 03 - HUMAN RESOURCES

Position Description/Performance Evaluation - Maternal Child Health Nurse Manager Performance Evaluation - Population-Specific/Age-Related Competency - Maternal Child Health Nurse Manager Annual Competency Clinical Skills Assessment - Maternal Child Health Nurse Manager Position Description/Performance Evaluation - Labor and Delivery RN Performance Evaluation - Population-Specific/Age-Related Competency - Labor and Delivery RN Annual Competency Clinical Skills Assessment - Labor and Delivery RN Position Description/Performance Evaluation - Labor and Delivery LPN/LVN Performance Evaluation - Population-Specific/Age-Related Competency - Labor and Delivery LPN/LVN Annual Competency Clinical Skills Assessment - Labor and Delivery LPN/LVN Position Description/Performance Evaluation - Maternal Child Health Unit Secretary Performance Evaluation - Population-Specific/Age-Related Competency - Maternal Child Health Unit Secretary Annual Competency Skills Assessment - Maternal Child Health Unit Secretary Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol Staff Qualifications and Competency New Employee Orientation Orientation/Skills Checklist - Labor and Delivery RN/LPN/LVN Orientation/Skills Checklist - Maternal Child Health Unit Secretary Competencies for Drug Administration Insertion of Intrauterine Pressure Catheter Performance Evaluation Form - Sample Peer Review Feedback Form Employee Preparation for Performance Review Form

SECTION 04 - INFECTION PREVENTION AND CONTROL

Infection Prevention and Control - General Procedures Infection Prevention and Control - Labor and Delivery Infection Prevention and Control - Nursery Standard Precautions Transmission-Based Precautions (Isolation Precautions)Hand Hygiene - CDC Guidelines Surgical Hand Scrub Closed Gowning and Gloving Technique HBsAg and Prophylaxis to the Neonate Hospital Report Form - Perinatal Hepatitis B Hepatitis B Vaccine - What You Need to Know Instruments - Cleaning and Processing Sharps Injury Protection Plan Sharps Injury Log Form Handling of Biohazardous Waste

SECTION 05 - INFORMATION MANAGEMENT/RECORD OF CARE, TREATMENT AND SERVICES

Prenatal Record - Antepartum Documentation of Intrapartum Procedures and Care Fetal Monitor Strip - Documentation Labor and Delivery Log Reporting of Critical Results of Tests and Diagnostic Procedures Panic Values Legibility of Medical Record Documentation Documentation and the Use of Abbreviations, Acronyms and Symbols Unacceptable Abbreviation and Symbol List

SECTION 06 - LEADERSHIP

Organizational Description Accountability and Responsibility Standards of Care - Admission Standards of Care - Comfort Standards of Care - Education Standard of Care - PACU Services Staffing Nurse Recognition Program - Introduction Staff Rights and Ethical Dilemmas in Patient Care Resolution of Conflicts with Staff Member's Cultural/Ethical/Religious Belief System Request for Revised/Excused Duty Form Sentinel Event

SECTION 07 - MEDICATION MANAGEMENT

High Alert Medication Management Insert List of High-Risk/High Alert Medications for Your Facility Patient Medication Information/Reconciliation Patient Medication Information/Reconciliation Form Controlled Drug Management on Patient Care Units Narcotics Emergency Crash Carts Emergency Crash Cart Security and Accountability Emergency Medications Sample Crash Cart and Defibrillator Checklist Signature Form Resuscitation of Neonate - Supply and Equipment Checklist Prescribing/Ordering - General Practices Verbal and Written Orders - General Telephone, Verbal and Written Orders for Medications Medication Ordered STAT and at Specified Time Intervals Standing Orders Titrating Medications Range Orders for Medications Medication Administration Safe Medication Practices Medication and Solution Administration - Invasive Procedures Apresoline (Hydralazine Hydrochloride) Administration Betamethasone (Celestone) Administration Cervidil Administration for Pre-Induction Cervical Ripening and Labor Induction Eye Treatment of Newborn Magnesium Sulfate Administration Oxytocin Induction/Augmentation - Care of the Patient Rubella Vaccination Rubella Virus Vaccine Post Delivery - Consent to Administer Form - Sample Measles, Mumps and Rubella (MMR) Vaccines - What You Need to Know Terbutaline Tocolysis Decreasing Medication Errors Medication Errors Medication Inadvertent Incident Report Form Medication Error Analysis Tool

SECTION 08 - PERFORMANCE IMPROVEMENT

Performance Improvement Plan Labor and Delivery Nursing - PI Monitoring and Evaluation Plan Labor and Delivery Nursing - PI Trending Sheet Labor and Delivery Nursing - PI Outcome Evaluation Maternal Child Health Nursing - PI Volume Measures/Statistics Cesarean Section Response Log - Sample Occurrence Report Form (Incident Report)

SECTION 09 - PROVISION OF CARE, TREATMENT AND SERVICES

Patient Care

Patient Identification for Clinical Care and Treatment "Hand-Off" Communication - Labor and Delivery Amnioinfusion Amniotomy Amniocentesis - Care of the Patient Antepartum Hemorrhage Apgar Scores Birth Out of Asepsis (BOA Delivery)Blood Alcohol Breastfeeding - Baby-Friendly Hospital Initiative Breast/Nipple Stimulation - Antepartum Testing Carboprost (Hemabate) - Management of Patient Care and Observation of the Patient in Labor Care of the Dying Patient Care Planning Catheterizing the Bladder During Labor Indwelling Urinary Catheter Insertion and Maintenance - Female Patient Cesarean Section - Preparation of the Patient Cesarean Deliveries in Labor and Delivery Cord Blood Banking for Donation or Private Banking Epidural Anesthesia - Care of the Patient Estimation of Blood Loss Fetal Fibronectin Testing Fetal Heart Rate (FHR) Abnormalities Fetal/Neonatal Demise Forceps Application for Assisted Vaginal Delivery - Care of the Patient Gestational Age Evaluation Induction of Labor Infusion Pumps - Equipment Inspection, Care and Maintenance Insulin Infusion During Labor and Delivery Invasive Procedure Site Identification (Outside of the OR)Invasive/Surgical Procedure Verification/Time Out Checklist Lithotomy Position Management of Patient with Malignant Hyperthermia (MH)Malignant Hyperthermia (MH) Cart Multiple Gestation Labor and Delivery Nonstress Test (NST) - Antepartum Testing Oxygen, Free-Flow, in Emergency Situations Placement of a Fetal Scalp Electrode by a Registered Nurse Placenta Examination Positions During Labor Postpartum Hemorrhage Precipitous Birth Pre-eclampsia (Pregnancy-Induced Hypertension)Rapid Response Team Neonatal Resuscitation Team Resolving Conflicting Interpretations of Fetal and/or Maternal Data Rh Sensitization Ruptured Membranes - Care of the Patient Sedation Sedation Monitoring Form Sterile Speculum Examination by a Registered Nurse Umbilical Cord Blood Gas Umbilical Cord Prolapse Use of Clinical Alarms on Medical Equipment Vacuum Extraction for Assisted Vaginal Delivery - Care of the Patient Vaginal Birth After Cesarean (VBAC)Vaginal Delivery Version - External Cephalic Vital Signs Waived Testing Urine Dipstick Testing Scheduling Elective Labor Inductions and Cesarean Sections Cesarean Section Scheduling Classification

Patient and Family Education

Education of Patient and Family Childbirth Education

Discharge or Transfer

Discharge Planning Maternal Transfer for Level II Care Transfer Summary and Certification Transfer Summary and Certification Form - Sample Transfer Request/Refusal/Consent to Transfer Form - Sample Nursing Transfer Summary Form Maternal Consultation - Receiving Transfer Record Form Transport Log Form Referral to Outside Agency - Infant

SECTION 10 - RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

Patient Rights and Responsibilities Informed Consent Photography and Videotaping on the Labor and Delivery Unit Advance Directives Confidentiality of Information - General Issues Patient Complaint and Grievance Process Recognizing and Reporting Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation Toxicology Screening for Suspected Maternal Substance Abuse Drug and Alcohol Exposure - Reporting Protocol Substance Use (Maternal) and Neonatal Drug Withdrawal Father and/or Support Person in Labor and Delivery Room Cesarean Section - Criteria for Admission of Support Person to OR