Policies, Procedures and Guidelines

Cancer Center Staff Documents & Forms Policies, Procedures and Guidelines are linked below. Many of these links are from the HSC Intranet, Policies and Procedures document center.

Policy or Guide Effective/Updated Date Reviewed On
Acceptable Computer Use, policy 2500 3/26/15 11/20/17
Access 8/22/14 8/22/14
Admission from Clinic to Hospital 8/6/12 6/20/14
Advance Directives - English 8/8/14
- Spanish 8/8/14
- Vietnamese 8/8/14
Allowance for Doubtful Accounts 11/21/05
Appropriate Use of Intravenous Immune Globulin-IVIG 9/7/11 8/13/14
Attendance 1/14/09 7/15/14
Automatic Renal Dose Adjustment 6/24/11 8/13/14
Bomb Threat 8/22/14 8/22/14
Blood Transfusion Refusal 1/21/14 6/20/14
Capital Equipment Purchasing 2/28/05
Care of Forensic Patients 2/3/09 6/20/14
Cash Handling 10/15/08
Central Venous Line Care 3/18/13 6/20/14
Chain of Command Procedure 9/20/12 6/20/14
Chemotherapy 4/2014 8/13/14
Chemotherapy Administration-Extravasion 6/25/12 6/20/14
Chemotherapy Bladder Instillation 7/15/15 7/15/15
Chemotherapy Competence 8/17/12 8/22/14
Chemo Order Procedure 7/21/14
Child Safety 8/22/14 8/22/14
Clinical Operations Policies, Procedures, & Guidelines 10/27/08 7/21/14
Code Silver Emergency Response Plan Off-Sites 1/21/11 6/20/14
Code Status Orders and Advance Directives 1/21/14 6/20/14
Consent Form for Surgery Special Procedure Transfusion 12/9/09 6/20/14
Consulting a Provider Regarding Chemotherapy Orders 11/1/17 11/1/17
Controlled Substances 12/20/11 8/13/14
Controlled Substance Licensure 12/20/11 8/13/14
Controlled Substance Prescription Processing, Security and Issuance 8/11/10 8/13/14
CPR Procedure Documentation 12/21/11 6/20/14
Critical Tests and Critical Results 9/12 6/3/15
Designated Record Set 9/13/12 6/20/14
Destruction of Confidential Documents & Records 1/27/09 8/8/14
Distinguishing Gifts, Grants, Contracts and Licensing Agreements Guideline  4/29/15 4/29/15
Disinfection of Shared Point of Care Instruments  7/11/11 6/20/14
Document Destruction – E-Media 1/6/14 8/14/14
Documentation of clinical activities by medical staff and house staff 2/7/13 6/20/14
Dress Code 10/21/15 10/21/15
Drug Reimbursement Program 9/12/14 9/12/14
Drug Shortages 4/27/11 8/13/14
Electronic Medical Record Corrections 1/10/13 8/8/14
Elekta Vendor Maintenance Support Policy 6/5/15 8/27/15
Elevator Use and Emergency Procedures 1/8/08
Emergency Carts - Defibrillators-Transport Boxes 10/12/10 6/20/14
Emergency Crash Cart Restocking 12/23/14 2/4/15
Emergency Response to Off-Site Locations 3/20/12 6/20/14
Employee Separation Checklist 1/12/16 1/12/16
Energy Conservation 8/22/14
Ethics and Compliance Officer 1/14/09
Exit Interview Procedure 1/12/16 1/12/16
Fall Risk Prevention 8/10/12 6/20/14
Filling a Staff Position 2/3/12 7/15/14
Financial Assistance 10/--/09
Fire Drills 8/22/14
Fire Extinguisher Inspections 2/12/10 8/22/14
Hand Hygiene 10/2009 6/20/14
Hand Off Communication Guideline 12/28/10 6/20/14
High Alert, and Sound Alike Look Alike Medications 10/28/09 8/13/14
HIPAA Right to Access of Protected Health Information by the Patient 4/12/12 8/8/14
HIPAA Use and Disclosure of Protected Health Information 4/18/12 8/8/14
Hostage Situation 1/14/09 8/22/14
HSC-200 Security and Management of HSC IT Resources 1/9/12 8/15/14
HSC-210 Security of HSC Electronic Information Policy 6/23/10 8/15/14
HSC-220_Information_Access_and_Security 12/22/11 8/15/14
HSC-230.P1 Health Domain SSL Certificate Issuance 1/9/13 8/15/14
HSC-240_IT_Security_Incident_Response 12/22/11 8/15/14
HSC-250_Systems_and_Network_Security 12/22/11 8/15/14
HSC-260_Device_and_Media_Control 12/22/11 8/15/14
HSC-280_Physical_Security 12/22/11 8/15/14
HSC-300_ePHI_Security_Compliance 1/9/13 8/15/14
Human Immunodeficiency Virus & Reporting (HIV) Testing 12/16/08 6/20/14
Ice Machines Cleaning 4/1/13 6/20/14
Identification Badge 6/26/09 6/20/14
In Contact Call Monitoring 11/30/17 11/22/17
Infectious Waste Disposal 3/2012
Influenza and Pneumococcal Disease Vaccinations 12/12/08 6/20/14
Informed Consent for Chemotherapy 3/25/15 3/25/15
Interim Life Safety Measures 9/20/10 6/20/14
Internal Alarm Testing 2/12/10  8/22/14
Intraperitoneal Chemotherapy 11/8/17  11/1/17
Intrathecal Medication Compounding Guideline 8/26/15 8/26/15
Intravenous (IV) Medications - Compounded Sterile Preparations (CSPs) 7/21/09 8/13/14
Investigational Drug Service (IDS) 10/28/09 8/13/14
Keys and Locks 12/22/08 6/20/14
Lactation Room Guideline 11/1/17 11/1/17
Language Interpreter Services 1/11/13 6/20/14
Latex Allergy Precautions 7/15/11 6/20/14
Logo, Use-of 8/29/14 8/29/14
Maintenance Hours of Operation and Coverage 1/15/09 8/22/14
Management of Patients with MDRO or C 1/1/11 6/20/14
Mandatory Reporting for Abuse, Neglect and Exploitation 9/8/09 6/20/14
Media Communications Plan 3/27/09
Medication Error and Adverse Reaction Reporting 3/22/12 8/13/14
Medication Orders & Administration 4/12/12 8/13/14
Medication Reconciliation 6/2013 6/20/14
Misidentified Specimens (Request for Re-labeling of a Unique Specimen) 6/18/08 6/20/14
Mosaiq Access Security 5/28/15 8/27/15
Mosaiq Access Security - ADDENDUM 9/21/15 9/21/15
Mosaiq Access - Unauthorized 5/28/15  8/27/15
Mock Codes 9/1/11 6/20/14
No Show Protocol 7/16/14 8/8/14
Nonmotorized Vehicle Parking 1/8/08  8/22/14
Nursing Quality and Peer Review Council 12/28/10 6/20/14
Nutrition Screening 11/7/11
Nutrition Supplement Samples 8/29/14 8/29/14
OHP- Authorization for Individuals to Provide Services as Other Health Professionals 9/27/12 6/20/14
Oncology Medication Subcommittee  4/26/11 8/12/14
Oncology Medication Shortage  9/27/12 8/13/14
Orders, Verbal & Telephone 9/27/12 6/20/14
Pain Guideline
Parking Policy 11/27/17 11/27/17
Patient Access Ambulatory Services 5/20/14 8/8/14
Patient Discharge & Departure-Release of Patient from Hospital and Leaving AMA 1/22/14 6/20/14
Patient Enrollment Ambulatory Services 5/20/14 8/8/14
Patient Financial Activities Ambulatory Services 5/20/14 8/8/14
Patient Identification 7/20/09 6/20/14
Patient Payment 12/2009 9/15/14
Patient Observation Procedure for Adult & Pediatric Patients 4/22/06 6/20/14
Patient Re-indentification, Information Correction, & Duplicate Medical Record Number Removal 10/29/12 6/20/14
Patient Rights and Responsibilities 5/30/12 8/8/14
Patient/Visitor Complaints and Grievances 8/29/14 8/29/14
Patient/Visitor Compliments 8/29/14  8/29/14
Patient/Visitor Dismissals 10/25/10 6/20/14
Pediatric Waiting Room, Outlet Safety Covers 2/12/10
Persons on Hospital Premises Needing Medical Assistance 12/1/09 6/20/14
Photography of Patients *Consent form is on last page for videotaping, filming and imaging. 3/17/09 6/20/14
Physical Plant Hours of Operation and Coverage 8/22/14  8/22/14
POCT Accu-Chek Inform II 3/13/13 6/20/14
POCT - Clinitek Status Connect 12/22/10 6/20/14
POCT Hemaprompt Fecal Gastric Occult Blood Test 11/27/12 6/20/14
POCT Lactate Pro 11/19/12 6/20/14
Point of Service Collection 1/17/06
Program - Outpatient Services 340b 10/2/12 8/13/14
Program - Prescriptive Services 340b 10/2/12 8/13/14
Prohibited Abbreviations 4/21/11 8/12/14
Psychosocial Nutritional and Rehabilitation Services 8/29/14 8/29/14
Quality Improvement for Radiation Oncology 9/12/14 9/12/14
Radiation Exposure Event Reporting 5/19/2014 6/20/14
Radiation Oncology Progress Through Course of Therapy 9/12/14  9/12/14
Radiation Oncology Services 9/12/14 9/12/14
Radiology-Information System RIS Order Replace Correction 8/20/10 6/20/14
Recording Communications 8/29/14  8/29/14
Records Management, Retention & Disposal 11/19/13 8/8/14
Release of Information Minimum Data Set 8/19/12 8/8/14
Reportable Diseases 2/29/12 6/20/14
Regulatory Reporting Requirements 12/15/08 6/20/14
Requests for Electronic Copies of Medical Records 9/13/12 8/8/14
Responding to Breaches of Protected Health Information 3/6/11 6/20/14
Root Cause Analysis & Investigative Processes for Sentinel Events, Near Misses & Other Critical Incidents 2/9/09
Safe Medical Device Act 9/20/10 6/20/14
Safe Medication Vial Practices 8/20/12 6/20/14
Safety Chemical Spill Response 4/26/11 6/20/14
Same Day Procedure Requests 12/2008
Shift Differential 2/5/16 2/5/16
Sign-on Bonus Eligibility 4/1/17 4/1/17
Smoke-Free & Tobacco-Free Campus 10/3/12 6/20/14
Specimen Labeling 11/27/12 6/20/14
Stem Cell Transplant - Thawing & Reinfusion 6/7/12 6/20/14
Suicide Screening 5/8/14 6/20/14
Surgical Counts 9/6/11 6/20/14
Suspected Acute Transfusion Reaction 12/20/11 6/20/14
Suspicious Package 1/8/08 8/22/14
Tamper Resistant Prescription Paper Pads 11/19/09 8/13/14
Temperature Monitoring-Patient Care Areas 9/5/12 6/20/14
Therapeutic Phlebotomy 9/10/13 6/20/14
Time Clock 4/19/07
TNM Staging 9/12/14 9/12/14
Transfusion of Blood or Blood Products 5/2014 6/20/14
Training Affiliates Responsibilities 6/20/14
Tumor Board Conferences 9/12/14 9/12/14
Tumor Registry Database Management - Quality Control 9/12/14 9/12/14
Unauthorized Persons on Premises 1/29/09 8/22/14
Universal Protocol / Time Out 12/7/09 6/20/14
Use of "inError" or Retractions within the UNMH EMR 6/20/14
Utility Failure 12/22/08 8/22/14
Variance Reporting 4/10/12 6/20/14
Violent Individuals 1/14/09 6/20/14
Volunteer Program 8/25/11

Instructions for Using Policy Procedure Guidelines Template

 11/20/17 11/20/17
Policy, Procedure and Guideline  (it will automatically download) 11/20/17 11/20/17