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Medical Office Policy and Procedure Manual

The Medical Office Policy and Procedure Manual is cross referenced to Joint Commission standards for Ambulatory Care and Primary Care Medical Homes and NCQA standards for Patient Centered Medical Homes. This manual includes policies that meet OSHA requirements for safety and infection control, Human Resources policies and Medical Office Compliance Plan and much more!

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Table of Contents - TJC Standards Table of Contents - NCQA Standards Copyright Disclaimer Approval/Signature Sheet Introduction

SECTION 01 - ACCESS TO CARE

1001 - 24/7 Access 1002 - Access During Office Hours 1003 - Documentation of Phone Calls 1004 - Phone Message Form - Sample 1005 - After Hours Access and Care 1006 - Appointment Scheduling 1007 - Appointment Follow-Up 1008 - Appointment Failure Notification 1009 - Reschedule Notification Letter 1010 - Patient Certified Letter - Second Request 1011 - Patient Certified Letter - Third Request 1012 - Patient Letter - Three Appointments Missed 1013 - Final Patient Notification Letter

SECTION 02 - PATIENT CARE

2001 - New Patients 2002 - Designated Primary Care Clinician 2003 - Interdisciplinary Team 2004 - Patient Treatment Plan 2005 - Patient Medication Information/Reconciliation 2006 - Annual Wellness Visits and Personalized Prevention Plan Services 2007 - Health Assessment Form - Adult 2008 - Preventive Care Guidelines for Asymptomatic Male and Female Adults (Over 21 Years)2009 - Health Assessment Form - Obstetric 2010 - Health Assessment Form - Pediatric 2011 - Preventive Care Guidelines for Asymptomatic Children and Adolescents (Birth - 20 years)2012 - Childhood Lead Poisoning Evaluation Questionnaire Form 2013 - Adolescent Health Inventory Form 2014 - Clinical Decision Support Tools 2015 - AHRQ 2012 Guide to Clinical Preventive Services 2016 - Administering the Tuberculin Skin Test (TST)2017 - Emergencies - Patient 2018 - Emergency Supplies - Office 2019 - Examination Equipment 2020 - Health Education 2021 - Sample Patient and Family Education Form 2022 - Community Resources List for Patients and Families 2023 - Heat-Related Health Conditions Fact Sheet 2024 - West Nile Virus Fact Sheet 2025 - Invasive Procedures - Staffing of 2026 - Lab and Diagnostic Test Results 2027 - Abnormal Lab or X-ray Results - Patient Notification 2028 - Latex Sensitive Patient - Care of 2029 - Management of Multidrug-Resistant Organisms in Non-Hospital Healthcare Settings 2030 - Pregnant Patients - Radiological Examination 2031 - Recognizing and Reporting Suspected Child, Adult, Disabled Person or Elderly Abuse, Neglect or Exploitation 2032 - Sexual Assault or Abuse 2033 - Reporting of Injuries Related to Criminal Conduct 2034 - Reporting Medically Impaired Drivers to the Department of Motor Vehicles (DMV)2035 - Transferring Care of Patients to Another Practitioner 2036 - Physician Letter - Transferring Care to Another Provider 2037 - Non-Compliance Letters - Physician to Patient (HMO)2038 - Non-Compliance Letter #1 (HMO)2039 - Non-Compliance Letter #2 (HMO)2040 - Non-Compliance Letter #3 (HMO)

SECTION 03 - INFECTION PREVENTION AND CONTROL

General Policies

3001 - Infection Prevention and Control - Medical Offices 3002 - New Employee Infection Prevention and Control Orientation 3003 - Infection Prevention and Control - New Employee Orientation Outline (Sample Form)3004 - Standard Precautions 3005 - Hand Hygiene - CDC Guidelines 3006 - Respiratory Hygiene and Cough Etiquette in Healthcare Settings 3007 - Communicable Infections 3008 - Notice - Airborne Infection 3009 - Nationally Notifiable Infectious Diseases 3010 - Quarantinable Diseases 3011 - Reportable Diseases

Bloodborne Pathogens and Exposure Control Plan

3101 - Exposure Control Plan 3102 - Sharps Injury Protection Plan 3103 - Sharps Injury Log Form 3104 - Disposal of Sharps 3105 - Management of Accidental Blood or Body Fluid Exposure 3106 - Accidental Exposure to Blood or Body Fluids - Medical Evaluation Form 3107 - Accidental Exposure to Blood or Body Fluids - Employee Follow Up Instruction Sheet 3108 - Consent for the HIV Test (Sample Form)3109 - Authorization for Disclosure of the Results of the HIV Antibody Blood Test (Sample Form)3110 - CDC - Summary of Recommendations for Immediate Prophylactic Intervention 3111 - CDC - Recommended Postexposure Management by Risk Category and Specific Pathogen 3112 - Infectious Waste Management Plan 3113 - Medical Waste Disposal Guidelines

Employee Health

3201 - Injury and Illness Prevention Program 3202 - Employee Incident Reporting 3203 - Employee Health Program 3204 - Immunization Status of Employees 3205 - Bordetella Pertussis 3206 - Influenza Vaccination Program for Healthcare Staff 3207 - Measles, Rubella and Varicella Disease Screening - Staff 3208 - Varicella Zoster 3209 - Hepatitis B Vaccine Program 3210 - Informed Consent for Hepatitis B Vaccine Form 3211 - Hepatitis B Vaccine Declination Form 3212 - Tuberculosis Screening Program 3213 - TB Risk Assessment Worksheet 3214 - TB Risk Assessment Flowchart 3215 - Health Questionnaire for Positive Tuberculosis Skin Test Reactions Form 3216 - Suggested Guidelines for Work Restrictions for Staff with Infectious Diseases 3217 - Respiratory Protection Plan 3218 - N95 Fit-Testing 3219 - Staff Latex Sensitivity

SECTION 04 - MEDICATION MANAGEMENT

4001 - Standing Orders 4002 - Influenza Vaccination 4003 - Sample Medications - Physician Offices 4004 - Storage of Medications 4005 - Refrigerated Drug Storage 4006 - Medication Refrigerator Temperature Log Form 4007 - Medication Freezer Temperature Log Form 4008 - Routine Vaccine Storage and Handling Plan 4009 - Available Vaccines 4010 - Use of Vaccine Information Statements (VISs)4011 - Controlled Substance Storage and Documentation 4012 - Narcotic Count Record Form 4013 - Narcotic Drug Dispensation Record Form 4014 - Expired Medication Log Form 4015 - Medication Recall 4016 - Use of Multiple Dose Vials (MDVs)4017 - Insulin Pens 4018 - E-Prescribing 4019 - Prescription Pad Security

SECTION 05 - WAIVED TESTING

5001 - Waived Testing 5002 - Rapid Influenza Diagnostic Tests

SECTION 06 - MEDICAL RECORD

6001 - Confidentiality of Information - General Issues 6002 - Confidentiality Statement (Employee)6003 - Electronic Health Record System 6004 - Administrative Safeguards - Risk Analysis 6005 - Administrative Safeguards - Risk Management 6006 - Administrative Safeguards - Security Awareness and Training 6007 - Administrative Safeguards - Password Management 6008 - Physical Safeguards - Workstation Use 6009 - Meaningful Use Overview 6010 - Timelines for Meaningful Use 6011 - Attestation for Meaningful Use (MU)6012 - Overview of Stage 1 Meaningful Use - Eligible Professionals 6013 - Overview of Stage 2 Meaningful Use 6014 - Overview of Stage 3 Meaningful Use 6015 - Reporting Data Externally 6016 - Protection and Availability of Medical Records 6017 - Access Requests 6018 - Patient Access to Medical Records 6019 - Release of Medical Information 6020 - Medical Records Request and Release Form 6021 - Release of Information Regarding HIV or AIDS 6022 - Confidential Messages 6023 - Purging and Destruction of Medical Records 6024 - Medical Record Standards 6025 - Medical Office Documentation 6026 - Patient Problem List 6027 - Prescription Medication Record Form 6028 - ICD-9-CM Diagnosis Codes 6029 - Medical Record Review Form 6030 - Pediatric Medical Record Review Form 6031 - Office Surgical Review Form 6032 - Asthma Review Summary Form 6033 - Diabetes Management Form 6034 - Utilization of the Facsimile Machine 6035 - Faxing Medical Records 6036 - Fax Transmittal Sheet 6037 - Employee Training Log for Computer and Fax Stations 6038 - Guidelines for Use of Electronic Mail 6039 - Social Media - Use of

SECTION 07 - PATIENT RIGHTS AND RESPONSIBILITIES

7001 - Patient Bill of Rights Handout 7002 - Patient Responsibilities Handout 7003 - Informed Consent 7004 - Consent to Sterilization (Elective)7005 - Advance Directives 7006 - Durable Power of Attorney for Healthcare 7007 - Patient Complaints 7008 - Complaint Log Form 7009 - Posting of Patient Rights and Responsibilities 7010 - Patient Communication Rights 7011 - Interpreter Services

SECTION 08 - PERFORMANCE IMPROVEMENT

8001 - Performance Improvement Plan

SECTION 09 - ADMINISTRATIVE

9001 - Scope of Services 9002 - Staff Meetings 9003 - OIG Compliance in the Medical Office 9004 - Compliance Plan for Medical Offices 9005 - Medical Office Self-Assessment Tool 9006 - Office Evaluation Form 9007 - HMO Referral Policy 9008 - HMO Prior Authorization Worksheet 9009 - HMO Areas of Risk 9010 - HMO Member Disenrollment Requirements 9011 - Criteria and Procedure for Removal of Members from Your PMG and IPA

SECTION 10 - HUMAN RESOURCES

10001 - Equal Employment Opportunity 10002 - Staff Qualifications and Competency 10003 - Primary Care Clinician Credentialing Process 10004 - Employment Application Form - Sample 10005 - Proof of Right to Work 10006 - Reference Checking 10007 - License Verification 10008 - Inservice Education 10009 - Continuing Education 10010 - Performance Evaluations 10011 - Personnel Action Form 10012 - Attendance and Tardiness 10013 - Dress Code 10014 - Employee Requests for Time Off 10015 - Harassment, Sexual (Either Sex)10016 - Lunch and Rest Breaks 10017 - Paid Time Off (PTO)10018 - Workers' Compensation 10019 - Termination of Employment 10020 - Position Description/Performance Evaluation - Office Manager - RN 10021 - Performance Evaluation - Population-Specific/Age-Related Competency - Office Manager - RN 10022 - Annual Competency Clinical Skills Assessment - Office Manager - RN 10023 - Position Description/Performance Evaluation - Nurse Practitioner 10024 - Performance Evaluation - Population-Specific/Age-Related Competency - Nurse Practitioner 10025 - Annual Competency Clinical Skills Assessment - Nurse Practitioner 10026 - Position Description/Performance Evaluation - Physician's Assistant - Medical Office 10027 - Performance Evaluation - Population-Specific/Age-Related Competency - Physician's Assistant - Medical Office 10028 - Annual Competency Clinical Skills Assessment - Physician's Assistant - Medical Office 10029 - Delegation of Services Agreement Between Supervising Physician and Physician Assistant - Example 10030 - Approved Supervising Physicians Responsibility for Supervision of Physician Assistant - Example 10031 - Position Description/Performance Evaluation - Office RN 10032 - Performance Evaluation - Population-Specific-Age-Related Competency - Office RN 10033 - Annual Competency Clinical Skills Assessment - Office RN 10034 - Position Description/Performance Evaluation - Office LPN/LVN 10035 - Performance Evaluation - Population-Specific/Age-Related Competency - Office LPN/LVN 10036 - Annual Competency Clinical Skills Assessment - Office LPN/LVN 10037 - Position Description/Performance Evaluation - Medical Assistant - Office 10038 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Assistant - Office 10039 - Annual Competency Skills Assessment - Medical Assistant - Office 10040 - Position Description/Performance Evaluation - Office Receptionist 10041 - Performance Evaluation - Population-Specific/Age-Related Competency - Office Receptionist 10042 - Annual Competency Skills Assessment - Office Receptionist 10043 - Position Description/Performance Evaluation - Office Bookkeeper 10044 - Annual Competency Skills Assessment - Office Bookkeeper 10045 - Position Description/Performance Evaluation - Medical Office Insurance Biller 10046 - Annual Competency Skills Assessment - Medical Office Insurance Biller 10047 - Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol for Ambulatory Care