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Telemetry & Progressive Care Unit Policy and Procedure Manual

Telemetry & Progressive Care Unit Policy and Procedure Manual

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Telemetry & Progressive Care Unit 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, NIAHO standards Copyright Disclaimer Approval/Signature Sheet Introduction

SECTION 01 - EMERGENCY MANAGEMENT

Emergency Management

SECTION 02 - ENVIRONMENT OF CARE

Safety Body Mechanics Training Body Mechanics - Staff Education Handout Violence Management Recognizing Inappropriate Behavior Conduct to Minimize Violence Hazardous Materials and Waste - Nursing Services Hazardous Materials and Waste - Training How to Read MSDS Chemical Training Record Form Compressed Gas and Oxygen Use Fire Safety Types of Fire Extinguishers FDA Safety Tips for Clinical Staff for the Prevention of Fires Caused by Hospital Beds Electrical Safety Personal Electrical Equipment Use of Electrical Equipment in Oxygen Enriched Environment Reporting Equipment Malfunction

SECTION 03 - HUMAN RESOURCES

Position Description/Performance Evaluation - Telemetry Unit Nurse Manager Performance Evaluation - Population-Specific/Age-Related Competency - Telemetry Unit Nurse Manager Annual Competency Clinical Skills Assessment - Telemetry Unit Nurse Manager Position Description/Performance Evaluation - Telemetry Unit Registered Nurse Performance Evaluation - Population-Specific/Age-Related Competency - Telemetry Unit Registered Nurse Annual Competency Clinical Skills Assessment - Telemetry Unit Registered Nurse Position Description/Performance Evaluation - Telemetry Unit LPN/LVN Performance Evaluation - Population-Specific/Age-Related Competency - Telemetry Unit LPN/LVN Annual Competency Clinical Skills Assessment - Telemetry Unit LPN/LVN Position Description/Performance Evaluation - Telemetry Unit Secretary/Monitor Technician Performance Evaluation - Population-Specific/Age-Related Competency - Telemetry Unit Secretary/Monitor Technician Annual Competency Clinical Skills Assessment - Telemetry Unit Secretary/Monitor Technician Staff Qualifications and Competency BCLS/ACLS Resuscitation Certification New Employee Orientation Organizational Personnel Education Plan Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol Restraint and Seclusion - Staff Training and Competency Requirements Restraint Application/Removal Competency Checklist

SECTION 04 - INFECTION PREVENTION AND CONTROL

Infection Control Hand Hygiene - CDC Guidelines Standard Precautions Transmission-Based Precautions (Isolation Precautions)Asepsis Management of Patients with Methicillin Resistant Staphylococcus Aureus (MRSA)MRSA, VRE Screening Clostridium difficile (C. difficile)Sharps Injury Protection Plan Sharps Injury Log Form Handling of Biohazardous Waste

SECTION 05 - LEADERSHIP

Scope of Services Staffing Plan Sentinel Event Staff Rights and Ethical Dilemmas in Patient Care Resolution of Potential Conflict with Staff Member's Cultural/Ethical/ Religious Belief System Request for Revised/Excused Duty Form Convening of the Ethics Committee

SECTION 06 - MEDICATION MANAGEMENT

Automated Dispensing Machines - Policies and Procedures Automated Dispensing Machines - Malfunction/Downtime Automated Dispensing Machines - Preventive Maintenance Automated Dispensing Machines - Access to Automated Dispensing Machines - Inspection and Inventory Controlled Drug Management on Patient Care Units Automated Dispensing Machines - Controlled Substances Narcotics Controlled Drug Sheet Controlled Drug Sheet Form Disposal of Controlled Substance Patches Floor Stock Storage of Medications and Solutions in Patient Care Areas Automated Dispensing Machines - Stock Medication Concentrated Electrolyte Solutions and Other Drug Concentrations Emergency Crash Carts Emergency Crash Cart Security and Accountability Emergency Medications Emergency Medications List Contents of Emergency Adult Crash Cart Contents of Emergency Pediatric Crash Cart Patient's Own Medication (Usage)Patient's Own Medications (Storage and Destruction)Prescribing/Ordering - General Practices Medication Ordered STAT and at Specified Time Intervals Automated Dispensing Machines - Emergency/STAT Medication Orders Standing Orders Automatic Stop Orders Automatic Stop Orders for Surgery Patients and Transfer Patients Titrating Medications Tapering of Medications Range Orders for Medications Telephone, Verbal and Written Orders for Medication Pediatric Dosing - General Guidelines Automated Dispensing Machines - Pharmacist Order Verification and Drug Distribution Authorized Access to the Pharmacy Night Medication Locker Medication Administration Medication Administration to Pediatric Patients Safe Medication Practices Food-Drug Interaction Notification and Counseling Food and Drug Interactions Guide - Patient Brochure Automated Dispensing Machines - Removing Medications Medication and Solution Administration - Invasive Procedures Pain - Patient Controlled Analgesia (PCA)Parenteral Nutrition Protocol International Normalized Ratio (INR) - Warfarin Therapy Independent Double Check Before the Administration of Heparin Programmable Pumps for the Administration of Continuous IV Heparin Discharge Teaching - Anticoagulation Diet Patient Education - Anticoagulation Therapy Verification of Insulin, Heparin and Cardiac Drugs Medication - Insulin Administration Use of Multiple Dose Vials (MDVs)Calculation of Medication Dosages - IV Route Infusion of Vasopressors Lidocaine Protocol Documentation of Discontinued Medications High-Alert Medication Management Look-Alike, Sound-Alike Medication Management Discharge Medication Counseling Decreasing Medication Errors Medication Errors Adverse Drug Reaction Reporting Adverse Drug Reaction Reporting Form (Internal)Potential Adverse Drug Reaction Form Medication Inadvertent Incident Report Medication Inadvertent Incident Report Form Medication Error Analysis Tool Performance Improvement Analysis - Medication Inadvertent Incident Form

SECTION 07 - PERFORMANCE IMPROVEMENT

Performance Improvement Plan Telemetry/Progressive Care Unit - PI Monitoring and Evaluation Plan Telemetry/Progressive Care Unit - PI Trending Sheet Telemetry/Progressive Care Unit - PI Outcome Evaluation Telemetry/Progressive Care Unit - PI Volume Measures/Statistics Restraint Monitoring - Hospitalwide - PI Trending Sheet Performance Improvement Department - Notification Form Incident Reporting Staff Questionnaire Form

SECTION 08 - PROVISION OF CARE, TREATMENT AND SERVICES

Admission and Assessment

Admission Guidelines Initial Patient Assessment and Reassessment Admission Assessment Form Medication Reconciliation/Verification Medication Reconciliation/Verification Form Admission from the Emergency Department Fall Prevention Assessment of Adult Patient/Resident at Risk for Falls Form Neurological Assessment Nutritional Screening/Monitoring Care of the Latex Sensitive Patient Latex and Non-Latex Alternatives Latex Allergy Assessment Form Pain Assessment, Reassessment and Management Pain Scale, Admission Pain History Pain Scale Examples Behavioral-Physiological Pain Scale for Nonverbal or Preverbal Patients Recognizing and Reporting Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation Care Planning

Patient Care Procedures

Patient Identification for Clinical Care and Treatment Hand-Off Communication Bed Assignment Abdominal Paracentesis - Assisting with Arterial Line Management Arterial Puncture Authorization for Autopsy Authorization for Autopsy Form Autotransfusion Blood/Blood Components - Patient's Guide to Blood Transfusions Blood Bank Requisitions Sign-Out Protocol for Blood/Blood Components Blood Transfusion Record Blood/Blood Components - Transfusion Blood/Blood Components - Transfusion Reactions Bronchoscopy Cardiopulmonary Resuscitation - Definitions Cardiopulmonary Resuscitation Protocol Code Blue Evaluation Form Cardioversions - Elective Insertion of Central Venous Lines and PICC Lines - Bundle Central Venous Catheter and PICC Line Time Out Checklist What You Need To Know About Central Line Infections (CLI)Central Venous Pressure Monitoring - Assisting with Central Venous Catheter - Removal Peripherally Inserted Central Catheter (PICC) - Removal Chest Tube Insertion - Assisting With Chest Tube Drainage System Reporting of Critical Results of Tests and Diagnostic Procedures Panic Values Critical Points in Arterial Blood Gases Pressure Ulcer Prevention Program Management of Pressure Ulcers Pressure Ulcer Assessment Form - Sample Defibrillation Defibrillator Check Sample Crash Cart and Defibrillator Checklist Signature Form Drains - Removal of Endotracheal Intubation - Maintenance and Care Endotracheal Extubation Enteral Feeding via Nasogastric or Gastrostomy Tube Groshong Catheter Hypoglycemia Treatment Protocol Infusion Pumps - Equipment Inspection, Care and Maintenance Intralipids - 10% Solution Invasive Procedure Site Identification (Outside of the OR)Invasive/Surgical Procedure Verification/Time Out Checklist IV Therapy - Monitoring IV Therapy - Complications IV Therapy - Extravasation Management Extravasation Management Guidelines IV Therapy - Blood Sampling from Groshong Catheter and Implantable Vascular Access Devices Lumbar Puncture (Spinal Tap) - Assisting with New Onset of Chest Pain Chest Pain Protocol Postmortem Care Pulse Oximetry Restraint or Seclusion Use CMS Reporting Requirements for Death Associated with Restraint or Seclusion 24-Hour Restraint Record Form Sedation Sedation Monitoring Form Seizures - Nursing Management Suctioning - Endotracheal Suctioning - Tracheostomy Telemetry - Application of Telemetry Monitoring Station Telemetry Monitoring on Other Patient Care Units (Remote)Monitoring Telemetry Patients When They Are Off the Telemetry Unit Telemetry Monitoring - Troubleshooting Thoracentesis - Assisting With Use of Clinical Alarms on Medical Equipment Patient-Ventilator Maintenance/Monitoring - Recommended Parameter Vital Signs in Children

Patient Education

Education of Patient and Family Instructions for Home Care Form

Discharge or Transfer

Discharge Planning Discharge Guidelines Patient Transfers Patient Transfers - Skilled Units/Intrafacility Nursing Transfer Summary Form Patient Transfer and Referral Record Form

SECTION 09 - RECORD OF CARE, TREATMENT AND SERVICES/ INFORMATION MANAGEMENT

Documentation Telemetry Unit 24-Hour Flow Sheet Twenty-Four (24) Hour Clock Telemetry Unit 24-Hour Flow Sheet Form and Nursing Progress Summary Notes Telemetry Unit Monitoring Flow Sheet Form Glasgow Coma Scale Form Cardiopulmonary Arrest Record Form Legibility of Medical Record Documentation Documentation and the Use of Abbreviations, Acronyms and Symbols Unacceptable Abbreviation and Symbol List Verbal and Written Orders - General

SECTION 10 - RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

Patient Rights and Responsibilities Alternative Therapies Notification of the Pastoral Care Department Informed Consent Decision Maker - Informed Consent Authorization for and Consent to Surgery or Special Diagnostic or Therapeutic Procedures Form Autorizacion y Consentimiento de Cirugia or Procedimientos Diagnosticos or Terapeuticos Especialies Blood/Blood Component - Informed Consent Blood/Blood Component Transfusion Consent Form Refusal of Blood/Blood Component Transfusion Refusal to Permit Blood/Blood Component Transfusion Form Consent for HIV-1 Antibody Blood Test Recordings, Films or Other Images of Patients Authorization and Consent Form - Recordings, Films or Other Images, and Publication End of Life Issues Advance Directives Withholding or Withdrawal of Life-Sustaining Measures Directives for Resuscitation Sample Directives for Resuscitation Confidentiality of Information - General Issues Complaint Resolution Process Patient Complaint and Grievance Process

SECTION 11 - TRANSPLANT SAFETY

Organ/Tissue/Eye Donation Organ/Tissue/Eye Donation - Nursing Staff Responsibilities

SECTION 12 - WAIVED TESTING

Waived Testing Blood Glucose Monitoring Blood Glucose Monitoring Competency Checklist Hemoccult Testing