Hospital Policy and Procedure Manual

Group I    Organization

1.1.0   Hospital Mission

1.1.1   Improving Organizational Performance Policy

1.1.2   Organizational Chart - School of Medicine

1.4.0   Medical staff committee functions and membership are outlined in the LSUHSC Bylaws

1.4.2   Ethics Committee

Group II    Administrative

2.1.0   Hospital Policy Implementation and Revision

2.2.0   Observation Bed Policy

2.4.0   Patient Valuables

2.5.0   Utilization Review

2.6.0   Use of Alias Name

2.6.1   Name Change

2.7.0   Employee Possession of Weapons on State Property

2.9.0   Transfer of Emergency Patients from other Hospitals

2.9.1   Transfer of Stable Patients

2.9.2   Helicopter Transported Patients

2.10.0   Contract Approval Process

2.11.0   Access to Care

2.11.1   Treatment for Non Resident Patients

2.11.2   Managed Care Transfers into the Facility From Non-Contracted Providers

2.11.3   Nonresident Pediatric Patient Registration

2.11.4   Access To Emergency Service Within 250 Yards Of Main Campus

2.12.0   Approved Guidelines and Manuals

2.13.0   Adoption Protocol

2.15.0   Smoking Policy

2.16.0   Visitation Policy

2.17.0   University Hospital Dress Guidelines

2.18.0   Acquisition Of Equipment

2.18.1   Management Of Equipment Service and Maintenance and Repair

2.18.2   Single Vendor Contract Equipment Maintenance

2.19.0   Organizational Ethics

2.20.0   Prisoner patients

2.21.0   Fee Assessment for On-site Clinical Education / Training

2.21.1   Requirements for Clinical Rotations

2.22.0   Variance Reporting / Sentinel Events

2.23.0   Management of Patient / Visitor Complaint

2.24.0   Requests for Educational Programs

2.25.0   Referral Policy for Post Discharge Services / Care

2.26.0   Plan for Provision of Care

2.27.0   Supply Inventory

2.28.0   Photography, and the recording of Video, Audio, Cinematography of Patient

2.30.0   Certification, Registration and Licenses

2.31.0   Courtesy Beds

2.32.0   Vendor Solicitation Policy

2.33.0   Authorization of Infant Release

2.34.0   Relinquishment of Newborn

2.35.0   Disclosure of Unanticipated Outcomes and Medical Errors

2.36.0   Notification of death

2.37.0   Consultation Policy

2.38.0   Patients on Non-LSU Patient Care Equipment

2.39.0   Increased Controls For Readioactive Sources

2.40.0   Free Care Determination Policy

2.41.0   Tissue Procurement, Storage, and Disposition

Group III    Human Resource Management

3.1.0   Orientation, Education and Training

3.1.1   Documentation of Response to Learning Needs: In-service Education Record

3.2.0   Staff Rights

3.3.0   Pregnant Workers in Radiation Areas

3.4.0   Staffing

3.5.0   Competency Assessment Program

3.6.0   Personnel Radiation Monitoring

3.7.0   Employee Time and Attendance

3.7.1   Educational Time and Attendance

3.9.0   Personnel Identification Badges

3.10.0   Physician Impairment

3.11.0   Employee Access To Care

3.12.0   Leave and Holiday Pay for Shift Employees

3.13.0   Employee Debriefing Counseling Policy

Group IV    Environmental Care

4.12.0   Emergency Procedures for Dislodged or Missing Cesium Implants

4.50.0   Radiation Safety During Iodine Therapy Over 30 Millicuries

Group V    Planning and Providing Care

5.0.0   Planning and Providing Care

5.1.0   Patient and Family Education

5.1.2   Patient Education Regarding Potential Food/Drug Interactions

5.1.4   Tutorial Services (Public School System)

5.1.5   Immunization Education and Documentation

5.2.0  

5.2.1   Point of Care Testing

5.2.2   Transport of Specimen via Pneumatic Tube

5.2.4   Infection Control Guidelines for all POCT Areas

5.2.5   Non POCT Physician Practice Guidelines

5.3.0   Nutritional Screening

5.4.0  

5.4.10   Personnel Authorized to Prescribe Medications

5.5.0   Abuse and Neglect

5.6.0   Abortion

5.7.0   Organ Procurement

5.7.1   Organ Donation After Cardiac Death (DCD) Protocol

5.8.0   Ambulatory Care Division

5.9.0   Patient Assessment

5.9.2   Anesthesia Care

5.10.0   Admission

5.10.1   Patient Identification Band

5.11.0   Patient Callback

5.12.0   Code 99 Resuscitation Team

5.12.1   Crash Carts

5.12.2   Cardiopulmonary Resuscitation Form

5.13.0   Latex Allergy

5.14.0   Patient Communication Needs

5.15.0   Restraints

5.15.1   Restraint of Behavioral Health Disorder

5.15.2   Restraint of Nonviolent Patient

5.16.0  

5.16.1   Informed Consent

5.17.0   Patient Rights and Responsibilities

5.18.0   Management of Pain via Continuous IV Infusion

5.19.0   DNR

5.20.0   Brain Death Evaluation

5.21.0   Withholding or Withdrawal of Life-Sustaining Treatment

5.22.0   Advanced Directives

5.23.0   Continuum of Care

5.24.0   Discharge Policy

5.26.0   Management of Patients Receiving Conscious Sedation

5.27.0   Management of Violent and / or Committed Patients

5.28.0   Audiology Services

5.29.0   Substance Abuse

5.30.0   Reporting of Laboratory Critical / Non-Critical Test Results

5.32.0   Prevention of Wrong Site Surgery

5.34.0   Pain Management

5.35.0   Scope of Rehabilitation Services

5.36.0   Speech

5.37.0   Pastoral Care

5.38.0   Social Services

5.40.0   Post-Mortem Care

5.41.0   Patients Leaving AWOL without Notification/Permission

5.42.0   Fall Prevention Program

5.43.0   Patient Handoff

5.44.0   Adult Vaccination Program

5.45.0   Shock Treatment and Resuscitation Team

Group VI    Information Management

6.2.0   Confidentiality, Security and Integrity of Information

6.3.0   Release of Information

6.3.1   Fax Policy for Transmitting Patient Information

6.3.2   Poison Control Center

6.5.0   Medical Records Content / Documentation

6.5.1   Accuracy and Timeliness of Medical Record Documentation

6.5.2   Abbreviations and Symbols

6.12.0   Handling Medical Records and Documents Contaminated with Blood or Body Fluids

6.13.0   Verbal and / or Telephone Physician's Orders

6.14.0   Hospital Forms Review and Approval Process

6.15.0   Information Management Training

Group VII    Miscellaneous

7.1.0   Use of Animals for Research

7.3.0   Emergency Biomedical Coverage

7.4.0   Body Donation

7.5.0   Pager System

7.6.0   Autopsies

7.6.1   Coroner's Case

7.8.0   University Police

7.9.0   Posting of Announcements

7.10.0   Handling of Foreign Objects Considered Evidence, Removed from the of Patient's Body

7.11.0   Transportation Services (External)

7.12.0   Loaning and Borrowing Equipment and / or Supplies

7.14.0   Management of Radiation Producing Equipment

7.15.0   Clinical Alarm System

7.16.0   Cellular Phones Use

Group VIII    Medication Use

8.1.0   Pharmacy Services

8.2.0   Prescription Pads

8.4.0   Allergy and Adverse Drug Reactions

8.5.0   Drug Samples

8.6.0   Medication Administration

8.6.1   Standard Administration Times

8.6.2   Duration of Drug Administration

8.6.4   High Risk Medication Protocols

8.6.5   Intravenous Medications

8.7.0   Formulary System

8.7.1   Hospital Drug Storage and Control

8.7.2   Restrictions In The Use Of Special Drugs

8.8.0   Investigational Drug Use

8.9.0   Personnel Authorized to Prescribe Medications

8.9.1   Medication Order Information

8.9.2   Discarding Medications

8.9.3   Medication Requested on IT

8.11.0   Outpatient Prescription Availability

8.12.0   Medications Brought Into Hospital by Patients

8.13.0   Control of Medications

8.14.0   Use of Preferred Medications (Therapeutic Interchange)

8.15.0   Intravenous to Oral / Internal (IV to PO) Medication Switch Policy

8.16.0   Medication Assistance Program (Outpatient)

8.17.0   Drug Recall

8.18.0   Drug Shortage

8.19.0   Medication Administration Check (MAK)

8.20.0   Medications Administration Via the Interathecal Route

8.21.0   Medication Reconciliation