patient care services policy and procedure manual - sample

7/30/2019 Patient Care Services Policy and Procedure Manual - Sample

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Patient Care Services Manual Samples

PATIENT CARE SERVICES POLICY AND PROCEDURE MANUAL

TABLE OF CONTENTS

Ref. # Page #

Approval/Signature Sheet 998

Introduction 999

A-B

Abdominal Surgery - Care of Patient(TJC PC.02.01.01 EP1, PC.02.01.03 EP7)

1001

Abdominal Paracentesis - Assisting with(TJC PC.02.01.01 EP1, IC.02.01.01 EP2)(NIAHO IC.1)

1002

Admission Policy(TJC PC.01.01.01)

1003

Admission Criteria - Critical Care(TJC PC.01.01.01 EP2)

1004

Admission from the Emergency Department(TJC PC.01.01.01 EP2)

1005

Admission Guidelines - Patients with Acute Coronary Syndrome orPossible Impending M.I.

(TJC PC.02.01.01 EP1, PC.02.01.03 EP7)

1006

Assessment and Reassessment(TJC PC.01.02.01 EP1, PC.01.02.01 EP2, PC.01.02.01 EP4,

PC.01.02.01 EP23)

1007

Admission Assessment Form(TJC PC.01.02.01 EP1, PC.01.02.01 EP2, PC.01.02.01 EP4,

PC.01.02.01 EP23, RC.02.01.01 EP2)

1008

Assessment for Self-Harm(TJC NPSG.15.01.01 EP1)

1009

Assessment of the Critical Care Patient(TJC PC.01.02.01 EP1, PC.01.02.01 EP2, PC.01.02.01 EP4,

PC.01.02.01 EP23)

1010

Allen's Test (Verification of Ulnar Circulation)(TJC PC.02.01.01 EP1)

1011

Angiography of the Head and Neck(TJC PC.02.01.01 EP1)

1012

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SUBJECT: ADMISSION GUIDELINES - PATIENTS WITH REFERENCE #1006

ACUTE CORONARY SYNDROME OR

POSSIBLE IMPENDING M.I.

PAGE: ii

DEPARTMENT: PATIENT CARE SERVICES OF: 6

EFFECTIVE:APPROVED BY: REVISED:

PURPOSE:

To provide appropriate guidelines for admission of the cardiac patient to Critical Care.

POLICY:

Admission Guidelines:

The most expedient route to an adequate environment is strongly recommended.

These include:

n Direct transport to Critical Care (i.e., ambulance gurney to Critical Care):

A physician with Critical Care admission privileges to the hospital's Critical

Care may gain direct Critical Care admission for his/her out-of-hospitalpatient.

The admitting physician will assure notification of the Administrative

Supervisor of admission.

The admitting process will be completed after the patient is being

monitored in Critical Care.

n Admission from Emergency Department criteria:

When the initial ED patient contact suggests a presumptive diagnosis of

MI, a suspected MI, or a patient with unstable angina, the patient needsimmediate attention and cardiac monitoring.

Risk stratification to identify patients with possible acute coronarysyndrome that would include a brief history with positive TIMI risk factorsthat dictate the necessity for Critical Care admission. (EKG and enzymesat this point may be normal.)

Examination findings that validate the need for admission to Critical Care

are (but not limited to) hypotension, pulmonary edema, diaphoresis,valvular regurgitation, rales, history of known coronary artery disease.

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SUBJECT: INVASIVE PROCEDURE SITE REFERENCE #1109

IDENTIFICATION (OUTSIDE OF THE OR) PAGE: iii


EFFECTIVE:APPROVED BY: REVISED:

POLICY:

__________________ Hospital shall identify those procedures that require markings of the

incision or insertion site.

The correct patient, procedure and site will be verified by the patient and/or family, the patient

care RN, LIP performing the procedure, and the anesthetist as applicable immediately prior to

the initiation of the invasive procedure.

PROCEDURE:

The invasive procedure and site/side will be verified by the following means:

Patient identified using two (2) patient identifiers

Verbal identification by the patient and/or family

Invasive procedure informed consent

History and Physical

Physician's orders

The above documents along with patient/family identification must indicate the same type and

site/side of procedure.

The LIP and patient care RN will identify the patient and verify the invasive procedure and

site/side in the department where the procedure is to be performed.

The patients identity is re-established if the practitioner leaves the patients location

prior to initiating the procedure.

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SUBJECT: TRANSFERRING PATIENT TO A REFERENCE #1171

WHEELCHAIR PAGE: iv


EFFECTIVE:

APPROVED BY: REVISED:

EQUIPMENT:

Wheelchair

Pillow

Cotton pillowcase

Patients bathrobe and slippers

Blankets

POLICY:

__________________ Hospital has a uniform method of transferring a patient to a wheelchair.

Patients who require assistance will be transferred to a wheelchair maintaining patient safety

and proper patient body alignment techniques.

PROCEDURE:

Place the wheelchair parallel to the patients bed, with the back of the wheelchair facing the

foot of the bed.

Lock the wheels of the wheelchair.

Fold up footrest of wheelchair.

Place blanket over wheelchair.

If a pillow is necessary, place the pillow in the back of the wheelchair with the open end of the

pillow case down, or place the pillow in the seat. Place Chux over the pillow, if needed.

Ensure the patient's bed is in the lowest position and the wheels are locked.

Patient Care Services Page iv Medical Consultants Network Inc. (800) 538-6264


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SUBJECT: PSYCHIATRIC EVALUATION OF A MEDICAL REFERENCE #1150

SURGICAL PATIENT PAGE: v


EFFECTIVE:

APPROVED BY: REVISED:

POLICY:

__________________ Hospital is a non-psychiatric receiving hospital. Any patient accessing

care at this facility who requires psychiatric treatment (emotional illness, alcoholism or drugabuse) is managed through referral and transfer to a behavioral health facility and/or

management through consultative psychiatric services on a temporary basis, until the patientsclinical condition has stabilized to allow for psychiatric facility transfer.

For Patients Accessing the Hospital Through the Emergency Department:

The Emergency Department physician will evaluate the patient and determine the need

for a psychiatric evaluation. If the patient is deemed in need of psychiatric treatment,the following criteria is assessed and documented:

n All medical complaints are stabilized:

The patient must be medically cleared prior to transfer to appropriatebehavioral healthcare

n If the patient is a danger to self, staff or others, a security officer will be requestedto continually observe the patient.

n Call Emergency Psychiatric Evaluation Team (PET).

n Maintain patient safety.

n Utilize restraints when needed, per policy and procedure.

n Call local law enforcement agency, if there is potential danger to patient, staff orothers.

Assessment and documentation includes:

n Patient history

n History from family member or others with whom the patient resides or otherclinicians involved in the patients care

Patient Care Services Page v Medical Consultants Network Inc. (800) 538-6264


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Patient Care Services Page vi Medical Consultants Network Inc. (800) 538-6264

patient care services policy and procedure manual - sample

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