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Provision of Care, Treatment and Services Manual

Provision of Care, Treatment and Services 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

Provision of Care.4.changes Provision of Care.4.1.changes Most current changes

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

SECTION 01

Entry to Care, Treatment and Services

Provision of Care, Treatment and Services - Entry to Care, Treatment and Services Plan for the Provision of Patient Care and Services Admission of Inpatients EMTALA Guidelines for Emergency Department Services EMTALA Community Call Plan (CCP)Triage Emergency Care Responsibilities - Hospitals That Do Not Have an Emergency Department List of Transfer Agreements Form Acceptance of Patients Transferred from Another Facility Admission Process - Outpatient Surgery Admission Criteria - ICU/CCU Admission to Labor and Delivery Labor, Delivery, Recovery, Postpartum (LDRP) Criteria Patient Referral When Admission Criteria Not Met Admission for Observation Status Patient Requiring Psychiatric Evaluation Transferring a Patient to a County Psychiatric Facility Care of the Patient Under Legal or Correctional Restrictions Sample Conditions of Admission to Hospital Form

Assessment and Reassessment

Provision of Care, Treatment and Services - Assessment and Reassessment Initial Patient Assessment and Reassessment Admission Assessment Form Patient Medication Information/Reconciliation Patient Medication Information/Reconciliation Form Care of the Latex Sensitive Patient Latex Allergy Assessment Form Assessment and Reassessment - Intensive Care Patient Assessment and Reassessment - Medical Surgical Patient Assessment and Reassessment - Pediatric Patient Pediatric Assessment Form (Newborn - 18 Months)Pediatric Assessment Form (18 Months - 4 Years)Pediatric Assessment Form (5 - 11 Years)Pediatric Assessment Form (12 - 21 Years)Preadmission - Patient Assessment Assessment and Reassessment - Surgical Patient Assessment and Reassessment - Ambulatory Procedures Assessment and Reassessment - Cardiopulmonary Patient Cardiopulmonary Clinical Assessment Form Assessment and Reassessment - Emergency Department Emergency Department Initial Nursing Assessment Form Admission and Assessment - Postpartum Patient Neonatal Assessments for High-Risk Psychosocial Issues Nutritional Screening/Monitoring Patient Nutritional Levels - Definition Nutritional Assessment of Patients by the Registered Dietitian Nutritional Assessment Form Prioritization of Nutritional Consult Nutritional Screening - Perinatal Patient Nutritional Screening - Ambulatory Patient Functional Assessment and Reassessment of the Patient Initial Patient Assessment - Rehabilitation Services Initial Patient Assessment Summary Form - Rehabilitation Services Daily Treatment and Functional Assessment Form - Rehabilitation Services Psychosocial, Spiritual and Cultural Beliefs and Values History and Physical - Surgical Services Standards of Practice - General Nursing Standards of Practice - ICU/CCU Standards of Practice - Maternal Child Health Standards of Practice - Surgical Services Position Description/Performance Evaluation - Medical Surgical Unit Registered Nurse

Assessment and Management of Pain

Provision of Care, Treatment and Services - Assessment and Management of Pain Pain Assessment, Reassessment and Management Pain Assessment in Children Pain Scale, Admission Pain History Pain Scale Examples Behavioral-Physiological Pain Scale for Nonverbal or Preverbal Patients Form Comprehensive Pain Assessment Form (Sample)Pain Assessment Form - Sample Pain Management - Pediatric Pain Assessment and Reassessment Form Pain Management Treatment Plan Pain Management Flowsheet Pain Management Patient Education Checklist Form Patient and Family Education Guideline - Pain Management Patient and Family Education Handout - Pain Relief Without Medication

Assessment and Management of Patient Falls

Provision of Care, Treatment and Services - Assessment and Management of Patient Falls Fall Prevention Assessment of Adult Patient at Risk for Falls Form (Sample)Assessment of Pediatric Patient at Risk for Falls Form (Sample) Patient Fall Review Sheet

Assessment: Victims of Abuse/Neglect

Provision of Care, Treatment and Services - Assessment: Victims of Abuse/Neglect Recognizing and Reporting Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation Child Abuse and Neglect - Identification and Reporting Criteria Toxicology Screening for Suspected Maternal Substance Abuse Neonate with Suspected Drug Withdrawal or Exposure to Maternal Chemical Abuse Recognizing and Reporting Elder Abuse/Neglect - Criteria Domestic Violence Assessment and Reporting Identification of Rape Victims Sexual Assault Survivors - Rape Victims Documentation of Assessment - Possible Abuse or Neglect Community Resources List for Abuse/Neglect Victims Personnel File Review Sample Form

Assessment: Patients Being Treated for Alcoholism, Substance Use Disorders

Provision of Care, Treatment and Services - Assessment: Patients Being Treated for Alcoholism, Substance Use Disorders Assessment - Alcohol or Other Substance Use Disorders Assessment - Psychosocial Psychosocial Assessment Form Identification of Patients with Alcohol Withdrawal Symptoms ETOH and CNS Depressants Withdrawal Assessment Record Identification of Patients with Substance Withdrawal Opiate Narcotic Withdrawal Assessment Record Chemical Dependency Withdrawal Assessment Scale (Sample) Identification of Drug Seeking Behavior

Assessment: Patients Being Treated for Emotional or Behavioral Disorders

Provision of Care, Treatment and Services - Assessment: Patients Being Treated for Emotional or Behavioral Disorders Patient Assessment Nursing Admission Assessment Form - Behavioral Health Assessment for Self-Harm Initial Screening for Self-Harm Potential Form (Addendum to Nursing Assessment)Assessment for Level of Nursing Care Form

Diagnostic Services

Provision of Care, Treatment and Services - Diagnostic Services Clinical Laboratory Guidelines for Test Requisition and Results Patient Care Unit Specimen Collection and Identification Collection and Care of Specimens Imaging/Radiology Services Order Requisition Electrocardiograms Reporting of Critical Results of Tests and Diagnostic Procedures Acknowledgment of Results of Diagnostic Testing

Planning Care, Treatment and Services

Provision of Care, Treatment and Services - Planning Care, Treatment and Services Care Planning Nutritional Plan of Care Parenteral/Enteral Nutrition Progress Notes Form Rehabilitation Services Patient Treatment Plan Rehabilitation Services Patient Treatment Plan Form Surgical Services Plan of Care Revision of Surgical Services Plan of Care Clinical Pathway - Physician's Orders: Acute GI Bleed Clinical Pathway - Physician's Orders: Acute Pneumonia Clinical Pathway - Physician's Orders: Congestive Heart Failure

Behavior Management and Treatment Interventions

Provision of Care, Treatment and Services - Behavior Management and Treatment Interventions Behavioral Management Procedures Patient Time Outs Behavioral Modification Unit PI Monitoring and Evaluation Plan Behavioral Modification Unit PI Trending Sheet Behavioral Modification Unit PI Outcome Evaluation Behavioral Modification Unit PI Volume Measures/Statistics

SECTION 02

Providing Care, Treatment and Services

Provision of Care, Treatment and Services - Providing Care, Treatment and Services Patient Identification for Clinical Care and Treatment Blood/Blood Components - Transfusion Prescribing/Ordering - General Practices Verbal and Written Orders - General Telephone, Verbal and Written Orders for Medication Medication Administration Case Management Plan Case Management Monthly Log Form Catastrophic Case Management Criteria List Policy Other Case Management Considerations List Social Work Interventions for Rehab or Transitional Units Patient Treatment Process - Rehabilitation Services Emergency Department - Patient Transfer to Another Facility Summary Form Nursing Transfer Summary Form Patient Transfer and Referral Record Form Discharge/Transfer of Patients with Known/Suspected Tuberculosis Referral Disclosure Computerized Process for Social Service/Discharge Planning Alert Social Service/Discharge Planning Alert Notification Descriptions Form Hand-Off Communication Hand-Off Communication in the Perioperative Setting Hand-Off Communication - Behavioral Health Crisis Intervention

Availability of Resuscitation Services

Provision of Care, Treatment and Services - Availability of Resuscitation Services Cardiopulmonary Resuscitation (CPR)Cardiopulmonary Resuscitation Protocol Cardiopulmonary Arrest Record Form Emergency Resuscitation Evaluation Form Emergency Crash Carts Emergency Crash Cart Security and Accountability Contents of Emergency Adult Crash Cart Form Contents of Emergency Pediatrics Crash Cart Form Cardiopulmonary Resuscitation Training Requirements Position Description/Performance Evaluation - Emergency Department Registered Nurse II

Recognition and Response to Change in Patient's Condition

Provision of Care, Treatment and Services - Recognition and Response to Change in Patient's Condition Rapid Response Team Position Description/Performance Evaluation - Rapid Response Team RN Performance Evaluation - Population-Specific/Age-Related Competency - Rapid Response Team RN Annual Competency Clinical Skills Assessment - Rapid Response Team RN Rapid Response Team Evaluation Form

Academic Education for Children/Youth

Provision of Care, Treatment and Services - Academic Education for Children/Youth Interruption of Patient Academic Education Social Service Arrangement of Patient Academic Needs Academic Community Resources List Form

Access to the Outdoors

Provision of Care, Treatment and Services - Access to the Outdoors Patient Access to the Outdoors

End of Life Care

Provision of Care, Treatment and Services - End of Life Care End of Life Issues Guidelines for Pain Management in the Terminal Patient

Patient Education

Provision of Care, Treatment and Services - Patient Education Organizational Patient/Family Education Plan Education of Patient and Family Patient Educational Record Form Medication Education Food-Drug Interaction Notification and Counseling Food and Drug Interactions Guide - Patient Brochure Discharge Medication Counseling Patient Education for Modified Diets Patient and Family Education Handout - Cholesterol Lowering Diet Medical Equipment Education Patient and Family Education Handout - Crutch Training Basics Crutch Training Pre-Test/Post Test Crutch Training Pre-Test/Post Test Answer Key Instructions Checklist - Home Equipment Form Patient and Family Education - Imaging Services Patient and Family Education - Physical Therapy Home Exercise Program Handout - General Instructions - Amputation Home Exercises Handout - Amputation - Quad Set Increasing Patient Independence Instructions for Home Care Form Patient and Family Education Handout - What You Can Do to Prevent Falls

Additional Standards for Hospitals with Behavioral Health Units

Provision of Care, Treatment and Services - Additional Standards for Hospitals with Behavioral Health Units Personal Hygiene Oral Health Program

SECTION 03

Operative or Other High-Risk Procedures - Planning and Monitoring

Provision of Care, Treatment and Services - Operative or Other High-Risk Procedures - Planning and Monitoring Scope of Services - Anesthesia Guidelines for Administration of Anesthesia Perioperative Nursing Practice Perioperative Nursing Standards and Process Patient Safety in the Operating Room Pre and Post Anesthesia Evaluation Policy Preanesthesia Assessment Pre and Post Anesthesia Evaluation Form Assessment Prior to Induction of Anesthesia/Sedation Anesthesia Record Form Anesthesia Safety Anesthesia Equipment Safety Anesthesia Awareness Management of Patient with Malignant Hyperthermia (MH)Sedation Sedation Monitoring Form Preoperative Requirements for Inpatients Outpatient Surgery Admission Criteria Outpatient Surgery Requirements Preoperative Patient Assessment for Emergency Surgical Procedures Surgical Site Identification Invasive Procedure Site Identification (Outside of the OR)Surgical Checklist and Preoperative Nursing Record Form Invasive/Surgical Procedure Verification/Time Out Checklist Intraoperative Nursing Record Form

Patient Care After Operative or Other High-Risk Procedures

Provision of Care, Treatment and Services - Patient Care After Operative or Other High-Risk Procedures PACU Admission Protocol Post Anesthesia Care Unit Record Form Post Anesthesia Orders Form Use of PACU Scoring Guidelines Discharge from PACU Discharge from Ambulatory Care/Outpatient Surgery Management of Hypotension in (Post) Pain Management Patients Acquisition, Identification and Administration of Blood Products Blood/Blood Components - Transfusion Reactions Postoperative Care - Patient Care Units Standard of Care - PACU Services - Discharge Appropriateness Standard of Care - PACU Services - Management of Spinal Anesthesia Recovery Standard of Care - PACU Services - Postoperative Pain Management

Tissue Specimens Removed During a Surgical Procedure

Provision of Care, Treatment and Services - Tissue Specimens Removed During a Surgical Procedure Pathology Specimens Frozen Section Protocol

Electroconvulsive Therapy

Provision of Care, Treatment and Services - Electroconvulsive Therapy Electroconvulsive Therapy (ECT) Treatment Behavioral Medicine - Convulsive Therapy Indications for Treatment Form Electroconvulsive Therapy Performance Improvement Review Form

Surgical Treatments for Emotional, Mental or Behavioral Disorders

Provision of Care, Treatment and Services - Surgical Treatments for Emotional, Mental or Behavioral Disorders Surgical Procedures for the Behavioral Health Patient Petition for Psychosurgery Form

Restraint and Seclusion - Review of Standards for Hospitals That Do Not Use Joint Commission Accreditation for Deemed Status Purposes

Restraint and Seclusion - Review of Standards for Hospitals That Do Not Use Joint Commission Accreditation for Deemed Status Purposes

Restraint and Seclusion

Provision of Care, Treatment and Services - Restraint and Seclusion Restraint or Seclusion Use Seclusion of Patient Use of Immobilization Devices Restraint/Seclusion Orders - Physician's Order Sheet 24-Hour Restraint Record Form Restraint and Seclusion Flowsheet Use Restraint and Seclusion Nursing Flowsheet Form Restraint and Seclusion Use Limited to Emergencies Restraint and Seclusion Criteria for Discontinuation Restraint and Seclusion - Staff Training and Competency Requirements Staff Orientation and Training for Restraint and Seclusion Restraint Application/Removal Competency Checklist - Restraint for Management of Nonviolent, Non-Self Destructive Behavior Use of Restraint and Seclusion Application/Removal Competency Checklist - Restraint for Management of Violent or Self-Destructive Behavior Restraint and/or Seclusion Monitoring - Post-Incident Review Process Form Performance Improvement Program - Organizational Restraint or Seclusion Use Restraint Monitoring - Hospitalwide - PI Trending Sheet CMS Reporting Requirements for Death Associated with Restraint or Seclusion

SECTION 04

Discharge or Transfer from the Organization

Provision of Care, Treatment and Services - Discharge or Transfer from the Organization Discharge Planning Social Service/Discharge Planning Screening Discharge Planning Assessment/Evaluation Form Social Service/Discharge Planning - Medicare/Medicaid Patients Discharge Planning When No Family Available Referrals to the Public Guardian's Office Probate Conservatorship Guidelines Transfer of Patients In-House Transfer Summary and Certification Transfer Summary and Certification Form Patient Transfers - Documentation in the Medical Record Patient Transfer to Another Facility - Interfacility Patient Transfers - Skilled Units/Intrafacility Managed Care Transfers into the Facility from Noncontracted Providers Discharge Planning Documentation by Outside Case Manager from Managed Care Providers Discharging a Patient to a Skilled Nursing Facility Maternal/Fetal Transport Equipment for Maternal/Fetal Transport List Transfer Request/Refusal/Consent to Transfer Form Maternal Consultation - Receiving Transfer Record Form Transferring an Inpatient to a County Hospital Home Health Referral Social Service Resources Community Resources Community Resources List for Patients and Families Outpatient Post-Op Instructions and Physician's Orders Form Emergency Department Aftercare Instruction Sheet Form Infant Teaching and Discharge Plan Form Utilization Management Plan

SECTION 05

Blood and Blood Components

Provision of Care, Treatment and Services - Blood and Blood Components Blood Supply and Look-Back Notification of Recipients of Possible Infectious Blood/Blood Components

SECTION 06

Donating and Procuring Organs and Tissues

Provision of Care, Treatment and Services - Donating and Procuring Organs and Tissues Organ/Tissue/Eye Donation Organ Donation After Cardiac Death Organ and Tissue Transplant Responsibilities Organ and Tissue Transplant Programs - CMS Regulations Organ Transplantation, Recovery, Receipt and Patient Management - CMS Regulations Organ Transplant Waitlist Management Living Person Organ Donation Organ/Tissue/Eye Donation - Nursing Staff Responsibilities Organ/Tissue/Eye Donation - Staff Education

Managing Tissues

Provision of Care, Treatment and Services - Managing Tissues Tissue and Cell Acquisition Receiving, Inspecting and Documentation of Tissue and Cells Verification Storage of Tissue and Cells Tissue Refrigerator/Freezer Maintenance Procedures Storage of Tissue in the Event of the Loss of Refrigeration Request for Tissue Documentation of Tissue Implantation Reporting Adverse Tissue Reactions

SECTION 07

Waived Testing

Provision of Care, Treatment and Services - Waived Testing Waived Testing Blood Glucose Monitoring Blood Glucose Monitoring Competency Checklist Blood Glucose Monitoring Parameters Hemoccult Testing Fingerstick and Point of Care Blood Testing Devices