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Nursery Policy and Procedure Manual

Nursery 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 Table of Contents - TJC standards Copyright Disclaimer Introduction

SECTION 01 - ETHICS, RIGHTS AND RESPONSIBILITIES

Patient Rights and Responsibilities Ethical Dilemmas in Patient Care Resolution of Potential Conflict with Staff Member's Cultural/Ethical/Religious Belief System Informed Consent Photographing the Infant Confidentiality of Information - General Issues Baptism Child Abuse and Neglect - Identification and Reporting Criteria

SECTION 02 - PROVISION OF CARE, TREATMENT AND SERVICES

Admission and Assessment

Admission of Newborn Admission of Newborn to Nursery After BOA Delivery Assessment, Newborn Examination of Newborn Guidelines Gestational Age Evaluation Small for Gestational Age Infant (SGA)Large for Gestational Age Infant (LGA)Hematocrit (Newborn)Hyperbilirubinemia Screening Newborn Screening (NBS)Rh Sensitization Pain Assessment in Children Pain Scale, Admission Pain History Pain Scale Examples Behavioral-Physiological Pain Scale for Nonverbal or Preverbal Patients Care of the Latex Sensitive Patient Latex and Non-Latex Alternatives Latex Allergy Assessment

Patient Care Procedures

Patient Identification for Clinical Care and Treatment Invasive Procedure Site Identification Boarder Nursery Rooming-In Infants Blood Glucose Monitoring Glucose Protocol Flowchart Blood Cultures - Neonatal Blood Gasses - Capillary Breast Milk Collection and Storage Breastfeeding - Assisting the Mother Bulb Syringe Use Care Planning Chest Tube Insertion Circumcision Cord Care Cord Clamp Removal Endotracheal Intubation - Assisting with Exchange Transfusion - Polycythemia Treatment Feeding the Normal Newborn Formula Gavage Feeding Infusion Pumps - Equipment Inspection, Care and Maintenance Intravenous Therapy - Insertion Intravenous Therapy - Maintenance (Peripheral)Monitor - Heart Rate and Apnea Nursery Attendance at Cesarean Section Deliveries Oxygen Administration for the Newborn Oxygen Administration via Hood Oxygen Administration via Nasal Cannula in the Neonate Phototherapy Resuscitation of Infant Sepsis Suspected in Newborn Standards of Care Vital Signs - Newborns Weaning to Open Bassinet Umbilical Arterial Line Insertion Use of Clinical Alarms on Medical Equipment Weighing Infants Death, Fetal - Infant Waived Testing Blood Glucose Monitoring - Quality Assurance Hemoccult Testing

Education

Infant Care Teaching Guidelines Discharge Instructions - Mother/Infant

Discharge/Transfer

Discharge Planning - Nursing's Role Discharge of Newborn from Nursery Discharge of Infant to Someone Other Than Mother Release of Newborn to Parent/Legal Guardian and Discharge Documentation Form Neonatal Transfer Transfer Refusal/Consent to Transfer Form Transfer Summary and Certification Transfer Summary and Certification Form Referral to Outside Agency - Infant

SECTION 03 - MEDICATION MANAGEMENT

Controlled Drug Management on Patient Care Units Narcotics Storage of Medications and Solutions in Patient Care Areas Decreasing Medication Errors Emergency Crash Carts Emergency Crash Cart Security and Accountability Emergency Medications Resuscitation of Infant - Equipment/Supplies/Medications Emergency Crash Cart and Defibrillator Check Signature Form Prescribing/Orders - General Practices Medication Ordered STAT and at Specified Time Intervals Standing Orders Telephone, Verbal and Written Orders for Medication Pediatric Dosing - General Guidelines Safe Medication Practices Medication Administration Medication Administration to Pediatric Patients Eye Treatment of Newborn Intramuscular (IM) Injection Neonate Vitamin K Administration (Hemorrhagic Disease)Medication Errors Adverse Drug Reaction Reporting Form Medication Inadvertent Incident Report Medication Inadvertent Incident Report Form Medication Error Analysis Tool Performance Improvement Analysis - Medication Inadvertent Incident Form

SECTION 04 - SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION

Infection Control Isolation of the Newborn Bassinet Supplies Standard Precautions Asepsis Surgical Hand Scrub Hand Hygiene HBsAg Hepatitis B Vaccine - What You Need to Know Hospital Report Form - Perinatal Hepatitis B Sharps Injury Protection Plan Sharps Injury Log Form Handling of Biohazardous Waste

SECTION 05 - IMPROVING ORGANIZATION PERFORMANCE

Performance Improvement Plan - Newborn Nursery Nursery PI Monitoring and Evaluation Plan Nursery PI Trending Sheet Nursery PI Outcome Evaluation Maternal Child Health Nursing PI Volume Measures/Statistics Performance Improvement Department - Notification Form Sentinel Event Incident Reporting Staff Questionnaire Form

SECTION 06 - LEADERSHIP

Organizational Description Accountability and Responsibility Relationship of Maternal Child Health to Ancillary Services Within the Hospital Staffing - General Unit Based Staffing Grid - Sample Coroner's Cases Nurse Recognition Program - Introduction RN Clinical Advancement Program Tuition Reimbursement - Nurse Recognition Program Request for Tuition Reimbursement - Nurse Recognition Program Sample Form

SECTION 07 - MANAGEMENT OF THE ENVIRONMENT OF CARE

Safety Practices Car Seat Identification of Infants Infant Security Plan Infant/Child Abduction Response Plan Infant/Child Abduction Flow Sheet for Communication Department Court Hold Guidelines Violence Management Recognizing Inappropriate Behavior Conduct to Minimize Violence Hazardous Materials and Waste - Nursing Services Hazardous Materials and Waste - Training How to Read Safety Data Sheets (SDS)Emergency Management - Obstetric Department Fire Safety Types of Fire Extinguishers Electrical Safety Use of Electrical Equipment in Oxygen Enriched Environment Reporting Equipment Malfunction

SECTION 08 - MANAGEMENT OF HUMAN RESOURCES

Position Description/Performance Evaluation - Maternal Child Health Nurse Manager Performance Evaluation - Age-Related Competency - Maternal Child Health Nurse Manager Annual Competency Clinical Skills Assessment - Maternal Child Health Nurse Manager Position Description/Performance Evaluation - Nursery RN Performance Evaluation - Age-Related Competency - Nursery RN Annual Competency Clinical Skills Assessment - Nursery RN Position Description/Performance Evaluation - Nursery LPN/LVN Performance Evaluation - Age-Related Competency - Nursery LPN/LVN Annual Competency Clinical Skills Assessment - Nursery LPN/LVN Position Description/Performance Evaluation - Maternal Child Health Unit Secretary Performance Evaluation - Age-Related Competency - Maternal Child Health Unit Secretary Annual Competency Clinical Skills Assessment - Maternal Child Health Unit Secretary New Employee Orientation Staff Competency Competency Assessment, RN (New Staff)Skills Inventory/Orientation Checklist - Nursery Annual Skills Assessment Form - Nursery Blood Glucose Monitoring Competency Checklist Employee Preparation Checklist for Peer Review Peer Review Feedback Form Orientation/Skills Checklist - Maternal Child Health Unit Secretary Continuing Education Inservice Programs Nursing Personnel Data/Education Record for the Maternal Child Health Unit

SECTION 09 - MANAGEMENT OF INFORMATION

Log - Nursery Acceptable Abbreviations Unacceptable Abbreviation and Symbol List Acknowledgment of Results of Diagnostic Testing Critical Test Result Reporting Panic Values

SECTION 10 - MEDICAL STAFF

Consultation Requirements - Guidelines for Nursing Staff