The Administrative Manual For Ambulatory Care Facilities is part of MCN Healthcare’s ellucid® Policy Library. MCN Healthcare is the health care industry’s leading provider of TJC (formerly JCAHO) accreditation tools and CMS accreditation help, consisting of policy and procedure templates, forms, competencies and other compliance tools. MCN’s policy and procedure manuals are used in more than 25,000 healthcare organizations throughout the world to help with compliance, accreditation, and health care quality improvement.

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SECTION I - ETHICS, RIGHTS AND RESPONSIBILITIES

Code of Ethics

Corporate Compliance Plan

Conflict of Interest

Conflict of Interest Disclosure Letter - Sample

Decisions Regarding Coverage of Care

Utilization Management

Billing Practices

Resolution of Conflict Related to Patient Billing

The Entry Into Care

Eligibility Criteria

HMO Treatment/Authorization Consent Form

Bioethics Committee Consultation

Staff Rights and Ethical Dilemmas in Patient Care

Resolution of Potential Conflict with Staff Member’s Cultural/Ethical/ Religious Belief System

Patient Rights and Responsibilities

Patient Informed Decision Making

Care of the Terminally Ill Patient

Informed Consent

Consents

Consent - HIV Testing

HIV Antibody Test and Results

Healthcare Workers Consent to Perform HIV (AIDS Virus) Antibody Test (Sample Form)

Consent for the HIV Test (Sample Form)

Photographing/Videotaping Patients

Authorization and Consent Form - Photograph and Publication

Consent to Sterilization (Elective)

Surrogate Decision Makers

Conduct of Clinical Trials/Research Projects

Use of Investigational Treatments/Trials

Investigational Drugs

Consent for Use of Investigational Drug - Sample Form

Investigational Drug Information Record Form

Conflict Resolution

Advance Directives

Confidentiality of Patient Information

Confidentiality of Information - General Issues

Management of Patient Pain

Facility Security

Loss or Theft of Property or Money

Speech or Hearing Impaired Patients

Interpreter Services

Interpreter Services and Protected Health Information

Patient Complaints

Patient Complaint Form

SECTION II - PROVISION OF CARE, TREATMENT AND SERVICES

Admission/Assessment

Assessment Policies

Patient Assessment

Assessment and Reassessment - Ambulatory Procedures

Documentation of Patient Allergies

Patient Problem List

Patient Medication Record

Patient/Resident Immunization Record

Care of the Latex Sensitive Patient

Latex Allergy Assessment Form

Latex and Non-Latex Alternatives

Nutritional Screening/Monitoring

Functional Assessment/Evaluation - Rehabilitation Services

Suspected Child, Adult, Disabled Person or Elderly Abuse/ Neglect/Exploitation

Domestic Violence Assessment and Reporting

Pain Assessment, Reassessment and Management

Pain Management Program - Initial Pain Assessment Form

Pain Assessment in Children

Behavioral-Physiological Pain Scale for Nonverbal or Preverbal Patients

Pain Scale Examples

Acknowledgment of Results of Diagnostic Testing

Follow-Up of Abnormal Results on Diagnostic Tests

Requirements for Surgical Procedures

Initial Patient Assessment and Reassessment

Triage

Follow-Up Assessment

High-Risk Call Back Questionnaire

Ambulatory Surgical Care Unit - Patient Phone Questionnaire

GI Laboratory - Patient Phone Questionnaire

Patient Care

Patient Identification for Clinical Care and Treatment

“Hand-Off” Communication

Triage of Patients

Emergency Care

Patient Nutritional Requirements

Pregnant Patients - Radiological Examination

Rehabilitation Services

Critical Tests and Result Reporting

Standards for Administration of Blood and Blood Products

Blood/Blood Component Transfusion - Informed Consent

Blood/Blood Component Transfusion Consent Form

Refusal of Blood/Blood Component Transfusion

Refusal to Permit Blood/Blood Component Transfusion Form

Storage and Procurement of Blood

Obtaining Blood and Blood Components

Blood/Blood Components - Transfusion Reactions

Restraint Use for the Management of Nonviolent, Non-Self Destructive Behavior

Use of Immobilization Devices

Restraint and Seclusion - Staff Training and Competency Requirements

Reporting Requirements for Death Associated with Restraint and/or Seclusion

Procedures Not Acceptable for Outpatient Surgery

Appropriateness of Procedure

Attending Physician Responsibilities

Surgical Site Identification

Invasive Procedure Site Identification

Sedation

Sedation Monitoring Form

Anesthesia Informed Consent

PACU Admission Protocol

Use of PACU Scoring Guidelines

Physician Notification of Change in Patient Condition

Discharge From PACU

Pain Management in the Post Anesthesia Care Unit

Standard of Care - PACU Services - Postoperative Pain Management

Waived Testing

Patient/Family Education

Education Plan

Education of Patient and Family

Educational Record Form

Patient and Family Education Form

Use of Medications

Food-Drug Interaction Notification and Counseling

Medical Equipment Education

Community Resources List for Patients and Families

Contracted Educational Programs

Discharge/Transfer

Discharge Planning

Discharge Instructions

Initial Home Safety Evaluation and Instruction

Home Hazard Analysis Checklist

Referrals for Infusion Therapy

Home Health Referral

Instructions for Home Care Form

Transfer to a Higher Level of Care Facility

SECTION III - MEDICATION MANAGEMENT

Patient Information for Medication Dispensing and Administration

Drug Availability

Procurement of Medications

Automated Dispensing Machines - Access to

Controlled Drug Management on Patient Care Units

Emergency Crash Carts

Emergency Crash Cart Security and Accountability

Alternative Medication Administration

Telephone, Verbal and Written Orders for Medication

Range Orders for Medications

Medication Orders

Pharmacist Order Verification

Drug Recalls

Monitoring of Drug Outdates

Unusable and Outdated Drugs

Medication Reconciliation/Verification

Medication Reconciliation/Verification Form

Medication Administration

Medication and Solution Administration in the OR

Medication and Solution Administration - Invasive Procedures

Safe Medication Practices

Decreasing Medication Errors

Medication Errors

Medication Error Analysis Tool

Medication Inadvertent Incident Report Form

Performance Improvement Analysis - Medication Inadvertent Incident Form

Adverse Drug Reaction Definition and Process

Adverse Drug Reaction Reporting Form

SECTION IV - SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION

Infection Control Committee

Surgical Wound Infections

Post Surgical Questionnaire

Communicable Infections

Reportable Diseases

Review of Healthcare Associated Infections

Exposure Control Plan

Sharps Injury Protection Plan

Sharps Injury Log Form

Employee Health - Injury

Employee Health - Employee Illnesses

Standard Precautions

Hand Hygiene - CDC Guidelines

Contamination Control - Responsibilities, Cleaning and Stocking

SECTION V - IMPROVING ORGANIZATIONAL PERFORMANCE

Organizational Performance Improvement Plan

Performance Improvement Monitoring and Evaluation Plan (blank)

Performance Improvement Trending Sheet (blank)

Performance Improvement Outcome Evaluation (blank)

Performance Improvement Volume Measures/Statistics (blank)

Clinical Laboratory PI Monitoring and Evaluation Plan

Clinical Laboratory PI Trending Sheet

Clinical Laboratory PI Outcome Evaluation

Clinical Laboratory PI Volume Measures/Statistics

Pharmacy Department PI Trending Sheet

Pharmacy Department PI Volume Measures/Statistics

Imaging/Radiology PI Monitoring and Evaluation Plan

Imaging/Radiology PI Trending Sheet

Imaging/Radiology PI Outcome Evaluation

Imaging/Radiology PI Volume Measures/Statistics

Department of Imaging/Services/Radiology - Patient Satisfaction Questionnaire

Engineering PI Monitoring and Evaluation Plan

Engineering PI Trending Sheet

Engineering PI Outcome Evaluation

Engineering PI Volume Measures/Statistics

Outpatient Surgery/Ambulatory Care PI Monitoring and Evaluation Plan

Outpatient Surgery/Ambulatory Care PI Trending Sheet

Management of the Patient in the Ambulatory Surgical Setting Worksheet

Licensed Independent Practitioner Quality Monitoring Review - Moderate/Deep Sedation

Anesthesia Generic Screens Form

Ambulatory Surgery - Outpatient to Inpatient Form

GI Laboratory PI Monitoring and Evaluation Plan

GI Laboratory PI Trending Sheet

GI Laboratory PI Outcome Evaluation

GI Laboratory PI Volume Measures/Statistics

Urgent Care - Nursing Staff Quality Assessment Review:

Documentation

Definitions of Elopement, AMA, LWBS

Elopement

Against Medical Advice (AMA)

Left Without Being Seen (LWBS)

Follow-Up Care for Patients Being Discharged Home

Standard of Care - Infection Control Worksheet

Urgent Care - Medical Staff Quality Assessment Review:

Lacerations

Abdominal Pain

Orthopedic Injury

Respiratory Distress

Sepsis

Seizures

Chest Pain

Pediatric Fever

Pediatric Gastroenteritis

Eye Pain

Code Blue

Generic Medical Record Review

Return to Clinic Within 72 Hours

Medical Staff Peer Review Program

Committee Activity Summary Form

Practitioner Quality Monitoring Profile

Audit Review Summary Form

Peer Review Form

Office/Clinic Evaluation Form

Preventive Care Worksheet

Management of the Diabetic Patient Worksheet

Management of the Hypertensive Patient Worksheet

Management of the Pediatric Patient Worksheet

Newborn to 24 Months

2 Years to 10 Years

Upper Respiratory Infection

Code Evaluation

Code Blue Quality Review Worksheet

Patient Satisfaction Questionnaire

Analysis of Risk Potential Form - Blank

Analysis of Risk Potential Form - Sample

Failure Mode and Effects Analysis Form

Sentinel Event

Intensive Assessment Flow Chart

Conducting Root Cause Analysis

Performance Improvement Department - Notification Form

Performance Improvement Incident Analysis Form

Incident Report Trending Sheet

Risk Management Follow-Up Form

Risk Management Monthly Safety Committee Report Form

Incident Reporting Staff Questionnaire

SECTION VI - LEADERSHIP

Mission and Vision Statements

Mission Statement

Vision Statement

Outline for Strategic Plan

Organizational Chart

Plan for the Provision of Patient Care and Services

Organizational Policies - Corporate Level

Quarterly Report to Governing Body - Personnel Evaluations

Communication Process

Budget Process

Levels of Care

Non-Discrimination

Staff Recruitment - Retention - Education

Outside Resources - Use of

Approval and Use of Contracted Services

Patient Safety Plan

Patient Safety Program Checklist

SECTION VII - MANAGEMENT OF HUMAN RESOURCES

Licensure, Certification and Registration Verification and Control Systems

Background Screening

New Employee Orientation

New Employee General Orientation Checklist

Performance Evaluations

Inservice Education Program

Education Needs Assessment Form - Clinical

Education Needs Assessment Form - Non-Clinical

Position Description/Performance Evaluation - Chief Executive Officer, Ambulatory Care Services

Annual Competency Skills Assessment - Chief Executive Officer, Ambulatory Care Services

Position Description/Performance Evaluation - Ambulatory Care Services Director

Performance Evaluation - Age-Related Competency - Ambulatory Care Services Director

Annual Competency Clinical Skills Assessment - Ambulatory Care Services Director

Position Description/Performance Evaluation - Ambulatory Care Services Nurse Manager

Performance Evaluation - Age-Related Competency - Ambulatory Care Services Nurse Manager

Annual Competency Clinical Skills Assessment - Ambulatory Care Services Nurse Manager

Position Description/Performance Evaluation - Ambulatory Care Outpatient Surgery RN

Performance Evaluation - Age-Related Competency - Ambulatory Care Outpatient Surgery RN

Annual Competency Clinical Skills Assessment - Ambulatory Care Outpatient Surgery RN

Position Description/Performance Evaluation - Ambulatory Care Operating Room Technician

Performance Evaluation - Age-Related Competency - Ambulatory Care Operating Room Technician

Annual Competency Clinical Skills Assessment - Ambulatory Care Operating Room Technician

Position Description/Performance Evaluation - Ambulatory Care Services Secretary

Performance Evaluation - Age-Related Competency - Ambulatory Care Services Secretary

Annual Competency Skills Assessment - Ambulatory Care Services Secretary

Annual Competency - 2007 Joint Commission National Patient Safety Goals

Credentialing and Privileging

Privileges of Licensed Independent Practitioners

Application Policy

Application Process

Your Facility’s Appointment Application

Application - Medical Staff Membership - Sample

Medical Staff Application Worksheet

Information Release/Acknowledgments

Sample Letter to Medical Staff Applicants

Primary Source Verification

Credential Verification Organizations

Adverse Credentialing Decision Policy

The Privileging Process

Criteria for Privileges

Clinical Privileges Request Form

Medical Staff Reappointment and Renewal of Clinical Privileges

Medical Staff Reappointment Worksheet

Temporary Privileges

Privileging of Licensed Independent Practitioners During Emergency Events

Telemedicine Services

Intravenous, Moderate and Deep Sedation Examination

SECTION VIII - MANAGEMENT OF INFORMATION

Management of Information Plan

Organizational Assessment of Information Management Needs

Legibility of Medical Record Documentation

Unacceptable Abbreviation and Symbol List

Acceptable Abbreviations List

Protection and Availability of Medical Records

Patient Access to Medical Records

Confidentiality Policy

Confidentiality Statement

Review of Medical Record

Information Management Training

Medical Record Content

Medical Record Review Tool - Sample

Medical Record Retention

Verbal and Written Orders - General

Documentation of Operative and Other High-Risk Procedures

Postoperative Recovery Documentation

Use of Summary List

Sample Summary List - Ambulatory Care Services

Tracking and Locating Medical Records

Professional Library and Health Information Services