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.

See the policy, procedure and guidelines instructions and template at the bottom of the list below.

 

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 1/16/18 1/16/18
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
Measuring Patients Height and Weight 2/1/18 2/1/18
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 7/19/17  2/6/18
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 TEMPLATE  (it will automatically download) 11/20/17 11/20/17